Polite Dissent

An atypical episode of House as it focused on a day in Dr. Cuddy’s life, moving every other character to the background. A change of pace, but a solid and enjoyable show nonetheless.

Cuddy gets up at five AM and starts the day with some yoga. Her daughter Rachel wakes up a little while later, sick, and Cuddy comforts her while getting ready for work. The nanny arrives, and then Lucas, who’d been up all night on a stakeout. He talks her into a quickie before work, but unfortunately he was a little premature in his efforts and she heads off to work unsatisfied.

Cuddy arrives at the hospital at eight and things are already going crazy.

House strolls up to discuss his patient he thought had resistant Staph, and who he wanted to treat by infecting him with malaria.

Cuddy walks off, telling House that she has to finish a proposal before an important 8:30 meeting and there’s a crisis in the pharmacy where some paperwork, and some ephedrine, is missing. Next, there’s a problem in surgery, where one of the surgeons is complaining because House has turned on the air conditioning. She gets the heat turned back on and heads to her meeting.

Meeting Cuddy in the hallway, House informs her that his patient now has boils and a large abscess.

Cuddy hears from the nanny that Rachel is still sick, only now she’s running a fever and vomiting. She finally makes it to her 8:30 appointment with the contract negotiator from AtlanticNet Insurance, the largest insurance company in the area. He and Cuddy have been arguing about a contract for eight months, and today Cuddy lays it all on the line. She agrees to capitated care, but wants a 12% increase in rates. He refuses. She tells him that this is the hospital’s final offer and he has until 3PM to agree, or she will make a public announcement that they are no longer accepting AtlanticNet, and why.

Thirteen and Taub report to House that their patient is now hallucinating and has a falling blood pressure and rising heart rate. They suspect congestive heart failure, but House disagrees, telling them that the patient has [elevator door shuts before we hear the answer].

On the way to the hospital board meeting, Cuddy has a run in with Dr. Thomas, the hospital’s Chief of Surgery. He is seething about House — upset primarily about the fact that he stole Chase back from the surgery department. She heads into the board meeting where the board makes it clear that Cuddy’s job is on the line if she can’t pull off the contract with AtlanticNet.

House skipped clinic again, so Cuddy fills in for him. The patient is an older man with metastatic cancer who wants a prescription for breast milk. He has heard that breast milk can help with his cancer, and wants a prescription so the insurance company will pay for it. She refuses, pointing out that even with a prescription the insurance company won’t pay for it. He accuses her of being in the pocket of the insurance company before insulting her and storming out.

Back at her office, Cuddy finds a lawyer waiting for her. He is representing Martin Acevedo, a man who had his thumb reattached after cutting it off with a saw. He is suing because he didn’t want the thumb reattached — he is poor and that was too expensive — but Chase went ahead and did the surgery anyway. When confronted Chase admits that he did sew the thumb back on even though that was not what the patient wanted because he felt that the reattachment was the best option for the patient medically.

A little while later, Cuddy meets with Gail, the pharmacy tech who stole the ephedrine. She tells Cuddy that it was to help her lose weight and asks Cuddy not to fire her. Cuddy takes a little pity on her and tells Gail that she has to fire her, but she won’t report her to the DEA. She grabs a quick unhealthy lunch from the cafeteria.

House is sitting in Cuddy’s office – in her chair – waiting for her. He tells her that his patient has renal cell cancer (kidney cancer) and he wants to treat with malaria in addition to chemotherapy.

Lucas swings by the office, bringing Cuddy a real lunch. He tells her that Rachel seems to be doing better — she is no longer running a fever — but she has developed a rash. Unfortunately, Lucas accidentally grabbed the nanny’s phone, and turned the ringer off on Cuddy’s phone at home, so there is no way to reach the nanny.

With Lucas’s help, Cuddy tracks down the CEO of AtlanticNet at lunch and confronts him about the contract. He blows her off, telling her he doesn’t care if her PR campaign makes him out to be a rich bastard, as long as he stays rich.

Back at the hospital she meets with the head of the pharmacy and discovers that a lot more ephedrine is missing from the hospital than previously suspected — $50,000 dollars worth — and the thefts have been going on for at least three years. She realizes that Gail has been lying to her and has been stealing the ephedrine to sell to a meth dealer (ephedrine can be used to make methamphetamine)

The negotiator from AtlanticNet returns and offers an 8% increase as their final offer. Cuddy declines, wanting the full 12%.

Now House’s patient has liver failure and needs a transplant.

Three o’clock arrives, and as there have been no new offers from AtlanticNet, Cuddy calls a staff meeting and informs the physicians that the hospital has terminated the contract with the insurer. This causes widespread disbelief and dismay among the staff, as many of them made much of their money from AtlanticNet patients.

Foreman arrives, telling Cuddy that they’ve found a liver, but now there’s another conflict. House wants Chase to do the surgery, but Thomas refuses to put him on the schedule. Foreman needs someone who outranks both House and Thomas to schedule the surgery.

Cuddy meets with Acevedo and his lawyer. She tells them that not only will the hospital fight the lawsuit tooth and nail, but that she wants Acevedo to pay the remaining bill for his care.

Next, Cuddy arrives at the surgical suite and breaks up a brawl between Drs. Chase and Thomas. She then returns to her office and confronts Gail, the recently fired pharmacy tech, about lying to her. Gail freely admits the theft and tells Cuddy she can’t do anything about it because she’ll lie to the DEA, telling them that she did it on House’s orders, and that House and Cuddy were having an affair. Frustrated, Cuddy walks out of her office, telling the staff that she quits. She sits quietly in her car for a few minutes until House arrives. He cheers her up, as only House can, by insulting her, but this is enough to get her to head back into the hospital.

Cuddy confronts Gail again, who once again brags of her theft and her plan to lie to the DEA. Luckily, Cuddy captured it all on one of Lucas’s hidden recording devices. The nanny calls and tells her that Rachel is doing fine. To complete the hat trick, the negotiator from Atlantic Net arrives and tells Cuddy that the insurer has agreed to her 12% proposal. Ecstatic, she informs the board and staff, who share her enthusiasm. Finally, she heads home to Lucas and Rachel after a long, exhausting day at work.

No significant medical complaints, and no grading this week either, as the episode didn’t give me much to work with in that regard. Just a few thoughts and comments:

Though I know nothing of its use in Staph infections or cancer patients, before the advent of penicillin, malaria was used a treatment for syphilis. The malaria gave the patients a high fever — high enough to kill off the syphilis germs — and malaria was curable with quinine.

On one hand, you could argue that Cuddy should have acceded to the patient’s wishes and given him a prescription for breast milk, since, as House said, “it might work.” However, I have to side with Cuddy on this one. First, she’s right: the insurance company will not pay for it, even with a prescription — they’ll consider it an experimental treatment. Second, it’s her signature on the prescription, and she should not write any prescription she is not comfortable signing. Finally, and she should have pushed this part harder, the breast milk is at best a shot in the dark — it’s wishful thinking — and by writing the prescription she would be confirming the patient’s false hope. She handled it well: she was upfront and truthful and told the patient she would not write the prescription. He didn’t like what she said, but he’s free to find a new physician.

Though it was mentioned briefly at the beginning, both Cuddy and the lawyer are glossing over the key fact that the treatment Mr. Acevedo received was not covered by the informed consent he signed. Chase may have done what he thought was best for the patient, but he did it through lying and dishonesty. Sure, Mr. Acevedo kept his thumb, and this will probably restrain the jury’s and judge’s enthusiasm for a large payout, but there is clear written evidence that Chase was deceitful in his treatment of the patient. The hospital’s insurance company will pay this off long before it sees a courtroom. And as for Chase, skipping informed consent or lying on it is a good way to lose a medical license.

Every place I’ve ever worked has a two people count the controlled substances in the pharmacy, just so situations like Gail’s can’t happen. And why does the hospital have so much ephedrine? It’s not that common a drug.

Anyone know what the rules in New Jersey are for surreptitiously recording a conversation? I know in Illinois it needs the consent of both parties involved, but I believe this is the exception, rather than the rule.

Consider this a non-scoring week for the House Challenge. Last week’s scores can be found here.

The review of the previous episode of House
A list of all prior House reviews

A recurrent controversy on this blog has been whether Dr. Jericho Drumm (better known as Brother Voodoo) is a psychiatrist or psychologist. In various stories over the years, he’s been referred to as both (sometimes within the same comic). Calling him a psychologist occurs the most frequently, and that seems to be generally accepted. But is it true?

With the recent release of Doctor Voodoo: The Origin of Jericho Drumm, which reprints Brother Voodoo’s first appearance, the question can finally be answered.

So which is Brother Voodoo?

Here is his first appearance (as Dr. Jericho Drumm) and he is clearly identified as a “noted psychologist.” So that answers the question, right?

Not so fast. Here is Dr. Drumm a page later whipping out his stethoscope and tending to his dying brother. He even pulls out a syringe and medication to administer to him.

It seems that Brother Voodoo’s first appearance only complicates the debate. He is clearly identified as a psychologist, yet he is practicing medicine just a page later. I think it can be chalked up to yet another writer confusing psychiatrist and psychologist, an all too common occurrence. However, given that Drumm’s use of Western medicine is key to his character at this point in the story, I suspect the writer fully intended for him to have medical training, and therefore be a psychiatrist.

All scenes from Strange Tales #169 (reprinted — and it appears re-colored — in Doctor Voodoo: The Origin of Jericho Drumm). Written by Len Wein (though Roy Thomas had some input into the creation of Brother Voodoo as well) and penciled by Gene Colan.

Tags: comics medicine brother voodoo psychiatrist psychologist

This was a Fringe episode left over from Season One that had never been aired — and it wasn’t a particularly good episode, but better than some that were aired. There was at least one good plot twist.

The Plot: Lisa, a seventeen year old high school junior has been declared brain dead after a cerebral aneurysm. Her life support is shut off and she is declared officially dead before being wheeled into the operating room to harvest her organs for transplant. Once the operation has started, she suddenly sits up, alive, and screams out a series of code numbers. It turns out the code refers to a naval officer by the name of Andrew Rusk — and he has been reported missing. The Fringe team is called in to investigate.

Lisa denies ever having met Rusk, but when his name is mentioned, she speaks a phrase in Russian which translates to “my (or ‘little’) star.” Lisa has developed a fever and the doctors are watching her closely. Her mother tells Agent Dunham that she doesn’t want the team questioning Lisa anymore when Lisa suddenly screams from the bathroom — when looking in the mirror she has seen the image of Rusk standing behind her. Walter hypothesizes that Lisa’s aneurysm affected Broca’s area, a part of the brain which controls language — and according to Walter — also controls psychic ability.

A little while later, Lisa calls Agent Dunham, telling her that she still is still seeing Rusk. She is at a junkyard, because she saw the image of it in her mind. When the Fringe team finds her, she tells them that Rusk was shot there. Sure enough, a 9mm casing is found and a short time later, Rusk’s body is found. Lisa has a sudden seizure and is readmitted to the hospital.

Walter deduces that Rusk’s death and Lisa’s rebirth occurred simultaneously, and somehow this allowed her to pick up his memories. Lisa’s mother allows Lisa to be taken to Walter’s lab to purge the memories.

Meanwhile, Dunham finds out that Rusk used to call his wife the Russian phrase “my star.” She also finds out that he was exposed to high radiation doses in a shipboard accident and was given an experimental radiation inhibitor.

Back at the lab, Walter hooks Lisa up to an EEG, pumps her full of drugs, and the team discovers that she doesn’t just have some of Rusk’s memories — his entire consciousness is sharing her brain. Rusk’s personality emerges when the drugs put Lisa to sleep. He is able to give the team enough of a lead to track down his killer — a former Navy SEAL. When the suspect is questioned by the FBI he admits that he killed Rusk, but he did it because Rusk was a wife beater — Rusk’s wife hired him to kill her husband. He tells the team that he mentioned this fact to Rusk before shooting him.

Rusk is still in control of Lisa’s body, but by pretending to be Lisa, manages to sneak out of the lab. He goes to his house and grabs his gun. He confronts his wife, but she denies having anything to do with his murder. He ties her up and is getting ready to start a house fire when Peter arrives, with the rest of the team following a short time later. Peter talks to Lisa/Rusk enough to distract him so that Charlie can shoot him with a tranquilizer dart. Further testing in the lab reveals that only Lisa’s consciousness remains within her mind.

1. Breathe, Breathe In The Air. Since Lisa stopped breathing and died once the ventilator was stopped, why are they bagging her on the way to OR? (And if you want to argue that they are bagging her to provide oxygenated blood to her organs, then they also need to 1) give CPR, and 2) continue to bag her in the OR).

2. Infection Control, What’s That?
Lisa has enough of a fever to worry her doctor, but is discharged the next day — and immediately returns to school and church? Where lots of sick people are? (Assuming she goes to church on Sunday, it seems impossible for her to have made it back to school. By my calculation she would have been discharged late Friday at the earliest.).

3. Total Nit-Pick About Balloons
Hospitals are picky about which balloons are allowed. The ones is Lisa’s room are not allowed due to concerns about latex allergy.

4. I Wish All Surgeries Were That Easy
Abdominal surgeries, even on dead people, are not that easy. The renal artery is way in the back and all the intestines have to be moved out of the way before it can be reached.

5. Seize Her
That was one of the more unconvincing seizures I’ve ever seen.
Speaking of seizures, while I agree with the hospital doctor that in most cases the cause of seizures are never identified, I would not so cavalierly dismiss the idea that it was related to her aneurysm. She had a recent bleed in her brain, and blood is a very irritating substance — not to mention the swelling from the injury — which is enough to set off a seizure.

6. Too Many To Choose From
It was nice of Walter to put her on 100 mikes (micrograms) of a benzodiazepine, but it would help if he told Astrid which one to use. He typically has used Valium, but the doses he is giving fits Versed better.

7. Too Late To Matter
With a dose of 600-1000 REM, Rusk would have had the initial symptoms of radiation poisoning starting shortly after exposure (mostly nasty gastrointestinal ones). His bone marrow would be dead and he would require a bone marrow transplant to have any chance of survival (and for the record, only one person has ever survived that dose of radiation).
Once Rusk was removed from the reactor, he was no longer exposed to the radiation — and since he is not radioactive himself (radiation doesn’t work that way) — giving a radiation inhibitor at this point is useless, like closing the barn door after the horse has left. There is no radiation left to inhibit. The damage has already been done.

8. Quickdraw McGraw
Intramuscular medications (like the tranquilizer dart) do not take immediate effect. The medicine must be absorbed into the blood stream and spread throughout the body — or at least reach the brain) before it knocks the victim out.

9. Enough Already, George Michael
Scientifically-based faith (e.g. I have faith the sun will rise tomorrow) is a completely different concept than religious-based faith and the terms are not really interchangeable.

Since this is not a current episode, it’s not going to affect the Doomsday clock — which is a good thing for the show.

Tags: television fringe brain psychic possession

In the closing panels of Red Robin #4, Tim Drake is stabbed in the abdomen with a sword by the villainous Widower. In the next issue, it is revealed that his injury required the removal of his spleen.

Found in the upper left aspect of the abdominal cavity, the spleen is roughly the size of a grapefruit and serves several important functions: It removes old and damaged blood cells from the circulation, as well as removing harmful bacteria. It assists the immune system by acting as a large lymph node. It stores extra blood to act as an emergency reserve in case of severe blood loss.

Both blunt and penetrating abdominal trauma can injure the spleen. Penetrating trauma can lead to splenic lacerations. Blunt trauma can rupture it. Unfortunately, the spleen is very difficult to repair — it was once described to me as having the consistency of a sopping, water-logged sponge. Imagine trying to sew that back together. Often the only treatment for a severely damage spleen is splenectomy (removal of the spleen), leaving the patient asplenic (without a spleen).

The main concern in people lacking a spleen is an increased risk of infection. This is not just a slight increase in risk, but a significant increase in the risk of serious infections. In the worst case scenario, there is a condition known as OPSI (overwhelming post splenectomy infection) that can be fatal within just a few hours.

Asplenic individuals are susceptible to a wide variety of germs, but the three most concerning are:

1. Bacteria that have a thick protective capsule. These bacteria include pneumoccocus (a cause of pneumonia and other infections), meningococcus (a cause of meningitis), and Haemophilus influenzae (another cause of meningitis, among other nasty infections).

2. Capnocytophaga canimorsus, a bacteria found in dog bites.

3. Parasites that like to hide within red blood cells (malaria is the main one, but also babesiosis and ehrlichiosis, rare tick-borne infections).

Asplenic individuals need to be aggressively immunized against the riskiest bacteria. They will require the pneumococcus, meningococcus, and Haemophilus influenza vaccines. The pneumoccocal vaccine may need to be repeated every 5 years. Additionally, pediatric patients who lose their spleen need to be started on daily broad spectrum antibiotics for the next 2-5 years. Those who are considered particularly high risk for infection may need daily antibiotics for the rest of their life.

Tags: comics robin trauma spleen asplenic infection

Power Girl #5 “Space Girls Gone Wild”
Jimmy Palmiotti, Justin Gray, writers
Amanda Conner, penciler

Power Girl is caught in the middle of the explosion of a spaceship that crashed in a city park. The local police, firefighters, and EMTs rush in survey the damage, provide first aid, and move her out of the crater.

They’ve got her on oxygen and they’re using a backboard, so everything’s good right?

Not quite. They forgot to secure Power Girl’s head/neck and if there’s any damage to the cervical spine or cervical spinal cord, this could be a big problem (what sort of problem? Quadriplegia). The image above shows the danger perfectly. Look at the angle her head is at compared to the rest of her body.

Here’s an annotated version to make it even clearer:

I suspect the rescue personnel were a little distracted.

This episode explores what happens when Foreman takes over the team after House quits. And the results are, frankly, dull. The House scenes were good, but the hospital scenes were uninspired. Even the usually humorous theme of “internet medicine is better than real medicine” couldn’t do much more than evoke a tired chuckle

Vince is a game programmer working on a virtual reality first person shooter. He has to drop out in the middle of a gaming session because he suddenly develops a severe burning pain in his hands. He is initially evaluated in the emergency room and told that his nerve conduction studies are normal (so no carpal tunnel) and his bloodwork is negative (which is quite a work-up for the ER). Instead of continuing to work this up as an outpatient, Vince is admitted to the hospital.

Currently, the team consists of Foreman, Taub, and Thirteen. Foreman has taken over the team because House has handed in his official resignation. Cuddy tells Foreman he has one chance to prove to her he can run the team. Looking at Vince’s case, the team suggests diabetic neuropathy (but his HbA1c, a blood sugar test, is normal), hypothyroidism (but no other symptoms match), or complex regional pain syndrome (a difficult to treat cause of chronic pain; previously called reflex sympathetic dystophy). The last one fits the symptoms the best so they plan on treating him with spinal stimulation. When they talk to Vince, he tells them that he has been doing research online and believes that he has mercury poisoning. To placate him, Thirteen draws a mercury level. It is mildly elevated, but nowhere near the toxic level. Nevertheless, Vince still believes that he has mercury poisoning and demands chelation therapy. Foreman steps up and draws the line, informing Vince that if doesn’t want to follow his doctor’s advice, he can do so elsewhere. Vince grudgingly agrees to the spinal stimulation.

The stimulation provides no improvement, and during the procedure, Vince develops a racing heart rate and flash pulmonary edema (the lungs quickly filling up with fluid). Further study demonstrates that Vince has a thickened left ventricle (part of the heart). Lyme disease and cocaine use are the new differential diagnosis. Lyme disease doesn’t quite fit, and Vince denies any cocaine use. Not entirely trusting him, Thirteen and Taub search his office. They find no cocaine, but seeing the realistic rendering of birds in his game, Thirteen suspects he has been in close contact with them and developed psittacosis (also known as “parrot fever,” a disease carried by birds than can be passed to humans). As the team is telling him about the disease, Vince mentions that he is suffering from priaprism — a persistant erection — for the past three hours. The priapism not only requires surgical correction (a shunt), but it also rules out psittacosis.

The new differential diagnosis consists of Guillain-Barre disease (an autoimmune disease of the nerves), thrombocytosis (a disease caused by too many platelets), or a brain tumor. Thirteen favors the tumor diagnosis, but Foreman presses ahead with thrombocytosis, despite Vince having a normal platelet count. He wants to start Vince on hydroxyurea (a medicine used to treat thrombocytosis). At this time, Foreman and Thirteen notice two other doctors — doctors that neither of them recognize — standing next to Vince’s bed. It turns out the other doctors came in response to Vince’s internet postings. Foreman reminds them that neither of them are credentialed to treat patients at Princeton Plainsboro Hospital. One doctor turns out to be a quack, but the other seconds Thirteen suspicion of brain tumor. Vince demands an MRI and Foreman agrees. When the MRI shows no sign of tumor, Vince is started on the hydroxyurea.

Instead of improving, Vince develops massively enlarged cervical (neck) lymph nodes. This should not happen in thrombocytosis. He is started on steroids, which bring down the swelling. Foreman suspects polyarteritis (an autoimmune disease of the arteries), but before the team can act they discover that Vince has posted all his symptoms online and is offering $25,000 to whoever can diagnose his condition. The diagnostic team is inundated with faxes, calls, and e-mails. They confront Vince and tell him that it will take way too long if they have to address every one of the online suggestions (samples include paraneoplastic syndrome, Graves disease, and demonic possession). Vince tells them that he thinks he has amyloidosis, since that’s what most of the people on his site are saying. Foreman agrees to biopsy one of his kidneys looking for amyloidosis, but only if Vince agrees to shut down his website and rescind his reward when the biopsy is negative. Of course, the biopsy is “suggestive” of amyloidosis, and Foreman starts him on dexamethasone (a steroid used, among other things, to treat amyloidosis).

The story isn’t over yet (clearly, as it is has only been 45 minutes), and a short time later Vince is running wild through the halls of the hospital, feverish and hallucinating. Antipyretics (fever reducing medicines such as Tylenol or Motrin) have no effect, so he is placed in a cooling bath. Foreman tells him that Light Chain Deposition Disease (the body overproduces the light chain — part of the antibody macromolecule — and it is deposited in various organs) is the most likely diagnosis, and he will require high dose chemotherapy for treatment. Wearily, Vince agrees. Just as the therapy is about to start, Foreman has his Aha! moment when he realizes that Vince’s fingers never became wrinkled in the bath. This is a sign of Fabry’s disease, a condition caused by the errant deposition of certain lipids throughout the body. His elation is short-lived, however, when he discovers Thirteen has already made the diagnosis and started treatment, based on an internet suggestion she read behind Foreman’s back.

As the episode ends, Foreman is officially put in charge of the team — what little team there is left. Taub has quit to take a surgical job and Foreman just fired Thirteen because he feels he can’t be both her boss and boyfriend. To further complicate matters, House has realized that difficult diagnostic situations are the only thing that keeps his mind off his leg pain and decides to come back to the hospital (after all, it was his suggestion of Fabry’s disease that Thirteen unknowingly used).

I found the medical aspect of the story to be rather uninteresting this week, but whether it was from the weak mystery or lack of House — or both — it’s hard to say. The medicine was haphazard, jumping from diagnosis to diagnosis and lacked the drive most episodes have. Still, there was some logic to it, just not much. Because there wasn’t much medicine, there isn’t much to criticize.

As usual, major complaints are in red, minor in blue, nit-picking in green:

I am concerned that the pathologist could not tell the lipid depositions of Fabry’s disease from the protein depositions of the LCDD and Amyloidosis.

The team couldn’t make up their minds whether to play hard with the diagnostic criteria (no joint pain, can’t be Lyme), or loose with them (sure, you can have thrombocytosis — a disease defined by elevated platelet counts — with normal platelet levels). A little consistency would be nice.

Shouldn’t abnormal lipid deposition in the nerves showed up on a nerve conduction study?

There was nothing about this patient’s initial presentation that required inpatient admission. Almost all the work-up, including the nerve conduction studies, should have been done as an outpatient.

While spinal stimulation seems to offer some relief in many patients with CRPS, it is does not work for everyone, and is generally not the first treatment tried.

The medical mystery was only modestly interesting, and never developed the “this guy is on the verge of dying” feeling that makes these shows interesting; I give it a C. The final solution was logical, and generally fit the symptoms so earns an B+. The medicine was stumbling, and seemed to arbitrarily ignore as many logical diagnoses as it focused it; at best, it was average: C. The soap opera, though predictable, was well done and also earns a B+.

Last week’s House review
A list of all prior House reviews

House Challenge scores have been posted. Pretty much everybody is tied for second this week.

New Avengers #57
Brian Michael Bendis, writer
Stuart Immonen, penciler

New Avengers #57 is the type of comic I like, but don’t see very often: a comic which addresses the effects of super-powers on a character’s medical care. In this case, the issue looks at Luke Cage and his unbreakable skin.

The New Avengers have just been handed a serious defeat at the hands of the Wrecking Crew and some of the villainous cohorts. It wasn’t strictly the Avenger’s fault, they were taken by surprise by some super-power draining technology the Wrecking Crew got their hands on. When the Dark Avengers also showed up, the New Avengers snuck out in the subsequent confusion. Most of the team suffered scrapes and bruises, but Luke Cage appears to be suffering from a heart attack. His teammates rush him to underground “doctor” Night Nurse.

Night Nurse is in serious trouble, and she recognizes it. All three reperfusion techniques require either IV access or a surgical incision. This means that Cage’s invulnerable skin prevents him from receiving the necessary treatment. She tells the team he needs specialty medical care — which is true, and would be true even if his skin weren’t invulnerable. Heart attack patients need to be treated in a facility where there is access to reperfusion techniques.

Even though she can’t break Cage’s skin, there are still treatments that Night Nurse can carry out to minimize the damage from his heart attack:
1. She can give him oxygen. And she does — she also intubates him, which is probably overkill, because there’s no evidence that he is having breathing difficulties. (And the nasogastric tube probably falls in that overkill category as well)
2. She can given him an aspirin, which has surprisingly powerful anti-platelet activity (and more platelets = more clot). Chewing the aspirin is best to get in into the bloodstream quickly.
3. She can give him nitroglycerin, which widens the blood vessels and lowers the blood pressure.
4. She can give him some painkillers. A little IV Morphine is usually recommended for heart attacks — because it also acts as vasodilator and antianxiety agent — but she could certainly give him some pain relieving pills.

Finally, Night Nurse should also place him on a heart monitor and be prepared to defibrillate because it is not uncommon to see nasty and potentially fatal arrhythmias occur with heart attacks (and to her credit, she does place him on a heart monitor).

All in all, a rather unexciting way to start the season. Though, to give the writers credit, they are just starting what seem to be several intriguing plotlines.

The Plot: The episode starts out with head on collision between two cars: a silver one and a black one. A wounded man stumbles out the silver car and runs down the street. He hides in a nearby apartment building and kills man who tries to help him. He then uses a strange machine to change himself into an exact replica of man he killed.

The black car is identified as Agent Dunham’s, but she is nowhere to be found and the evidence suggests no one was in the car at all. Peter and Walter arrive on scene and find a junior FBI Agent Jessup in charge. Walter jimmies the lock of the car open and looks around. As he leaves the car, it suddenly turns on and Agent Dunham comes crashing through the windshield and onto the road. She is rushed to the ER in critical condition. The doctors do everything they can, but Olivia remains in a coma (or maybe brain dead, the writers can’t make up their mind). Later that night, Peter comes in to sit by her, and Dunham suddenly regains consciousness and shouts a line of Greek at him. She has no memory of what happened other than she met with someone somewhere and there is something important she has to do or everyone will suffer.

Peter, Walter, and Agent Jessup team up to track down the driver of the silver car who they determined was purposefully trying to hit her car. Finding a body that matches the driver of the car, only more decomposed than it should have been, they bring it to Walter’s lab for autopsy. The examination reminds Walter of an old experiment he did (what doesn’t?), and he plays a tape of an old ESP project. The subject of the experiment warns of a soldier from another world who has the ability to shapechange, just like the one they are facing now. Belatedly, Peter and Agent Jessup realize the soldier still means to kill Olivia, so they rush to the hospital. Meanwhile, the soldier has killed and taken the appearance of Dunham’s nurse; he tries to weasel some information from her, but when he is unsuccessful, he starts to suffocate her. A couple of bullets from Agent Jessup send the nurse running but Charlie manages to catch her. There are some more gunshots, and when Peter and Agent Jessup arrive, Agent Francis is standing over the nurse’s dead body. Agent Dunham is safe and the soldier from the other world is dead — but is that that what really happened?

1. They Canceled ER, Didn’t They?
A sloppy ER/hospital scene.
“Possible brain herniation” — that’s a secondary diagnosis. What’s causing the brain to herniate? She’s probably bleeding inside the skull from the trauma, which in turn forces the brain down.
Pupils non-reactive — but are they dilated or fixed?
Blood pressure 180/20. Can one really measure of diastolic pressure of 20, particularly in an ambulance? 160 is quite a wide pulse pressure.
Instead of telling the EMTs to “prep her” when she is coding, how about actually doing something about it — like starting CPR?

2. Brain Death or Coma?
Olivia’s sister implies they are going to take Olivia off life support in the morning. What life support is that? Her heart is beating and she is breathing on her own. This isn’t brain death; it’s a coma. There is nothing to stop.

3. It’s All Greek to Me
For the record, here’s what Agent Dunham said: Einai kalytero anthropo apo ton patera toy

4. Eye See You
You can hear the cardiac monitor speeding up, but yet her heart rate on the machine remains the same at 72, a normal reading. While a beta-blocker would lower the heart rate, her heart’s not going fast enough to need one — and you risk dropping the pulse too low.

5. Silent Lividity
A short time after a person dies, their red blood cells settle to the lower parts of the body since there is no longer a working heart to pump them around. This results is a purplish discoloration of the skin which is known as livor mortis, or lividity. It starts at about 1-2 hours, and reaches its maximum at 6-12 hours. It persists after that, but becomes masked by other changes of decomposition. So all it could really tell Agent Jessup was that the victim had been dead around 6-12 hours; nothing to indicate he couldn’t have been in a car accident the day before.

6. Unpalatable
I think they’re confusing the palates. The soldier seemed to be putting the nail-plate directly behind the teeth, which is the hard palate not the soft palate (which is father back in your mouth than you think: feel the roof of your mouth all the way back until it switches from hard to soft).

7. Her Father Wasn’t in Intelligence, Was He?
It takes Agent Jessup several hours after they learn that they are dealing with an enemy soldier to suddenly realize that he is still going to try to kill Agent Dunham? I see she has the making to be just as incompetent an investigator as Dunham herself was last season.

UPDATE: I forgot to mention the “cocktail” Walter mixed to help him sleep. Sleep, hell, that concoction would knock out an elephant! It contained Valium (diazepam, an antianxiety drug with strong muscle relaxant and sedative properties), Haldol (haloperidol, a classic antipsychotic drug which is also a strong tranquilizer), Seconal (secobarbital, a barbiturate and another strong sedative), and lorazepam (Ativan, another drug from the Valium class). Unless he has developed one heck of a tolerance for these drugs, Walter should have been asleep for the rest of the show, if not the entire season.

Though it introduced a new hero, as well as a spooky new villain, the episode was rather “meh”. The medicine was pretty bad, but I’ll give them credit for the typewriter scene, which was cool. The Fringe Doomsday Clock remains where it ended last season, five minutes ’til midnight.

You’re sitting quietly at home reading when the doorbell rings. You open it to discover that, sadly, it’s not a Girl Scout selling cookies, but instead an attack by fiendish fire-apes!

What is your best course of action?

A: Ignore them and return to reading Marvel Apes — they must be a figment of your imagination.
B: Two words: barbecue ribs.
C: Call Jane Goodall and complain.
D: Turn the water hose on them.
E: Distract them with a bananas.

Click on the letter of your choice to see if your answer was correct

scene from Thrilling Comics #25

Useful bits of medical knowledge I’ve gleaned from Jack Kirby:

There was once a time when a doctor could start a raging fire — and nobody considered it out of the ordinary.

Medicines used to be really, really dangerous.

Scene from The Demon #13, written and penciled by the aforementioned Jack Kirby, where the doctor is question is Baron Von Evilstein — and really, with a name like that, your life’s plan is pretty much already laid out for you.

Blackest Night #1
by Geoff Johns and Ivan Reis

I know it’s just a typo, but still, it’s funny.

As far as I can tell, Damage either means:

Uncanny X-Men #512
Matt Fraction, writer
Yanick Paquette, penciler

Beast and his team of scientists have traveled back in time to the San Francisco of 1906 looking for Nicola and Catherine Bradley. They find Catherine just in time to rescue her from an attack by goons from the Hellfire Club — immediately afterward, Catherine Bradley suffers some significant vaginal bleeding. The doctor who examines her diagnoses her with placenta previa and places her on bedrest.

Placenta previa occurs when the placenta, instead of its normal location along the side or top of the uterus, implants along the bottom of the uterus, covering up the opening to the birth canal. It is a fairly common cause of vaginal bleeding during later pregnancy, but is very, very rare in the first trimester (the first three months of pregnancy).

More common causes of first trimester bleeding include implantation bleeding, miscarriage or threatened miscarriage, or an ectopic pregnancy. Trauma can play a role as well, as can non-uterine causes of vaginal bleeding.

There is nothing a physician or mother can do to cure placenta previa. Minimizing the recurrence of bleeding from the previa is wise, so that is why bed rest is recommended. Luckily, most placenta previa resolve by themselves — as the uterus grows during pregnancy, it pulls the placenta up higher. For a placenta previa discovered during the second trimester, there is a 90% chance it will resolve by the delivery date.

Currently, a cesarean (c-section) is the preferred method in the United States for delivering the baby when there is placenta previa. If c-section is not an option — for instance, in certain more remote parts of the world, or at the turn of the 20th century — the baby can be delivered vaginally, but it is a bloody mess. While there is a risk the mother may die due to placenta previa, it is the baby who faces the greatest risk of death. Currently in the United States, the maternal mortality rate from placenta previa is 0.03% (I don’t have the data, but I suspect the risk was several orders of magnitude larger in 1906).

Mike mentioned the Popeye and Environmental Careers comic a few days ago, but it’s not the only career PSA comic featuring the spinach loving sailor. In fact, King Features published fifteen different “Career Educational Comics” in the early ’70s. Sadly, the only one I own is Popeye and Public Service Careers, so that’s going to be this week’s public service comic.

Popeye and Public Service Careers features Popeye and Olive Oyl (both strangely eloquent, if not downright loquacious) telling readers about different careers available for them. The comic is clearly written for the high school student planning for their future. The educational requirements, from high school diploma to an advanced degree, are spelled out explicitly for each career, as are the benefits including vacation, pay, insurance, and retirement. As you would expect from a comic from 1972, there is more than a little implicit sexism in the comic (for example, no female firefighters or college professors, and no male nurses or elementary school teachers).

It’s a hefty comic, 32 pages, that goes into detail on an impressive variety of “public service careers.” It’s a long list of occupations (and I’d argue that calling a few of them “public service” is really stretching the term): police officers, firemen, sanitation workers, civil service workers, public health nurses, sanitarians (environmental engineers, food inspectors, etc), public utility workers, elementary school teachers, secondary school teacher, college professors, librarians, postal workers, lawyers (no, really — lawyers are “public service”), clergymen, city managers, and members of the military.

Tags: comics psa popeye olive oyl public service

Even before her revelation that she herself is a vampire, Spitfire’s history has been rife with vampiric shenanigans. Her origin revolves around a vampire bite and subsequent transfusion with android blood. Her son became a vampire and fathered a child on Baroness Blood before she killed him and the rest of her vampire followers by exposing them to sunlight¹.

That all brings us to New Invaders #5, where Spitfire has been captured by Baroness Blood. The Baroness explains that she needs Spitfire’s blood to keep her son — Spitfire’s grandson — alive. She goes on the explain that while the vampire bite/android blood gave Spitfire her powers, it caused an inherited degenerative blood disorder in her son², a disorder that was then passed on to his son³. The only way to keep the Baroness’s child alive is to regularly feed it Spitfire’s blood. Thus the Baroness has captured Spitfire and has her tied to a gurney (and continually transfused with blood⁴) so she can provide sustenance for junior whenever he wants it⁵.

The Baroness’s other plan is to feed her vampire lackeys⁶ some of her blood so that they will gain immunity to sunlight. Though unlike her, their immunity will only last for a few days. Still, that’s enough for them to wreak havoc across England. The Baroness also feeds her vampires some of Spitfire’s blood, though the reason for this is never explained – well, other than allowing the good guys a deus ex machina ending⁷.

Notes:
1. Not only did the Baroness clearly skip the leadership lectures of vampire school, but she never read the Evil Overlord list. (This all takes place in the first Union Jack mini-series.)

2. Apparently the vampire bite and/or android blood caused a deleterious mutation in Spitfire’s germ line cells, which is interesting because by that time in her life, her eggs had already formed. So either the blood disease was not related to the vampire/android blood, or they somehow mutated already formed cells.

3. It looks to be an autosomal dominant mutation, which means that a single copy of the mutated gene is enough to cause the disease (so it’s not a disease where the normal gene is simply not working — because that generally means both copies of the gene must be abnormal to see a negative effect — but instead one where the mutated version of the protein is actively causing the disease). This still doesn’t explain how Spitfire’s blood would keep the disease in remission. Maybe her mutated blood cells counteract the abnormal ones in the baby?

4. I’ve mentioned this before, but it bears repeating: why is an English vampire based in England using blood from the American Red Cross?

5. For a three to sixth month old baby, Johnny sure has a mouthful of teeth. I’m guessing vampire babies teeth a lot earlier than human babies.

6.The Baroness’s new lackeys that is, since she killed all of her previous ones. This is why you should always do some research on a prospective employer before signing on the dotted line.

7. The Human Torch (the android one) realizes that since the vampires drank Spitfire’s blood, they also have his blood in their system, thus he uses his powers to ignite his blood in the vampires, causing them all to burst into flame. Sound familiar? He just did the same thing to Ultron’s LMDs in the Avengers/Invaders series.

	In 1995, Warner Brothers and the American Red Cross published a disaster preparedness educational comic featuring the Warner brothers (and sister) called Animaniacs: Welcome to Emergency World. The “emergency World” of the title is an amusement park ride the brothers (and sister) persuade the unfortunate Dr. Scratchansniff to take them on. The ride tours a variety of disaster sites, with the Warner brothers (and sister) providing commentary along the way. As is to be expected, poor Dr. Scratchansniff takes the brunt of the ride, and anything than go wrong, does go wrong — to him at least.
This is a good PSA comic, if a little busy at times. The Warner brothers (and sister) as well as Dr. Scratchansniff are well-written and perfectly in character. There are no stupid characters here: everyone knows what to do and not to do — there is no ONISGS. The writing is humorous, though not as funny as your average Animaniacs episode — still, that makes this comic far funnier than any other PSA comic. Topics covered include stranger danger, seatbelts, winter storms, thunderstorms, lightning, tornadoes, hurricanes, floods, earthquakes, and fire. Nowadays, this would be a twelve-issue limited series. More PSAs Tags: comics psa animaniacs disasters fire tornado

A good season finale for Fringe. Lots of mysteries were tied up, or at least explained, but enough were left for next season to explore.

The Plot: Nina Sharp has been shot by David Robert Jones and is rushed into surgery. Agent Dunham and her team review the surveillance tapes and notices that Jones did something to Sharp’s bionic arm. After she recovers from surgery, she tells them that he stole an extremely powerful power cell that had been hidden there. Sharp tells Dunham that Jones was once an employee and protégé of William Bell, and he was fired for reasons she refuses to articulate. She goes on to tell Dunham that Jones is hunting for Bell so he can kill him. If Dunham can stop Jones, though, Nina will guarantee her a meeting with the elusive Bell. Nina goes on to explain that Bell is currently living in an alternate dimension, and Jones is trying to travel to that dimension to pursue him. Pulling all the “x-files” the FBI has, Dunham is able to come up with a pattern to the “Pattern” which points to Reiden Lake as the epicenter.

Meanwhile, Jones has set up a strange machine in a New York City street. It emits a high pitched whine, and then open a shimmering doorway into another dimension. A truck comes barreling through, but is cut in half when the unstable doorway closes. Jones later tries the same trick on a soccer field, but this time an unfortunate player is cut in half. He heads to Reiden Lake to try a third time.

Over in Massachusetts, Walter has gone missing. Peter tracks him to an old beach home the family owns. Digging through various boxes, Walter finds what the Observer sent him to locate: a machine that plugs dimensional holes. He and Peter head for Reiden Lake, because Walter tells Peter that’s where he opened the first doorway.

Dunham’s team meets up with the Bishops, and together they confront Jones. He has opened his doorway and is about to go through when Dunham shoots him, again and again. He shrugs off the bullets, explaining that while the radiation from the teleporter may be slowly killing him, in the meantime, it has made him more than human. He finally enters the doorway, but Peter uses Walter’s machine to shut the gate, cutting Jones in half and killing him.

As the episode ends, Walter stands tearfully over a grave labeled “Peter Bishop, 1978-1985″ — so the Peter we know must be the Peter from the alternate dimension. Olivia finds herself transported to the alternate world where she meets with William Bell in his office in one of the towers of the World Trade Center.

1. I’m As Shocked As You
The medicine in the emergency room scene was pretty spot on, so no complaints from me there.

2. It Keeps Going and Going and Going
I like the way Jones was being particularly careful with the energy cell, like it was on the verge of exploding. Meanwhile, Nina had just schlepped it around in her arm, swinging it this way and that, not careful at all.

3. Flight 19, Where Are You?
“The Pattern” works best when it is all fictional. Trying to work in the Bermuda Triangle just cheapens it for me — especially as all good skeptics know, there is no real mystery there at all.

4. A Little Dry
I’d expect more blood out of people cut in half.

5. You Must Learn To Govern Your Passions; They Will Be Your Undoing
There is little Leonard Nimoy can’t add a touch of class gravitas too — well, except this (and this).
Actually, I was expecting more from him. It sounded like he was on the verge of cracking himself up.

A good episode. I liked that it actually answered some questions, which was frankly more than I expected. Of course, there’s still a bunch left for next year. Anyway, it was a good episode — good enough to move the clock back to 11:55

A rather unexciting episode of Fringe overall, despite several clever plot concepts. Definitely a “sum of the whole is less than the parts” week.

The Plot: A young woman is desperately trying to get to a hospital when she suddenly catches fire and explodes. Agent Dunham and her team are called in to investigate. Through dental records, they are able to identify her as Susan Pratt, a 29 year-old toll booth attendant. They search her apartment and find a large check made out by a mysterious lawyer, a lawyer whose office seems hurriedly deserted. Walter initially suspects spontaneous human combustion, and then deduces that Susan was a pyrokinetic (think Firestarter) who could not control her own powers.

Meanwhile, Agent Dunham is having recurrent hallucinations. Walter tells her that she is experiencing déjà vu, which he explains are visions of an alternate reality. The next time Dunham has one of the hallucinations, she investigates and discovers that in this reality, Susan had a twin sister Nancy. Sure enough, in our reality there is a twin sister too, and Olivia’s team rushes to Nancy’s apartment, but she has been kidnapped. Luckily, Peter has invented a machine that can pull sounds from an apartment window which was melted during the kidnapping. Uncovering the sound of a phone dialing, Olivia is able to trace a call made to Sanford Harris’ phone (if you can’t remember, Sanford Harris is the new a**hole boss at the FBI who took over earlier in the season). She and Charlie track Harris to a warehouse where he and the lawyer have locked up Nancy and are experimenting on her. In the final confrontation, Nancy is rescued and Harris burned alive by her pyrokinesis.

The episode ends with a variety of short scenes: Olivia confronts Walter about the experiments he and Walter Bell performed on her and other children, Nina visits Broyle to discuss the reappearance of the Observer, Walter discovers the missing original ZFT manifesto just as the Observer walks in and tells him it is time to go, and Nina is shot by masked men in her apartment building.

1. Walter’s Reality, Quite Different From My Reality
A myth is an unverified fact? I’m sure Zeus would be happy to know he’s factual, merely unverified.

2. Again and Again
That is an interesting explanation for déjà vu. Just saying.
Would Robert Frost approve?

3. Too Close a Look
There are so many things wrong with Peter’s electron microscope/Geiger counter/mp3 player. Here are just a few:
Electron microscope samples have to be specially prepared.
At electron microscope level, there would be so many natural grooves and bumps in the surface of the glass that it would have tremendous background noise. Even an LP or CD at that level of detail would have so many imperfections it would be hard to hear the actual sound.
A flash fried window captured that much sound?
Peter was somehow able to reproduce the sound perfectly down to the exact voices and tones of a dialing phone?

4. Irony
I had to laugh when Walter told Olivia she was a good investigator — she’s anything but. For instance, she missed the entire closet full of gray clothes and the check from a mysterious lawyer that all tie into the emotion spewing guy from episode 17.

5. Y Kant Olivia Read?
Olivia is a cornflake gal. Is that anything like a Cornflake Girl?

A plainly mediocre episode. Not bad enough to advance the clock, but not good enough to gain some time. (With just one episode left, it is extremely unlikely the Doomsday Clock will run out…this year at least. Fringe has been renewed, so I’ll continue the clock next year.)

Identify these first lines to famous (and possibly infamous) comics:
Hint: All are from first issues (or maybe a zero issue or two), or the beginning of a well-known storyline.

1. Coffee tastes like your dog took a leak in it.

2. Good evening Slumburg! You’re tuned in to the WSLM Listener Line and we’re tuned in to you!

3. It is because of the accursed Thor that I am exiled to this barren isle, ordered to remain here by Odin, king of the gods.

4. In the beginning there was only one, a single black infinitude…so cold and dark for so very long…that even the burning light was imperceptible. But the light grew, and the infinitude shuddered…and the darkness finally…screamed as much in pain as in relief. And in that instant a multiverse was born.

5. roaringraringracing haring home on the homestretch now and the wind in my ears as the sound of the crowd 200 on the speedo…210…215…220…and oh the sky runningspilling blue smoke everything moves so slow and I should have seen it the oil slick i should have saved it

6. Good evening London. It’s nine o’clock and this is the Voice of Fate broadcasting on 275 and 285 in the medium wave…it is the fifth of the eleventh, nineteen-ninety-seven.

7. Mad Hettie? We got it for you.

8. Good morning ladies and gentlemen. My name is Guy Gardner and I’m a Green Lantern. Correction, I’m the Green Lantern. None of the other jerks can hold a candle to me.

9. You are looking a the entrance to Fogwell’s Gym on New York’s lower west side! It is here that our story begins…a story different from any you have ever read before!

10. There is a city. A glorious and singular place. Old and yet pristine. Ornate and yet streamlined. A metropolis of now and then and never was.

11. For the love of Dallan, my Prince! The Acroyear Air Patrol dog our heels.

12. It’s raining in Washington tonight. Plump warm summer rain that covers the sidewalk with leopard spots. Downtown, elderly ladies carry there houseplants out to set them on the fire escapes, as if they were infirm relatives or boy kings.

13. The comet appeared out of nowhere, catching Earth’s early-warning systems off-guard. If it was a comet! Ground based radar tracked it down, losing it finally in the lower altitudes over West Virginia! A seismograph registered its impact in the Allegheny Mountains. Tomorrow somebody from the university will investigate — if there is a tomorrow. By then it may already be too late!

14. Man. I am Metron. Have no fear. Here is knowledge.

15. Sales of the book are around 300,000. Good, not great. Good enough to get this editorship — still low enough to need it. The “Crimewatch” section. Christ, what a title. Why is everything “watch” around here?

16. I don’t belong. Not here. Not now. I have to get back there. The bet was rigged, he made me believe. Now there’s darkness in my soul. I want to die…again.

I’m out of town this weekend, so I’ll post the answers — if there are any unanswered ones remaining — on Monday.

With the 2009 NASCAR season just starting¹, I thought it was about time to finally get around to looking at the NASCAR Heroes Free Comic Day issue² from last year.

The story takes place shortly after the third issue of the comic³, but the scene shifts from the race track to a movie set. It’s the best issue of the series yet, probably because the racetrack is left behind⁴ — but with a slightly different ending, it could have been even better.

The director of the Zoom Speedster movie is in trouble. He has gone through three different lead actors because the set is haunted by a headless ghost — and not just any ghost, but the ghost of a racecar driver. In desperation, the director calls Jimmy Dash and asks him to play the role of Zoom Speedster. Dash agrees and when he asks why the previous stars quit, the director and his staff claim to have no idea.

The first day on the set goes well even though Dash encounters the ghost. His friends are scared, but Dash tells them that he doesn’t believe in ghosts. The next day, the ghost kidnaps the lead actress and in order to rescue her, Dash has to race him. It’s an eye pleasing — if unrealistic race — including vertical loops, flaming rings, alligators, and games of chicken at over 150 miles per hour⁵. In the end, Dash wins and the ghost mysteriously disappears. It’s not a happy ending though, as Dash is fired from the movie for wrecking the set.

The story is set up an awful lot like an episode of Scooby Doo, and there are many of the familiar characters and situations: a confident skeptical hero, cowardly friends, a mysterious ghost, and authority figures who know more than they’re letting on. There’s an important part of Scooby Doo that the writers of this story forgot though: the reveal at the end. That was always the best part of Scooby Doo.

As far as I can tell, this was the last issue of the comic distributed through standard comic retail channels. There have been two more issues released by Starbridge Media Group — and available at their site — but they don’t appear to have had distribution through Diamond⁶. Issue #4 appears to be this same comic with a slightly different cover, and issue #5 purports to start a new story arc⁷.

Previous NASCAR posts: Review of NASCAR Heroes #1 Review of NASCAR Heroes #2 Review of NASCAR Heroes #3 A History of Comics and NASCAR

Tags: comics nascar nascar heroes daytona

With the upcoming film, Warner Brothers has been busy preparing an avalanche of Watchmen merchandise. Among the t-shirts, action figures, mugs, video games, mad-libs, thongs, and pogs, these little beauties almost slipped by unnoticed. Which is a shame, because nothing says “I Love You” better than a Watchmen Valentine.

Previous Comic Book Valentines:
♥Legion of Super-Heroes (2008)
♥Legion of Super-Heroes (2007)
♥Legion of Super-Heroes (2006)
♥Spider-Man
♥The Legion of Doom
♥The X-Men

I notice the Invincible Chris had a similar inspiration.

Tags: comics watchmen valentines rorschach dr manhattan ozymandias

Three days left until Christmas, and the second super-hero cover in a row. Today’s cover comes straight from Gotham City, where the Riddler seems to have fallen victim to (or more likely, perpetrated) that most feared of Yuletide disasters: the Christmas tree fire.

The Batman and Robin Adventures #3 (DC Comics, December 1995)

Click on the cover for larger view

3 Days until Christmas!

This year’s Comic Book Cover Advent Calendar (so far).
One year ago, the cover was Geeksville #3.
Two years ago, the cover was Archie’s Christmas Stocking #3.
Three years ago, the cover was Batman: The Long Halloween #3.
Four years ago, the cover was The Goon #3
Don’t miss Yet Another Comic Blog’s annual advent calendar

Tonight’s episode of House was fairly light on actual medicine, focusing more on the personal aspects. Though there wasn’t much, for the most part, the medicine was well done.

Stewart is a thirty-five year old man with severe agoraphobia — he has not left his house since a mugging seven years before. Cameron stopped by and helped him with a case of the flu the previous year, and it is brought to her attention that he has had several days of a crushing headache as well as 3 seizures in the past 2 days; she in turn brings it to House’s attention. The initial concerns are a bleed, a clot, a tumor, a metabolic disease, or an infection (though they also mention vasculitis, which doesn’t fit in any of those categories). Since he refuses to leave the house, the team has to diagnose him with whatever they can bring to his house. The preliminary plan is to run an EEG while inducing a seizure to see if that will suggest where the problem in the brain is located. While Cameron runs that test, the rest of the team will search the house for toxins. At the end of the day, both the search of the house and the attempt to cause a seizure are fruitless.

House now decides to induce a seizure his own way, by bringing the outside world to Stewart. He pretends Stewart’s house is up for foreclosure and brings a passel of potential buyers through the house and into Stewart’s bedroom. Stewart immediately reacts, but the EEG reveals it’s not a seizure; instead he’s having severe abdominal pain caused by a partial small bowel obstruction (diagnosed by portable x-ray). Atrial fibrillation and Crohn’s Disease are mentioned as possible causes. House thinks surgery is the best option, but Stewart still refuses to leave his home. So they tell him that they will perform the surgery at his house, but plan on sneaking him to the hospital for the actual surgery, then returning him home before he awakens. Cuddy learns of the plan and insists that Stewart remain in the hospital for recovery; House agrees. Cameron decides it would be best to let Stewart know of the plan and wakes him from anesthesia to tell him that he’ll have to stay at the hospital. Surprising no one (except maybe Cameron) this causes him to freak out, and not only does he decide leave the hospital before having the surgery, but he gets a lawyer involved.

Cuddy responds by kicking Cameron, House, and Chase off the case, but since when has that stopped them? House has Cameron try some lactulose (a potent laxative) on Stewart, but his symptoms worsen. House now decides that they’re going to have to proceed with surgery, and actually perform it at Stewart’s house. Taub is roped into the job. The bowel obstruction is relieved and a bowel biopsy obtained, but not before there’s a little accident involving cautery, bowel gas, and fire. The biopsy shows flattened villi (tiny finger-like projections from the inner lining of the small intestine), which suggests Whipple’s Disease (a rare gastrointestinal infection), so House starts Stewart on antibiotics.

Stewart’s symptoms don’t improve, and in fact they worsen: he begins to develop numbness of his legs. The differential diagnosis now consists of porphyria, amyloidosis, and celiac sprue (an autoimmune disease caused by exposure to the wheat protein glutein in certain individuals), with sprue the most likely. This can be diagnosed by a blood test, but House prefers to feed Stewart wheat so that his symptoms will worsen and he’ll voluntarily decide to come to the hospital. He stops by Stewart’s house late at night to check on him, and Stewart happens to go into cardiac arrest at that moment. House views this as a chance to admit him to the hospital (it being an emergency and all), but Cameron shocks his heart back into a normal — albeit dangerously slow — rhythm. Taub sets up an external pacemaker to control the heart beat. The differential now consists of lymphoma or a toxic exposure, possibly organophosphates (a common chemical in insecticides). House then discovers that Stewart is something of a neatnik, and cleans his bathtub frequently with ammonia and bleach, which when combined, release chlorine gas. Could his symptoms all be due to chlorine gas poisoning? Stewart is started on steroids and sodium bicarbonate, but his symptoms continue to worsen. During a conversation with Cameron, House deduces that Stewart’s symptoms are not caused by chlorine gas, but instead all due to lead poisoning. When he was shot during the mugging several years before, the bullet split and some of the fragments remained in Stewart, embedded in the hip bone. As these slowly dissolved, the lead was enough to cause his symptoms. House quickly, and brutally, removes the fragments, and Cameron starts him on chelation.

Major complaints are in red, minor in blue, nit-picking in green:

Defribillation is not the treatment for a flatline. In fact, it is thought to make things worse (How can it be worse than a flatline, you ask? By making it even harder to get a normal rhythm back.)

Stewart suffered a cardiac arrest, not a heart attack. The two terms are not interchangeable.

House told the ambulance it was PEA (pulseless electrical activity), but the heart monitor showed a flatline, not PEA. Anyway, you don’t defibrillate PEA either.

I find it hard to believe that bullet fragments significant enough to cause Stewart’s symptoms would be missed on the x-ray. Hint: the hip should have no bright white spots on the x-ray. I also find it quite a stretch that bullet fragments in for seven years could be removed so easily.

Chlorine gas is extremely irritating (watery eyes, cough, sore throat), and would be hard for him to miss being exposed.

Why did Stewart need a jugular line?

Surgery is not first line for partial small bowel obstruction.

Wouldn’t Stewart be suspicious that there was no anesthetist or anesthesiologist? And once again, no eye protection during the surgery.

There’s no way Kutner made it though medical school without assisting in surgery. A large part of the third year is spent doing just what Kutner said he didn’t know how to do: retracting and keeping the field bloodless.

The medical mystery itself was rather pedestrian (for House, anyway), it was just the restrictions that made it challenging — I give it a C+. The final solution fit well, but was it ever mentioned before the final reveal that Stewart had been shot? I give it an A-. The medicine actually followed a more-or-less logical progression this week, though shocking a flatline is big mistake in my book, no knocks the score down to a B-. The soap opera aspects were all well done, particularly the Chase/Cameron aspect: another A-.

Last week’s House review
A list of all prior House reviews

Some interesting points in a couple of throwaway lines by Dr Mid-Nite in the recent Terra #1.

I. “Regular physicians don’t know how to store and maintain metahuman blood.”
I had not realized that metahuman blood required any different storage than normal blood, and I don’t recall this little tidbit having been mentioned before (so I guess that makes me just a “regular doctor”).
It raises some questions:

• Does metahuman blood require special care because it’s more fragile?
• By metahuman, does Mid-Nite mean any super-hero’s blood (including aliens, magical beings, etc), or specifically those with the metagene?
• Can metahumans donate blood to other metahumans? Or only to themselves? Or maybe to other metahumans with a similar power set*?

II. Dr. Mid-Nite then makes a somewhat wordy and not-entirely clear statement about transfusions, which seems to imply that metahumans essentially have a different blood type than non-metahumans.

There are over two-dozen different human blood type proteins. Most of these are minor proteins and don’t have much, if any, affect on medical care. However, there are two that are very important: the ABO and Rhesus (Rh) proteins; these are the two that make up the commonly understood definition of blood type (e.g. A+, O-, AB-, etc.). If there is a transfusion reaction due to blood cell compatibility, it will be because of a mismatch in one of these proteins.

It could be that the “blood type” that Dr. Mid-Nite refers to is one of the minor blood type proteins. In that case, the “blood type” is more of academic interest, and doesn’t affect medical care. On the other hand, Mid-Nite’s specifically mentions transfusions, which makes me think it is more similar to the ABO or Rh system, and that makes me wonder why it has never been mentioned before.

• Wouldn’t it be relatively easy to test for these blood cell proteins to determine if someone is metahuman, as opposed to testing for the gene, which seems to be the current technique?

*This similar-powers-required-for-transfusion idea has surfaced the most often in Jay Faerber’s corner of the Image universe. First, there was Firebird-lite donating blood to Firebird, (though admittedly they’re related), and then more recently in Noble Causes, when the team went looking for individuals with ice powers to provide blood for the injured Frost.

This transfusion comes from a Zatara story published in Action Comics #17 (October, 1939). For those unfamiliar with the character, Zatara was a magician who found himself involved in a variety of adventures. He had quite the sense of style, and was never without his top hat, even in the most extreme situations. He is the father of Zatanna, a former member of the Justice League, who shares his powers, if not his sense of style.

While on a boat to Europe for his annual vacation, Zatara encounters two old friends of his: Beth Jordan and her husband John. A short time later, strange characters try to grab Beth, but Zatara saves her. A few days after that, at dinner in a Paris café, another attempt is made — but once again Zatara saves the day (in this case by turning the assailant into a statue — which Zatara then uses to decorate his apartment. I told you Zatara had style.). The third time, the enemies have wised up and several of them jump and hogtie Zatara while other kidnap Beth and her husband.

The mysterious assailants load Beth and John on a boat for Africa. Remember the part where I said the bad guys had wised up? It seems I spoke too soon, as the villains also load Zatara on the same boat. Zatara decides not to escape, but to play along and see who is behind the kidnapping. Once the boat arrives in Africa, the trio are loaded on a plane and flown deep into the heart of the continent — to the fabled lost city of Ophir.

The Jordans are dragged before the ancient Queen Setapa, ruler of Ophir, who reveals her secret: she is an ancient sorceress originally from Atlantis who had been kept young through magic elixirs. But now her blood is so old the potions no longer work. She has decided that she needs new blood, and has kidnapped Beth Jordan because “the blood of the ancient race” runs in her veins.

John is chained in the dungeon and Zatara hoisted over a giant fire while Beth is hustled off to an operating room where her blood is transfused into the Queen. As predicted, the transfusion restores Setapa’s youth, but Beth is left a shrunken old woman.

Zatara escapes the Queen’s death trap, regains his top hat, and rescues John. Together they rescue Beth. Zatara then confronts Setapa in a magic duel. In the end, Zatara’s magic proves stronger: Beth’s youth is restored and the Queen once again becomes old and wizened. She vows revenge, but Zatara just blows it off as he and the Jordans leave Ophir.

A couple of thoughts on the transfusion seen in this story:

• Not only does the transfusion restore her youth, but it seems to change Setapa’s ethnicity as well. I think I’ll leave that for others to explain.
• Was the transfusion just of Beth’s blood into Setapa, or was Setapa’s blood also transfused into Beth? I think it must be the latter, for how else can you explain Beth’s mysterious aging? If just loss of her own blood caused Beth to age, I’d hate to be there when she accidentally cut her finger — or every 28 days for that matter.

Other Comic Book Transfusions

After gaining infamy for its lurid horror comics, EC Comics tried to rehabilitate its image by releasing its “New Direction” of wholesome comics. These included titles such as Valor, Aces High, and Impact as well as the medical comics M.D. and Psychoanalysis. As the name suggests, in Psychoanalysis the reader follows an unnamed pipe-smoking psychiatrist as he attempts to analyze and cure his patients.

Previous “analysis” of Psychoanalysis issues one, two, and three

For his first appointment, the psychiatrist sees Freddy Carter. Freddy is a fifteen year old who was initially brought for counseling after being caught stealing. The doctor deduced that the theft, along with Freddy’s asthma and poor grades, are really just desperate cries for attention. His parents are constantly sparring with each other — figuratively at least — with Freddy as the battleground.

The subject of this particular session is Freddy’s recent report card. Freddy is failing math and science — the classes important to his father — but doing well in English and history — classes important to his mother. In retaliation, Freddy’s father has grounded him and cut off his allowance. In addition, he has stopped giving any money to his wife other than for groceries, and he fired the maid. After talking with Freddy for several minutes, the doctor goes out to talk to Freddy’s parents who are upset that Freddy isn’t cured yet. The doctor points out that as long as the two of them are fighting, Freddy will never be cured because they each desire a different outcome. The doctor convinces the two of them that they each need psychiatric counseling for the good of their marriage and for Freddy’s sake. They both agree, and the doctor trades a single paying patient for two.

The last portion of the comic shows two sessions with Mark Stone, an unhappy screen writer. Mark has many difficulties, including problems with women, resentment towards his own success, and longstanding issues with his parents. This time, he is angry the psychiatrist because feels that he has become overly dependent on him. The doctor is able to get Mark to calm down, and then has him describe a recent dream. After hearing the dream, the doctor tells Mark that he is not mad at him, the psychiatrist, per se, but instead angry at authority figures in general — which goes back to his anger towards his father. The doctor is also able to deduce that Mark has a deep-seated fear of being abandoned, which brings out his feelings towards his mother. This has come to the surface because of the doctor’s upcoming vacation.

At a later session, Mark has once again started to experience the severe panic attacks and anxiety symptoms that brought him to the doctor in the first place. They started just a few days after Mark and the psychiatrist agreed that Mark had made remarkable progress and could cut back on his sessions. It doesn’t take a genius — or a board certified psychiatrist — to realize that this is nothing more than a subconscious reaction on Mark’s part. He is uncomfortable with the idea of cutting back on the counseling, so he recreates the symptoms that necessitated the visits in the first place. The psychiatrist is able to get Mark to realize the root of the problem, and once again Mark agrees that he doesn’t need many more sessions. This is probably a good thing as this was the final issue of Psychoanalysis.

Previous Flashback Weeks

After World War II ended and the Invaders disbanded, Spitfire retired and resumed her normal life as Jacqueline Falsworth. Her super-speed powers slowly faded, and over time she became a wife, mother, and then a widow. She appeared in the occasional comic book, generally as an elderly woman recalling her lost hero days. Her most notable cameo was probably in Captain American #253-254 which introduced the third, and current, Union Jack. Then John Byrne’s Namor the Sub-Mariner series came along, and in it, he revisited some of the foes the Invaders fought.

In issues #11 and 12, Master Man and Warrior Woman (the Nazi versions of Captain America) were reborn using some of the Human Torch’s blood (good stuff, that android blood). Namor, who was visiting Germany at the time, tried to stop them but was captured. His cousin Namorita flew off to get help and, ending up in England, encountered Jacqueline Crichton (nee Falsworth). She recruited Union Jack and the three of them headed off to Germany to rescue Namor and the Human Torch.

In the end, Master Man, Warrior Woman, their neo-Nazi gang, and the German scientist who had resurrected them were all defeated, but Jacqueline was gravely wounded in the battle. To save her life, the Human Torch hooked her and himself up to the German transfusion machine, and once more, transfused his blood into Jacqueline. Just like before, the Torch’s blood saved her life and (re-)awakened her speed powers. But it did more this time: it de-aged her back to age 16. (I don’t know if Spitfire has continued to age from 16, as she certainly appears older than that in recent comics, or if the powers-that-be decided that a 16 year-old Spitfire was a little too Lolita, so decided she was just better off as a twenty-something). Some technobabble (courtesy of John Byrne and Hank Pym) was used to explain this all away, but it wasn’t even very good technobabble as the writer seems to give up halfway through.

Spitfire was a super-speedster who first appeared in the pages of The Invaders, a 1970s comic that chronicled the adventures of a team of super-heroes during World War II. In the past few years, she has been seen in Captain America and the Union Jack mini-series. More recently, she has been appearing in Captain Britain and M.I. 13. Her origin story takes place in 1942.

During the events of The Invaders #9, Jacqueline Falsworth was attacked by the vampire Baron Blood — who also just happened to be her uncle, long thought deceased. He drained her blood in order to turn her into a vampire, in part to get revenge on the Falsworth family, but also because he wanted an undead consort¹. The Invaders arrived in time to stop Baron Blood, but Jacqueline had lost a tremendous amount of blood and was in grave danger. She was rushed to the nearest hospital in Invaders #11 ².

The doctors hurried Jacqueline to surgery and were amazed that she sustained that much blood loss from such tiny wounds³. Testing reveals that she has a strange substance in her blood that constantly changed her blood type. This makes transfusion a challenge, and the head doctor laments that Jacqueline cannot receive blood transfusions of any type, even type O⁴.

The Human Torch⁵ enters the operating room and volunteers his own blood; he tells the doctors that he is a true universal donor⁶. The doctors immediately agree⁷ and hook the Torch up to the transfusion equipment.

Jacqueline survives despite her tremendous blood loss, thanks to the incredible amount of blood donated by the Human Torch⁸. Other than merely saving her life, the Human Torch’s android blood somehow combined with the vampire proteins of Baron Blood that were already in her system to grant her super speed⁹, powers she used to become the super-heroine Spitfire.

NOTES:
1. I know vampire stories are supposed to represent some “forbidden” component of sexuality, but your own niece as a consort? That’s just creepy.
2. It didn’t really take 2 issues for the Invaders to find a hospital — there was an intervening fill-in reprint issue.
3. If I were a vampire, I would bite the neck vertically, along the blood vessels, not horizontally where you’re guaranteed to miss with at least one of your fangs.
4. Blood type is based on which proteins are present on the membrane of person’s red blood cells. Type A has A proteins, Type B has B proteins, Type AB has A and B proteins, and Type O has neither A nor B proteins. For Jacqueline’s blood to keep switching blood types would mean that these proteins must be constantly changing, and the body simply does not work that fast. Even if her blood type were constantly switching, she should still be able to receive a transfusion of Type O blood . It could be that there is some vampire antibody in her system that reacts against any human blood type — that makes the most sense, though it doesn’t really “change” her blood type.

5. This is the original Human Torch, an android. Not the Human Torch who is a member of the Fantastic Four.
6. The last time the Human Torch gave blood, it was described as “live fire” and required asbestos tubing. I guess he’s mellowed out since then.
7. Apparently, the doctors just take his word for it since they don’t run any tests on him.
8. If the Human Torch’s blood is that good, and he can produce so much of it, surely he could save more lives by donating it to blood blanks than by acting as a super-hero. There are other super-heroes to fill in on the Invaders, but only one blood producing android.
9. For those keeping track at home, like all previous super power giving transfusions, this was a whole blood transfusion (as much as androids have “whole blood”).

All images are from Invaders #11 by Roy Thomas and Frank Robbins

Other Comic Book Transfusions

As they hand you a citation for illegal fireworks possession, just remember “The Policeman is Your Friend.”

(I’ve got nothing against policeman; I respect the job they’re doing. However, I am annoyed at some of my idiot sown-the-street neighbors who continue to shoot off bottle rockets all night long. First, Independence Day was three days ago. Second, they’re illegal in this state. Third, you’re waking up the baby. And fourth, I’m sick and tired of finding dozens of spent bottle rockets littering the neighborhood’s yards every morning).

Back to the PSA — I am wondering how Timmy managed to get himself locked in the grocery store. A town with residents like that certainly needs a nice — and patient — policeman.

Click on the image to the right for the full ad

This public service ad was provided to me by H, who found it in Adventure Comics #347. It can be found in other DC comics from August 1966 as well. The script is by Jack Schiff (like always) with art by Sheldon Moldoff.

More PSAs

Another subtext laden post, just from a different point of view this time.

Cub Reporter Jimmy Olsen is denied entrance to the Bearded Band — a mysterious club only open to men with beards — because he lacks a beard (well, he tried to sneak in with a fake beard, but it was quickly exposed). As he slinks away, a strange bearded man accosts him and offers him a bottle of special beard tonic. Jimmy chugs the strange brew¹ and starts growing a thick beard almost immediately².

Jimmy attends the next Beard Band meeting and discovers that he’s been tricked. The beard tonic is real — but it is far too strong. His beard will keep growing, five or six feet per day, unless he receives the antidote. And the club members will only provide the antidote if Jimmy makes several public appearances across town, proudly displaying his new beard³.

Jimmy tries his best to uphold his end of the bargain, but he keeps getting his beard cut off through no fault of his own⁴ — simply bad luck. Angry, the club members destroy the antidote so that Jimmy will always be bearded. Then they proceed with “Operation Whiskers” — their plan to brew a huge amount of the beard tonic and pour it in Metropolis’s water supply. Thanks to more bad luck from Jimmy, their plan backfires and the beard tonic ends up turning into the very antidote they had earlier destroyed. Unaware of this, they all take a swig of the concoction and everyone — including Jimmy — suddenly loses their beards⁵. Superman appears and destroys the equipment so the members of the club can never brew their tonic again⁶. No more beards for the Beard Band (or Jimmy Olsen).

Notes:
1. Did Jimmy ever meet a potion, tonic, or medicine he didn’t sample?
2. It’s impressive the way the tonic only affects facial hair, and not scalp hair or other body hair. Of course, that’s probably a good thing or Jimmy would have ended up looking like Cousin Itt.
3. The Beard Band are under the impression that these public appearances will increase the popularity of beards. Why? He’s just a bowtie-wearing cub reporter at one of several newspapers in town. Why would men of distinction follow his example? If anything, I think it would make men who already had beards want to shave them off.
4. For the record, his beard is sliced off with a sickle, burned off while cooking lunch, shot off during a robbery, and cut off and used as a means of escape from quicksand — which is apparently common around Metropolis.
5. It’s not really an “antidote” if it caused everyone to lose their beards; more of a facial depilatory.
6. Or at least until they buy more equipment.

Source: Superman’s Pal, Jimmy Olsen #23, “Jimmy Olsen, The Bearded Boy,” by Otto Binder and Curt Swan. It’s actually quite a fun story, one of the better Jimmy Olsen/mad science tales.

X-Men: Legacy #209
Mike Carey, writer
Scot Eaton, penciler

After being shot in the head at the end of the Messiah X storyline, Charles Xavier lies comatose. He is captured by Exodus, the leader of the Acolytes. Realizing that he does not have the skill to heal Xavier, Exodus brings in Erik Lehnsherr, the ex-mutant formerly known as Magneto, to restore the professor’s consciousness. Eric is assisted by the woman/machine hybrid Karima Shapander, the Omega Prime Sentinel.

Sentinel: Effectively, I’m creating a local super-conductor within the professor’s nerve tissue. It will lower neural trigger points exponentially — encourage his body to make connections…

Sentinel’s plan is, to put it succinctly, a very bad idea.

First, it’s clear that she has no idea what she’s talking about, because the resting potential of cells is measured in volts, not amps — which are completely different units of measurement. Amps measure current, but potential difference (i.e. voltage) is what is important here. For the record, the average resting potential of nerve cell is -70mV.

Lowering the threshold of nerve cells like Sentinel describes will not “encourage the brain to make connections,” instead it will cause thousands — if not millions — of neurons (nerve cells) to fire off all at once. We doctors have a name for this phenomenon; it’s called a seizure. It’s going to do nothing to make Xavier healthy; in fact, in his weakened state, a seizure just might kill him.

Thanks to Travis K. for bringing this scene to my attention. Tomorrow I’ll take a look at a different scene in the same comic (the Magneto-burns-out-the-eye-and-brain-with-a-laser scene)

Despite being a small town, Smallville seems to have a surprising number of big city amenities. For instance, this PSA features the Smallville Teen-Age Club, which unfortunately catches fire. Luckily, Superboy is there to put out the fire — as well as lecture the teen-agers about fires.

Click on the image to the right for the full ad.

Being cynical, if were one of the teens, I’d be a little suspicious of Superboy. There’s mysterious fire damage and Superboy — with his heat vision — just happens to be there? That has Kryptonian-related arson written all over it.

Hey cats, dig the crazy use of teen slang: “Let the whole town get hep to the rules”

Why are there quotation marks around “junk” and why are they keeping it in closets (when everyone knows junk belongs in the trunk)?

More PSAs

Tags: comics psa superboy fire smallville

Blue Beetle #1 (1986, by Wein and Cullins)
A hint for the colorist: don’t color IVs red automatically. Giving blood, especially in the field, is very rare. Most commonly a saline solution is used, so the tubing and IV solution should be clear.
As for this specific situation, dehydration is common in fire victims, so IV fluid rehydration is very important. However, short of major trauma, blood wouldn’t be given (and even if it were, it would be at the hospital, not at the fire site).

(Yes, I am picking on a 20 year old comic, but this is still a very common error in today’s comics. I just grabbed Blue Beetle #1 because it was close at hand).

---

Azrael #7 (1995, by O’Neil and Kitson)

Just a little something extra for all you Azrael fans, building off of my previous post. Yep, that’s a little fetal Azrael in a jar full of ape amniotic fluid. I think that this certainly qualifies as one of the more disturbing concepts in post-Code comics.

Another of the “Verb — It’s What You Do” PSAs that are meant to encourage kids to become active. One of the least inspired PSA campaigns of recent memory, though both major comic companies did join in. Marvel Comics at least had new art for their Verb PSAs; DC, on the other hand, just took a stock image and slapped a few captions on it. At least this Teen Titans one is better than the Justice League one.

Click on the image above for the full ad.

I do wonder about the captions though. Robin, Cyborg, and Beast Boy all have captions that suggest they want to play with others. That’s good and fits the tone of the PSA campaign. Starfire’s caption is much more violent — she wants to destroy “opponents.” And I’m not sure how Raven’s “making new rules” is conducive to either good game play or friendship (”Raven, you can’t just skip over Boardwalk!” “Yes I can, I just mystically created a rule that says so!”)

More PSAs

Tags: comics psa justice league verb

Black Adam #4 “The Dark Age, part 4″
Peter Tomasi, writer
Doug Mahnke, penciler

Wounded by gunfire, Black Adam arrives in a veterinary clinic and demands that the doctor and her assistant treat his wounds. As part of his treatment, Adam required a blood transfusion, so both the doctor and her assistant donate their own blood.

Doctor: Relax. You’ve been out for over 2 hours.
Adam: Two hours?
Doctor: And I’d appreciate it if you waited till you left to pop open all my sutures, ’cause we’re all out of blood.
Adam: Whose blood?
Doctor: Luckily for you — and us — you’re an O positive. My assistant and I did what we needed to do.

There are two ways of interpreting what the doctor has said:

1. Black Adam and the doctor and her assistant are all O+. This is the only explanation that actually works, but I don’t think it’s what the author had in mind. First, it’s statistically unlikely. While O positive is the most common blood type, the chance for three random people to all have it is only 5%.¹ Second, the conversation doesn’t really support this interpretation. The doctor specifically says Adam has O+, not “luckily we were all O+“.

OR

2. The doctor (and the author) have a misunderstanding of type O blood as it relates to transfusions. They are confusing “universal donor” with “universal recipient.” If this interpretation is correct, the doctor is making a couple of mistakes:
First, O negative is the universal donor, not O+. Second, Black Adam is receiving blood, not donating, and an entirely different set of rules apply. There is an inverse relationship between donating and receiving. Blood types that are good for donations are poor recipients, and vice versa. For instance, AB+ can only donate to other AB+, but they can receive blood from any blood type (they are the “universal recipient”); conversely, O-, the “universal donor”, can only receive other O- blood. When Black Adam develops a transfusion reaction, we’ll know why.

To add one final wrinkle, if you read the comic, you’ll notice that Black Adam has received a whole blood transfusion (which is extremely rare in real world medicine. Usually only red blood cells are used). This means that not only are red blood cells transfused, but plasma as well. So not only do you have to worry about Adam’s plasma reacting with the donated red blood cells, but you also have to worry about the donated plasma reacting with Adam’s red blood cells. In this case, he should only receive a transfusion from an identical blood type — which in a roundabout way brings us back to the first answer.⁴

Other Comic Book Transfusions

Notes:
¹I’m going with the distribution of O+ in the US population (38%). Obviously, this wouldn’t apply to Black Adam, but I’ve yet to find any reliable data on the distribution of Quraci blood types, let alone Quraci blood types from a millennium ago — and 38% seems to be a good median value.
²Technically they’re glycoproteins (a structure composed of proteins and sugar molecules), not just proteins, but I’m trying to keep it as simple as possible (though that seems to be a moot point now. For more information, Wikipedia has quite a good explanation of blood types and transfusions).
³I have not mentioned the Rhesus factor (Rh, the positive or negative part of the blood type) yet because it is a little more confusing. Red-blood-cell-wise, it works in the same manner as the ABO blood types. People with a positive blood type have the Rh protein on the surface of their blood cells while those with negative blood type lack this protein. However, there is a slight difference when it comes to the plasma. Unlike the ABO blood types, people with Rh-negative blood will not generally develop anti-Rh antibodies unless they’ve been exposed to Rh-positive blood (generally from a previous transfusion or childbirth).
⁴None of this answers the key question of why a veterinarian has the proper supplies to type human blood.

Tags: comics medicine transfusion black adam veterinarian

This episode brings an end to the applicant competition, with satisfying results. The medicine tried to be clever, but succeeded mostly in being nebulous and vague (and fairly confusing).

Jimmy Quidd is a 38 year-old punk rock singer. He is hard-drinking, like drugs and fights, and has a generally poor attitude and outlook on life. He also has a severe bloody cough that causes him to pass out in the alley behind a punk rock club. He is brought to the ER for evaluation where House admits him to his service because he feels Jimmy will make a challenging case for his applicants.

Jimmy has a long list of symptoms including fever, arthralgia (joint pain), hyperinflated lungs, fatigue, anemia, low blood oxygen levels, melena (blood in his stool) and hematuria (blood in his urine). He also shows signs of hard living including a history of multiple traumas, cutting, and a drug screen that’s positive for alcohol, cocaine, opiates, and amphetamines. House suggests drug use, trauma, and “being a loser” as possible explanations for his symptoms. The team suggests endocarditis, hemorrhagic lesions of the lungs and gut, bronchiolitis obliterans (inflammatory obstruction of the bronchioles in the lungs), and bacterial meningitis.

Amber starts out by testing her suggestion of bronchiolitis obliterans. Her plan is to perform a bronchoscopy (look down the lungs with a flexible fiberoptic camera), but Jimmy sneaks a cigarette while on a bathroom break — unfortunately, he’s on oxygen, which leads to a nice little explosion (though fires are much more common since oxygen is more of an accelerant than explosive), giving him smoke inhalation making a bronchoscopy useless. Now Amber wants to perform an open lung biopsy. While prepping him for the biopsy, Foreman realizes that he is wearing all his Nicotine patches at once and overdosing on nicotine. Amber and Kutner notice blood clotting in his fingers, meaning that Jimmy has DIC (disseminated intravascular coagulation), but the cause of the DIC is unclear. Amber suggests drug impurities, but Dr. 13 suggests malaria. This intrigues House, and she now takes over the case.

Meanwhile, Jimmy has disappeared. They manage to track him down in Pediatrics, entertaining the children. He passes out and is returned to his room. The malaria tests come back negative, but other tests show that “bad blood fragments” are causing the DIC. Kutner suggests blood exposure during sex as a cause for the fragments, and 13 mentions that the malaria medication may be causing the destruction of the blood cells (but he had DIC before he was started on the antimalarials). House points out what really should be obvious: that Jimmy has been shooting up drugs with dirty needles, and this has been getting other people’s blood into his system, which explains the blood fragments and the DIC.

The new differential includes inhalant abuse, bleeding problems, and infection. Kutner suggests chronic pulmonary embolism and takes over the case. House performs an echocardiogram on Jimmy. He finds some masses near the heart, but the study is hard to read because Jimmy was moving around too much. There is no evidence of emboli, so Taub suggests Jimmy may have an abnormal blood vessel wrapping around his trachea. He wants to check an MRA, but that will be affected by patient movement as well. Instead, the team elects to do exploratory surgery of the heart (do I really have to mention what a bad idea and how ridiculously unrealistic this is?). The surgery reveals no abnormal vessels. The masses House saw on the echo were enlarged lymph nodes. About this time, the patient starts to crash with plummeting blood pressure so he is given two units of blood and started on Dopamine (a drug used to raise the blood pressure in critically ill patients).

House threatens to fire Kutner and 13, and under pressure, they suggest ARDS (Adult Rrespiratory Distress Syndrome), anaphylactic shock, or an immune overreaction from impurities in the drugs he’s been using. House starts Jimmy on Dimercaprol to treat presumptive heavy metal poisoning from contaminated drugs, but this is not successful. House then threatens Amber and Taub with their jobs, and then the whole team, but they can’t come up with any coherent ideas. House takes their four “wrong” ideas, and combines them into a single diagnosis: measles. He thinks Jimmy has measles that his drug use made him susceptible to. His immune system is overreacting in response to the measles and causing his symptoms. House wants to perform a brain biopsy. Cuddy refuses, pointing out that Jimmy would be having neurological symptoms if House were correct. Amber mentions that he has been showing some abnormal swallowing, and it could be a partial complex seizure. House then tries — and succeeds — to induce a seizure in Jimmy (a generalized tonic-clonic seizure, though, different from a partial complex seizure). This is enough proof to allow him to get his brain biopsy which shows measles, so Jimmy is started on corticosteroids.

In the end, House fired Amber for being unable to lose. He then fires 13 and keeps on Kutner and Taub. It turns out his is all a ploy — Cuddy confronts him and tells him that he can’’t fire both women and insists that he rehire 13. House acquiesces, and as Cuddy leaves the room she realizes that had been House’s plan all along.

---

The medicine was almost too vague this week, throwing around poorly defined phrases such as “impurities”, “bad blood”, and “immune over-reaction”.

I did have some concerns:

How did Jimmy get all those Nicotine patches? A nurse will only give one a day — and make sure the old one is removed.

The heart surgery made my brain hurt, the logic behind it was that bad. You can’t sedate the patient for an ultrasound or MRA, but you can place him under general anesthesia and cut his chest open?

Once again, the show is being vague about symptoms — was it a bloody cough, or bloody vomit? It’s referred to as both during the episode, though the differential focused on the lungs not the gastrointestinal tract.

Exactly what test is performed to show “bad blood fragments”? House already pointed out that Jimmy had schistocytes (fragmented red blood cells) as proof that he had DIC, now the writers are invoking them as the cause of the DIC as well as the result?

Why was House performing an echocardiogram? Pulmonary emboli don’t show up on ultrasound (you need a ventilation/perfusion scan or a spiral CT), and furthermore, pulmonary emboli don’t generally come from the heart — they come from the deep veins of the leg.

If the measles infection/immune overreaction was in the brain, something should have shown up on the lumbar puncture (LP) which was performed earlier in the show.

If Jimmy had been having a partial complex seizure then he would have lost consciousness (that’s what the word “complex” means in the name), not just had strange swallowing. Partial complex seizures are very different from the tonic-clonic seizure House induced later.

---

The medical mystery was strictly average this week. Nothing very dramatic or eye catching (and whatever happened to all the great “inside the body” animations?), just an average C. I’m still trying to make sense of the final solution (his immune system was so weak it allowed a measles infection, but still strong enough to cause an autoimmune reaction?) — I think the measles part was clever, but the autoimmune aspect not so much. I’ll split the difference and give it a B-. The medicine was just too vague. There was a lot of hand waving and terms that didn’t really mean anything. It earns a C+. The soap opera was the best part, but still not as good as a few of the earlier episodes, and earns a B+.

The previous House review
A list of all prior House reviews

Challenge scores can be found at the post immediately beneath this one (or click here)

Tags: television medicine house punk rock bronchiolitis obliterans malaria pulmonary embolism measles

Despite the use of a magician, the medical mystery on this week’s House was only a little better than average. The final solution though was unexpected and much awaited. It’s a shame the medicine was so wrong.

Cole (i.e Big Love) and Kutner (i.e. Kumar) are at a magician’s show when Flynn, the magician, performs his version of Houdini’s famous Chinese Water Torture trick. In it, the magician has his arms and legs shackled and is suspended upside down in a large glass box of water. Flynn struggles for a minute, then stops moving entirely. Cole quickly realizes something has gone wrong when blood starts oozing from Flynn’s mouth. Kutner has Flynn admitted to the hospital, telling the team that his heart stopped and he lost consciousness as soon as he hit the water. House is unimpressed and believes that Flynn just screwed up the trick, but Kutner truly believes that something is wrong. House tells him to go ahead and work up the patient, but if he’s wrong and it is nothing interesting, then he’s fired.

Kutner performs standard and transesophageal echocardiograms (ultrasounds of the heart), but both are completely normal. In the meantime, Dr. 13 is questioning Flynn about his past medical history, but he has no cardiac history or symptoms at all. Kutner turns to Foreman for help, and he suggests taking a look at the lungs because low oxygen in the blood could have led to heart failure. He suggests an MRI. As Kutner starts the MRI, Flynn starts complaining of severe abdominal pain. On exam, Kutner and Dr. 13 note bruising on his flanks (Grey Turner’s sign) and deduce that Flynn is bleeding internally. He receives a transfusion of 3 units AB blood and is rushed to surgery to find the source of bleeding. The team’s list of diagnoses now consists of liver disease, Vitamin K deficiency (Vitamin K is important in blood clotting, so low K results in easier bleeding), and an intestinal infarction (a blockage in the blood supply to the intestines). House disagrees and he marches into the surgical suite; in addition to lacerations in the digestive tract and a shredded spleen, he finds a small metal handcuff key. Flynn had this key hidden (in either his mouth or esophagus) and was going to use it to escape the shackles, but he forgot about it and the strong magnetic field in the MRI pulled it through his intestines. House fires Kutner.

Later, House goes to talk to Flynn himself. Flynn insists that he is an excellent magician and did not screw up the trick. He thinks something else must be wrong. He performs a card trick that stumps House and then suddenly develops an uncontrollable nose bleed. This intrigues House (both the card trick and the bleeding). Kutner is rehired and the differential diagnosis now includes cocaine use and polyarteritis nodosa (an autoimmune disease of the arteries). House sends Kutner and Taub to search Flynn’s house while Amber and Cole biopsy the blood vessels around his heart. The biopsy is negative, but Taub finds rabbits at the magician’s home and suspects that Flynn has Tularemia. Antibiotics are started to treat the tularemia.

A short time later, we are told that Flynn has passed out, and an ultrasound “revealed bleeding around the heart” which was subsequently drained (sound like cardiac tamponade). Tularemia is the wrong diagnosis. Cole and Amber might have botched the biopsy, or Flynn could have a clotting disorder, DIC (disseminated intravascular coagulation — a life threatening condition where both uncontrolled clotting and bleeding are occurring), or cancer. An MRI is ordered. As Flynn enters the MRI, hetells Cole that he knows he will be dead by this time tomorrow. The MRI shows fluid in the lungs, no masses, and some damage from where the key ripped through his intestines. It also reveals bleeding in the kidney and thigh. Cole reports Flynn’s suspicion that he is going to die and tells House that he believes his “sense of impending doom” could be a symptom. Amber suggests adrenal disease, blood disease, or anaphylaxis. Kutner suspects it might be tainted blood from a bad transfusion. Foreman, looking at the labs, notices a high low level of immunoglobulins (antibody proteins) and suggests Amyloidosis. About this time, Flynn suffers a gran mal seizure. The team notices leg edema (swelling of the lower legs), and then he has another seizure and “flank pain” (but how could they tell since he said nothing about pain and never even grabbed his side?) Cole and Kutner report back that Flynn has developed kidney failure which led to low sodium and seizures. House continues to suspect amyloidosis, but Kutner is firm in his belief that it was a bad transfusion. House gives Kutner and 13 two hours to proved it was transfusion related — meanwhile the rest of the team will be obtaining a subcutaneous fat biopsy to look for amyloidosis. Kutner and 13 can find nothing, and the fat biopsy in inconclusive, but House decides to treat Flynn for amylodidosis anyway with a bone marrow transfusion. First though, he will need radiation therapy to kill all his current bone marrow. Foreman — using his speaking-for-Cuddy fiat powers won;t let House go through with the radiation treatment without more evidence. House, since he has blood type AB as well, suggests the team transfuse blood from the same 3 donors Flynn had into him and see if he develops any symptoms. The transfusion is performed and House develops a fever. He blows it off as a common reaction is someone like him who has had multiple transfusions, but the team is suspicious. They suggest a Pneumococcus or Pseudomonas infection. House disagrees and stands up but begins to feel faint and realizes that they’ve spiked his coffee with narcotics. He wakes up a short time later, strapped to a chair, as Dr. 13 is performing a liver biopsy. That biopsy, along with the kidney and lung biopsy they already obtained, were all negative. Amyloidosis seems to be the cause and Flynn is scheduled for radiation. In the middle of a conversation with Wilson, House has his Eureka! moment and realizes that Kutner was right. He asks Flynn what blood type he is and Flynn tells him “A.” That means that he received the wrong type of blood. House tells the team that the laboratory doesn’t actually test the patient’s cells for blood type, but instead they test for antibodies against other blood types. Flynn has an antibody he shouldn’t have, which made the lab think he was AB when he was really A. The reason for this extra antibody? Lupus, which along with the transfusion reaction explains all his symptoms.

---

Huntington’s Disease is a particularly nasty inherited neurological disease. Symptoms are progressive and include an abnormal gait, uncontrollable body movements, severe dementia, and emotional changes. It is especially heartbreaking because most people don’t realize they have it until they’ve already had kids, and by then half of those kids will have inherited the disease. Having a parent with Huntington’s means that you have a 50% chance of inheriting it and there’s nothing you can do about it. Huntington’s is incurable.

---

Lung MRIs are rarely obtained, and is not an appropriate choice here. A much better study would be a lung CT scan or a even a ventialation/perfusion scan (VQ scan) if looking for a pulmonary embolus. Of course, those tests don’t use powerful magnets and wouldn’t fit what the writers needed to happen.

When people are transfused in the hospital, they receive a “type and cross“. Their blood type is obtained and their blood is tested against the donor’s blood in the laboratory to make sure there aren’t any unexpected reactions (like Flynn had). This takes time — about 30 minutes — so in emergencies Type O- blood (the universal donor) is used while the crossmatch is obtained. Flynn would have received 3 units type O, not type AB.

Furthermore, House’s explanation of how Flynn got mis-typed as AB is horrendously wrong Blood typing is done on blood cells, not antibodies. Anti-A antibodies are added to one sample of a patient’s blood, and Anti-B antibodies to a second. If the patient has A or B proteins on his blood cells, one or both of samples should clot as the antibodies react with the proteins on the blood cells. If neither tube clots, then the patient has blood type O (neither A nor B proteins on the blood cells). If only the A tube clots, then the patient has type A; and if only the B tube, type B. If both tubes clot, the patient has type AB. (This page has a nice explanation of the tests, with pictures!)

Antibody tests on the plasma can be performed as well, but this is never the primary means of blood typing. Anyway, House has this backwards. People with Type AB blood have no antibodies against A or B (that’s what makes them the universal recipient). If Flynn had an extra antibody, then he would be misread as type O, not type AB.

Does this hospital not test for the Rh factor (the positive/negative aspect of blood type) on its patients? It hard to hear doctors doctors talking about ABO blood types without mention the Rh factor as well. In fact, Rh mismatches cause worse transfusion reactions than ABO mismatches.

Why would you slip a narcotic mickey to someone on chronic narcotics? How could you even begin to guess what dose to give him without killing him. Benzodiazepines (the Valium class of drugs) or a major tranquilizer like Haldol would be a better choice.

It was nice to see the tables turned on House and seeing him on the receiving end of unethical experiments, but 1) those biopsies carry substantial risks, 2) it was really to soon for “tainted blood” to affect the organs enough to see on biopsy, and 3) House’s liver with his chronic acetaminophen overdosing (i.e. Tylenol, one component of Vicodin, and a known irreversible cause of liver damage) is going to already screwed up on the biopsy, transfusion reaction or not.

---

I give the medical mystery a C+; it started out slow and built up speed, but still barely finished above average. The final solution was so close to fitting exactly, and dose explain most of his symptoms, so I’ll give it a B. The medicine was was artificial (the MRI and key) and wrong (the blood typing) and earns a D-. The soap opera was strong, probably my favorite of the year so far. I was cringing when House first suggested stealing Cuddy’s thong, but the way it led to collusion between unexpected parties was inspired. I give the soap opera a strong A.

The previous House review
A list of all prior House reviews

Challenge scores can be found at the post immediately beneath this one (or click here)

Tags: television medicine house cardiac arrest tularemia amyloidosis transfusion scleroderma lupus huntington’s disease

A mediocre episode tonight. There were several good ideas (the facial deformity, the documentary crew), but it never gelled into a good episode. The medicine was spotty and the soap opera focused too much on a few characters instead of spreading the wealth.

Kenny, a sixteen year-old boy with a prominent facial deformation has arrived at Princeton-Plainsboro Hospital for reconstructive surgery. A documentary team is trailing behind, filming everything. As Kenny is being prepped for the operation, his heart rate shoots up and he goes into ventricular fibrillation. This requires defibrillation and the placement of a pacing wire to get his heart beating normally again (a temporary external pacemaker is being used to restore a normal heart rhythm). He is admitted to House’s team for the work-up of his heart problem.

The initial differential diagnosis includes increased intracranial pressure, a congenital heart defect, or endocarditis. House dismisses all these. He has noticed some darkened skin under Kenny’s nose (identified as acanthosis nigricans) and suspects that he has been inhaling (”huffing”) Freon, which has damaged his heart. He orders a nuclear study (a test which uses a radioactive dye or marker) to look for scarring in the heart. The nuclear study is essentially negative, and Dr Taub (the plastic surgeon candidate) suggests that Kenny might have Toxoplasmosis and he wants to perform a lumbar puncture. House points out that Taub doesn’t really think that Kenny has toxoplasmosis, he just wants to do the lumbar puncture to check the intracranial pressure; Taub admits as much. House still thinks that Kenny has been doing drugs and orders an EP study (an electrophysiology study is one that uses tiny catheters to look for and treat abnormal rhythms in the heart). Dr. Taub starts the EP study, but stops when he determines that Kenny has never used drugs. About this time, Kenny starts coughing up blood.

The differential is now a Mallory-Weiss tear (a bleeding rip in the esophagus from prolonged coughing or vomiting), a nasal papilloma, a peptic ulcer, nasopharyngeal angiofibrosis, stomach cancer with paraneoplastic syndrome, or liver failure. An EGD is performed which shows no stomach cancer, but does show bleeding varices (distended veins of the esophagus), which go with liver failure.

Dr. Terzi suggests an autoimmune disease like Scleroderma, but is shot down. A mitochondrial disorder is suggested as well, and Dr. Taub continues to think that Kenny has increased intracranial pressure. His retinas are examined. They show no degeneration (said to be a sign of mitochondrial disease), but do show papilledema (a type of retinal swelling — a sign of increased intracranial pressure). When informed of this fact, House points out that Kenny’s skull deformity gives him an increased intracranial pressure and he’s lived with it all his life so House doesn’t think this is the problem. Instead, he suspects JRA (juvenile rheumatoid arthritis) and wants to start Kenny on steroids. There is a dust up between Taub and House and Cuddy ultimately gets involved. A head CT is obtained. House believes that is shows signs of JRA, while Taub thinks it shows something different. Cuddy sides with House and steroids are started. Taub is fired (but told not to leave).

Kenny shows some signs of improvement on the steroids, but House notices his little finger twitching and decides that he must be wrong and he does not have JRA. The team suggests Kenny may just be nervous about the operation. Dr. 13 suggests Lyme Disease but House points out that Kenny has no rash. Amber suggests Rheumatic Fever. Everyone else thinks that House was correct with the JRA and the steroids have it under control. The pacing wire is successfully removed and Kenny proceeds to surgery. Dr. 13 hangs around, concerned that House is right and something besides JRA is wrong. Looking closely, she realizes that Kenny does have a rash, it is just hidden by his deformity and hair. Shaving his hair reveals the classic erythema migrans rash of Lyme Disease.

---

The candidates (those that talked this week, anyway), all came up with some pretty good possible diagnoses. House, on the other hand, just seemed to randomly throw out diagnoses with little logic behind them

Lyme Disease seemed quite a stretch to me. You’ll notice they were quite vague about the time course because Kenny was exhibiting symptoms of both acute and chronic Lyme disease simultaneously. Only 60-80% of people with Lyme have the classic rash — so not finding it does not mean it can’t be Lyme Disease (but finding it almost guarantees it is). They never even mentioned ticks once.

Performing a lumbar puncture on someone with increased intracranial pressure can be very dangerous. The sudden release of pressure from the LP can lead part of the brainstem to herniate downwards, killing the patient or rendering them comatose. Getting a CT scan first is always a good idea (and admittedly there’s no suggestion that Taub would not have gotten a CT before doing the LP).

House’s reaction to the increased ICP was a little strange: it’s not an increased ICP, it’s not an increased ICP, oh, of course there’s an increased ICP but he’s always had it so it doesn’t matter. Why not just tell Taub that at the beginning and be done with it?

No joint pain in either JRA or Lyme Disease?

Did Kenny have bloody cough — as his symptoms suggested to me — or was it gastrointestinal bleeding? The differential focused entirely on the GI aspect, ignoring the pulmonary possibilities.

I can (almost) accept the Young Guns or candidates performing x-rays and CT scans, but not electrophysiology studies. They are very complex, and can be quite dangerous (one of my patients had one 2 weeks ago and his heart stopped twice during the test requiring defibrillation). It takes specialty training beyond regular cardiology to get certified, and no plastic surgeon is going to have those credentials.

Acanthosis nigricans looks nothing like Erythema Migrans and there’s no way you’d ever confuse the two. Acanthosis doesn’t show up on the face like that, either.

Was Foreman in the bathroom for the entire case? Nope, he was there, just so bland I forgot him.

---

The medical mystery just wasn’t that compelling this week and earns a mere C. The solution was a stretch, and House ruled it out earlier when he should have known better, so another C. The medicine overall was only average at best — the diagnoses were good, but then dismissed with little logic for House’s pet diagnoses. This also earns a C, for a medicine hat trick. The soap opera was mostly forgettable. Dr. Terzi seemed like an intriguing character last week, but you couldn’t have told that this week. Cuddy was mostly toothless. The spotlight on Dr Taub had promise, but neglected too many of the other more interesting candidates. The House/Wilson banter nearly salvaged the soap opera and brought it up to a B-.

The previous House review
A list of all prior House reviews

Challenge scores can be found at the post immediately beneath this one (or click here)

Tags: television medicine house lyme disease intracranial pressure jra ventricular fibrillation

Episode Title: In Which Addison Finds the Magic

A show primarily about marriages this week. Pete and his dead wife. Violet and her ex-husband. Naomi and Sam doing more of their infighting. And Addison whining. Plus more bad ethics. I expect this from Dr. House, it’s his shtick, but not from these doctors who are supposedly better and brighter.

Dr. Cooper Freedman
Cooper is brought to see a young girl who is blue. Not depressed, as he thought initially, but the patient actually has blue skin. He asks about dyes, inks, or any topical compounds that could have dyed her skin, but there have been no exposures. There was no other chemical exposure, by history. He ultimately decides that she has methemoglobinemia (an abundance of chemically-damaged hemoglobin in the blood) and treats her, correctly, with intravenous methylene blue. He in unsure what exposure lead to her developing the condition, but she responds to the medication. Over the next day or two, her skin turns blue again, as does the skin of her three younger sisters. One of the girls has a seizure as well. Cooper and the mother search the house, but can find no source of toxicity. He eventually talks the girls into letting him spend the day playing with them and they lead him to their “castle” – a neighbor’s old shed filled with leaking bags of the fertilizer ammonium nitrate. Nitrates are a known cause of methemoglobinemia and the girls are inhaling enough of the fumes to make themselves dizzy and their skin turn blue.
Methemoglobinemia is rare. There is an inherited form of the disease, but the girls have an acquired methemoglobinemia. It is treated with oxygen and 5 minutes of intravenous Methylene Blue followed by a saline flush (a big bag of blue IV fluid shouldn’t just be left hanging like it was in the episode).
Other possible causes of methemoglobinemia include certain older antibiotics, local anesthetics, nitrates, and metoclopramide (Reglan). There are a few unusual household chemicals that may cause it. Well water with a high nitrate content has been known to cause methemoglobinemia.
Inhalation of ammonium nitrate generally causes a nasty headache, cough, and sore throat — symptoms that were missing but would have helped narrow down the type and route of exposure.
I find it hard to believe that a parent who chose to stay at home to raise her kids is not going to notice her four kids regularly disappearing from the yard like that?

Dr. Addison Montgomery and Dr. Pete Finch
Addison has a newlywed couple as her patients who complain that they cannot have sex. Any attempt causes severe pain to the wife. Addison attempts an exam, but even that is too painful for the patient to endure. She diagnosis her with vaginismus. She tries muscle relaxants first, but they do not work. Next she tries trigger point injections combines with guided imagery. That works miraculously.
Vaginismus is a real condition, and difficult to treat. It is almost always psychological in nature.
The best treatment for vaginismus is a combination on counseling, special exercises, time, and understanding. It rarely resolves overnight.
I’ve never heard of muscle relaxants being used as a treatment. I can imagine that benzodiazepines like Valium might work, but more for their psychological effects than the physical ones.
If her problem is indeed caused by overly-sensitive nerves, then trigger point injection might work. Her issues seemed much more psychological to me, though, so I suspect Pete’s therapy did the most good.
For a “world renowned” surgeon, Addison has some lousy bedside manner.

Dr. Violet Turner and Dr. Sam Bennett
Violet has a patient named Doug who is unhappy in his marriage and wants a divorce, but is scared to tell his wife. After three years of therapy, she has finally convinced him to stand up to his wife and tell her what he wants. When he does, his wife’s nose starts to bleed uncontrollably and he brings her to the clinic for evaluation and treatment. Sam is able to control the nosebleed, but the patient’s labs show that she has a moderate anemia (low blood count).
A day or so later, the wife confronts Violet and she once again begins bleeding. Not just a nosebleed this time, but hemoptysis (coughing blood). She is admitted to the hospital and diagnosed with Wegener’s Granulomatosis, a chronic disease caused by inflammation of the blood vessels. After a confrontation with the hospital chief of staff, Sam discovers that the patient has known she has Wegener’s for at least 6 months and never bothered to tell the husband. He and Violet confront both the husband and his wife with the truth, but in the end Doug chooses to stay in his unhappy marriage.
There are good treatments for Wegener’s now, but it can still be a fatal disease. Relapses occur in about 50% of patients, and about 80% suffer some variety of long-term complication (deafness or kidney disease, most commonly). Survival rates vary, depending on the study, but around 75-80% can expect to live at least another 5-10 years with treatment.
No chief of staff is going to overrule an attending physician like that. It’s bad form and it’s not her job. Plus, it will drive doctors from the hospital. Hospitals like doctors, they make them money.
The confrontation in the end may have been within the letter of privacy laws, but clearly against the intent. You don’t threaten patients into sharing information with each other. The wife should have refused to tell them anything and reminded Violet that she had been fired as her husband’s therapist, so her husband would not leave the room with her. (OK, ideally, she should have told her husband the truth in the first place, but how likely was that to happen?).

Tags: television medicine private practice methemoglobinemia nitrates vaginismus wegener’s

Another episode of House that focuses more on the applicants (or hirelings, if you prefer) and soap opera rather than the medicine. That’s not necessarily a bad thing, and it was an enjoyable episode soap opera wise. I just wish it had better medicine. Spoilers below!

The main patient tonight is Stark, a 37 y/o man with Spinal Muscular Atrophy, an incurable and progressive neurological disease that weakens muscles. He is wheelchair bound and assisted by his dog Hoover. While crossing the street, Stark faints without warning and is nearly hit by a car. He is admitted to the hospital to find out why he had the fainting spell.

House divides the ten remaining applicants into two teams of five each: boys versus girls. The team that diagnoses Stark correctly wins and gets to remain. The losing team is fired. Everybody’s favorite alpha-female Amber wants to join the men’s team but they rebuff her.

Both teams initially consider that Stark may have picked up a bacterial infection from his dog Hoover, but discard the idea. The women’s team now decides that he must have become infected with Strongyloides (threadworm) on his recent trip to Thailand. They treat him with Ivermectin, an antihelminthic drug (i.e. an anti-worm drug). The men have no working diagnosis and want to run a full battery of tests on Stark’s hair, blood, and stool. During this conversation, it is revealed that Stark is also incredibly constipated. Amber manages to finagle her way onto the men’s team by convincing them to try xenodiagnosis — basically, have a bug bite the patient, and test the bug for any parasites that the patient may have (of course, this would only test for blood-borne parasites, not ones in the intestines or other organs). In the middle of the test, Stark starts choking and coughing.

The next morning, House reveals that the patient has suffered an aspiration, but is improving on oxygen and chest PT (though the patient is shown receiving a nebulizer. Aspiration pneumonia, a nasty type of pneumonia, would be a concern in this patient). House seems intrigued by the women’s diagnosis of Strongyloides and dismayed that the men have only managed to run test after test. He places the men’s team in the “penalty box” — making them sit in his office and not talk about the case while the women go about proving theirs. Their plan is to perform a tilt table test on Stark and try to induce a fainting spell. If the test is negative and there is no fainting, then their diagnosis and treatment must be right (but not necessarily, the tilt table test only reproduces certain types of syncope — and not the type the patient has — and/or he might be getting better for other reasons beside their treatment).

Amber and the guys have not given up. They want to know whether Stark’s choking is dysphagia (difficulty swallowing) or achalasia (an esophageal motility disorder). The old guy suggests paraganglioma — a tumor in the neck that presses against the vagal nerve, thus causing fainting, whenever the patient eats. The tilt table test is negative, seeming to confirm the women’s diagnosis and treatment, but Amber runs a CT on Stark anyway. No tumor is revealed, but she believes the results are consistent with scleroderma, a type of connective tissue disease that commonly affects the skin and esophagus. House disagrees and fires the men and Amber. She’s not done though, she talks Chase into running labs on the patient for her. She wants to run an anti-centromere antibody test, a blood test that is sensitive for scleroderma. When she draws the patient’s blood, it turns out to be green.

With this finding, House “rehires” the men’s team and Amber because the diagnosis he thought was right clearly is not. The plastic surgeon deduces that the blood is green because the contrast for the CT the patient had the day before has not been filtered out by the kidneys meaning that Stark has kidney failure. (Who runs a contrast CT on a hospitalized patient without checking kidney function first? That’s very sloppy medicine by Amber, even if she did run the test herself).

The differential is now a gram negative bacterial infection from his indwelling catheter versus scleroderma. House orders Stark to be started on Ampicillin and Gentamicin, two potent antibiotics, for the possible infection; he also orders skin and lymph node biopsies to look for scleroderma. Shortly, the team reveal that the antibiotics are having no effect (though it seems mighty quick to make that judgment) and the biopsies are negative. Or are they? House notices some black specks in the cervical lymph node biopsy and suspects that Stark has melanoma of the eye that has spread throughout the body He wants to remove the eye and manages to talk Cuddy into agreeing with the surgery. Before surgery, the applicants are performing a thoracentesis (draining the fluid from around Stark’s lungs) to make his breathing easier when they notice the fluid is clear. This is not consistent with fluid from a cancer, which tends to be cloudy and bloody. Stepping in after House’s injury (discussed below), Wilson and the team decide that Stark has Eosinophilic Pneumonia, and he is started on corticosteroids and cyclophosphamide (a potent immune suppressant and chemotherapy drug, that has been used for certain types Eosinophilc Pneumonia). The medication doesn’t help and Stark dies quickly and quietly, his faithful dog by his side. When the dog is revealed to be dead a few minutes later, House realizes that Hoover took the patient’s Invermectin (which is fatal to that breed of dog) instead of the patient. Thus, the women were right and the patient had Strongyloides all along, and died of an overwhelming threadworm infection.

While the team is treating Stark, House sees a patient in clinic who pulls out a knife and sticks it in the wall socket right in front of him. House manages to revive him and the patient admits that he was in a car accident a few days previous and experienced a near death experience. He reports that it was the happiest that he’s ever been and wants to replicate the experience. Later, when Wilson accuses House of not knowing for sure whether there is an afterlife or not, House decides to find out for himself, and sticks the patient’s knife in a wall socket (but not before paging Amber). She performs CPR and manages to revive him, though he suffered a burned hand and an extended loss of consciousness. Because of this, Wilson had to take over Stark’s case in the end.

Meanwhile, at a hospital across town, Foreman is running his own diagnostic team, only he is trying to make it friendlier and more supportive than House’s. They have a patient with fever, boggy lungs, and blurry vision who the antibiotics aren’t helping. The team diagnoses Apergillosis and starts the patient on Amphotericin B. It doesn’t help, and the patient now develops yellow gums, a sign of jaundice. Foreman believes that the patient has anaplastic large cell lymphoma, a rare and aggressive cancer. He wants to start treatment right away. His boss disagrees and feels that a severe infection is most likely. He has Foreman start a potent antibiotic. Foreman’s gut feeling gets the best of him and he stops the antibiotic and starts the cancer therapy. He is correct and saves the patient life, but his boss fires him for not following the guidelines and putting his gut feelings ahead of medicine.

Medically, the episode was rather limited — which is to be expected in a story with six patients and more than a dozen doctors. The ultimate solution was interesting and not expected. I’m not sure exactly how the Strongyloides led to fainting, unless it was a severe case of disseminated Strongyloides, and even then it’s a stretch. The women never confirmed, or even tested for, the diagnosis of Strongyloides. Stool samples are the most common test, but it can take up to seven, but there is a good blood test for the infection. Most experts recommend at least two doses of Ivermectin, if not more. The disease progressed remarkably rapidly, but then Stark was in a debilitated condition, and given immunosuppressants, which are a bad idea with disseminated Strongyloides. It’s not generally the physician’s responsibility to make sure the patient takes the medication (I’m not sure whose it is — at some point, you just have to assume the patient wants to get better and trust that he will take the medication). I’m also unclear why the dog ended up with medication. Did he eat it of his own accord (his name “Hoover” suggests this may be a possibility), or did Stark feed it to the dog? If it’s the former, why wouldn’t Stark tell someone that he didn’t get his medication?

Just because a tilt table test was negative does not prove the diagnosis of Strongyloides. Tilt tables are best for certain kinds of fainting — for instance, orthostatic hypotension that occurs when people stand up suddenly. When was the last time Stark stood up? It’s a poor choice of tests to begin with, and did they have a positive test before treatment to compare it to? It’s basically a post hoc ergo propter hoc error.

Finally, where did House get the idea that the suspected cancer cells must come from the eye because the eye is the only thing that drains to that lymph node? Lymph node drainage is a lot more complex than that. An eye may indeed drain to one lymph node, but it is not the only part of the body that drains there.

As for the clinic patient — I am not an electrician — but wouldn’t you need to complete the circuit, that is have metal in both parts of the socket, for the electricity to flow (assuming the hospital is grounded correctly)?

---

I give the medical mystery a C, as it was vague and not particularly unusual (fainting?). The final solution I give a B- because it was unexpected but should have been diagnosed and treated better. The medicine was uninspiring, and either team came close to convincing of their cases (and nor did House); it earns a C-. Once again, the soap opera was the best part, though — with the exception of Amber and Dr. 13 — the female characters were bland. Seeing Cameron and Chase was good (Cameron was easily manipulated, but Chase caught on — but still went for it), though I would have liked to see more depth in the Foreman scenes. Still, I give the soap opera an A.

The previous House review
A list of all prior House reviews
Tomorrow night I’ll be taking a look at the new ABC show Private Practice (Last week’s review can be found here)

Tags: television medicine house syncope spinal muscular atrophy strongyloides ivermectin scleroderma melanoma

A fun episode of House this week, and let me start by breathing a sigh of relief and realizing that medical school and residency could have been a lot worse, particularly if I had applied to work with House. Spoilers follow!

There was not all that much actual medicine in this episode because most of the time was spent on interpersonal issues between House and his multitude of job applicants, and between the applicants themselves. This was actually the best part of the show, though several of the applicants reminded me a little too much of some of my less-than-fondly-remembered medical school classmates.

---

Greta is an Air Force captain who is training to be an astronaut. While in the simulator, she experiences a sudden episode of synasthesia — a neurological condition where the senses get their wires crossed, and one can hear vision or taste sounds — and crashes. She wants to find and fix what is wrong with her, but doesn’t want NASA to know, so she offers House $50,000 to admit her and solve her case “off the books.”

House, meanwhile, has 40 applicants for his three underling positions. He presents Greta’s case to them but tells them that no records can be kept of her stay. Under questioning from the group, Greta reports that the symptoms are new and she’s never had similar episodes before. She has no psychiatric history and is on no medications of any kind. She does admit to doing a lot of flying as one student suspects that the prolonged immobility from flying has led her to develop deep vein thromboses (clots) of the legs, which are breaking apart and traveling through her circulatory system and a PFO (patent foramen ovale, an abnormal hole in the heart) and causing strokes, which caused her synasthesia. House orders an EEG, MRI, angiogram, and lumbar puncture, as well as a whole battery of lab tests. He also sends a trio of applicants to search her house.

The radiology studies are all normal, and the only significant blood abnormality is an elevated red blood cell count. The inspection of Greta’s apartment revealed a broken fireplace flu flue. The suspicion now is that she has developed carbon monoxide poisoning and she is placed in a hyperbaric chamber (a high pressure chamber that will drive the carbon monoxide out of her cells and replace it with oxygen). As she is getting set-up for the chamber, Greta develops tachycardia (an abnormally fast heart rate), tachypnea (an abnormally fast respiratory rate), low blood pressure, and passes out. The applicants start a code, providing CPR and code medications (but did they check a pulse before beginning CPR?). When the monitors show her to be in ventricular fibrillation, one of the applicants defibrillates her. It restores her to a normal heart rhythm, but also starts a fire in the oxygen-rich environment of the hyperbaric chamber. The fire is put out, and Greta is started on nitroglycerin and “blood thinners” (heparin, probably) for a suspected heart attack.

With symptoms now consisting of synasthesia, increased red blood cell count, and a heart attack, House throws the case to the applicants again. They suggest Takayasu’s Arteritis(inflammation of the aorta and other large arteries) and Whipple’s Disease (a rare bowel disease — which doesn’t seem to fit at all). An older applicant makes a good case for cardiomyopathy (a heart condition that leads to weakening of the heart muscle), and a transeosphageal echocardiogram is ordered (an echocardiogram that looks at the heart through the esophagus — it provides better images of certain parts of the heart, particularly the valves. Frankly, a regular echocardiogram should have been sufficient, but then we would have missed the reveal and character moment at the end). The echo reveals a structurally normal heart, but brief episodes of an irregular rhythm: atrial flutter. A thyroid problem is now the suspect, and a TRH stimulation test (an old and rarely used thyroid test) is ordered. As the test is administered, Greta’s heart rate and BP rise and she complains of feeling warm. She suffers another synasthesia episode as well as a psychotic break (or panic attack, depending on whom you listen to). She runs into a conference room and locks the door. She is persuaded to come out (threatened, really), and sedated — but not before Cuddy realizes something is going on.

The thyroid results were normal, so one of the applicants suggests a liver problem — more specifically: liver cancer with an associated paraneoplastic syndrome. The difficulty is that the Cuddy won’t let them run any more tests without the patient’s name on them, and the patient won’t allow her name to be used. House has to figure out how to diagnose Greta without running standard tests. An applicant suggests loading Greta with intravenous Vitamin D and placing her on a tanning bed (because Vitamin D requires sunlight to function effectively and is metabolized in the liver — but it would take a huge dose of Vitamin D to accomplish this ) while another suggests giving her tequila to see how much alcohol her liver can tolerate. Unsurprisingly, House goes with the tequila option. While House’s team is administering the test, Greta develops severe shortness of breath. She won’t let the team intubate her or give her oxygen because it will show up in the records. Listening to her lungs, House detects a mass and suspects she has lung cancer. Greta refuses a biopsy because it will leave a scar. One of the applicants, a plastic surgeon, suggests giving Greta a cosmetic procedure to explain away the scars, and performing a lung biopsy during the procedure. Reluctantly, Great agrees to a breast augmentation. The surgical lung examination reveals multiple cysts within her lungs. The diagnosis now includes Alveolar Hydadtid Disease (a parasitic disease caused by tiny tapeworms) and pulmonary Langerhans (a disease caused by a proliferation of a line of abnormal cells, in this case in the lungs), but none of them quite fit the case. Chase appears in the gallery and suggests Von Hipple-Lindau disease (a rare genetic disease that causes tumors and cysts to grow throughout the body) with a pheochromacytoma (a tumor that releases high levels of adrenalin and similar compounds, it can be associated with certain types of Von Hippel-Lindau). The Von Hippel-Lindau explains the masses and increased red blood cells, while the pheochromocytoma explains the cardiac and neurological symptoms. The cysts and tumors are removed, but Greta is cautioned that Von Hippel-Lindau is a genetic disease and they could recur at any time. House tells Greta that he has reported her situation to NASA, but it turns out that he is lying and he only told her that to stop the applicants from reporting it to NASA themselves. In the end he picks his applicants, confronts Cameron in the ER (where she now works), and accuses one of the applicants (correctly) of not being a doctor, but hires him anyway as an assistant.

---

The medicine was mostly sound, though the team was jumping from one rare, poorly-supported diagnosis to another (but I can see that happening with a bunch of young doctors trying to outdo each other). Have you noticed how I’m not complaining about everyone running their own tests this year, but instead I’m going to stat complaining everytime people are in a surgical procedure without eye protection — it’s an OSHA rule! So far, House is 0 for 2, and Private Practice and Grey’s Anatomy are 0 for 1.

This episode marks a return engagement for the pheochromocytoma. Let’s give it a hand!

I give the medical mystery a B+, it was interesting and the constraints placed on the diagnostic options made it a little more exciting. The final solution I give a C because it came out of nowhere. The medicine was decent, though there wasn’t as much as usual; it earns a B. The soap opera was the best part, particularly the interaction among the applicants — I liked the old guy and Kumar, but Amber was too underhanded for my taste — an A for the soap opera.

The previous House review
A list of all prior House reviews
Tomorrow night I’ll be taking a look at the new ABC show Private Practice (Last week’s review can be found here)

Tags: television medicine house synasthesia thyroid von hippel lindau

The first episode of House’s fourth season begins with — well, not a bang, but not a whimper, either — more of moderately exciting spectacle, like one of those fireworks that trickles down rather than explodes outward. In this episode, bereft of a team, House must solve a case on his own. Mostly.

There are definitely spoiler warnings ahead, especially for the ending, so don’t read if you haven’t seen the episode. Or if you do, don’t whine about it afterwards.

As the episode starts, a young woman named Megan is at work talking on the phone to her boyfriend, Ben. He is trying to persuade her to go to a movie that evening, but she declines, citing fatigue and sneezing. She tells him that she thinks she’s having hallucinations because the building seems to be shaking. There is a sudden roar as her office building collapses in a gas main explosion.

It’s now two days later. Megan is one of the few survivors of the explosion, but she is still very severely injured. She has been through multiple surgeries for fractures and burns. Cuddy consults House because Megan has been running a persistent fever despite being on antipyretics (fever reducing medication like acetaminophen or ibuprofen). She has also been lapsing in and out of consciousness. Cuddy wants to use this case as a goad to get House working with a team again, but he refuses. He cuts her a deal: if he can solve the case by himself that day, she will not bug him for a week.

House ropes a passing janitor into helping him. He describes the case to him in mechanical terms, and asks him what he would do. The two of them come up with several possible diagnoses: brain damage with hypothalamic dysfunction (which House discards because it would have shown up on the brain MRI she already had), infection (possible parasitic or fungal infection, admits House), or Lupus (the janitor’s grandmother had Lupus). House wants to break into Megan’s house, but the janitor refuses (or at least refuses for the amount of money House is offering him). In the end, House shanghais Wilson to help him search the house. They find a diary which reveals that Megan had a history of fatigue and feeling blue. From this, House infers that Megan has depression. He then makes the leap that she was on a certain kind of antidepressant (an MAO Inhibitor — a class of antidepressants used only rarely, if that, because safer more effective drugs are now available), that when combined with Demerol (a narcotic pain killer) she received in the ER, can cause Serotonin Syndrome, of which fever is one symptom (This is true, but there are other symptoms of Serotonin Syndrome which should have shown up as well. Serotonin Syndrome appears rapidly, and should have shown up within a few hours of receiving Demerol, and should have resolved by now, several days since she has had either antidepressants or Demerol.) House decides to place Megan on dialysis to remove the drugs from her system (not a common treatment for Serotonin Syndrome, but it has been used in severe cases). Her boyfriend insists that Megan was not depressed, seeing a psychiatrist, or on antidepressants, but House believes that Megan was just hiding it from him. He gets her mother to sign the consent.

After the dialysis she wakes up and confirms through blinking that she was seeing a psychiatrist and was on an MAO Inhibitor. She then develops ventricular tachycardia and slips into unconsciousness and cardiac arrest. Cuddy has to defibrillate her back into a normal rhythm.

House considers his deal with Cuddy done and himself the winner, but Cuddy disagrees. She wants him to figure out why Megan developed tachycardia. Endocarditis (an infection of the heart) is considered at first, but discarded because blood cultures were negative. Cuddy and House now consider that Megan may have cardiac damage from Crush Syndrome. Crush Syndrome occurs when a patient has been trapped under a heavy object, crushing part of their body and cutting off blood flow. The damage from the crush injury causes an increase in toxic chemicals in the affected parts of the body. When the patient is then released from the heavy object and blood flow resumes, these chemicals circulate throughout their body, causing a variety of serious problems (She’s been in the hospital for 3 days at this point, routine labs should have shown any Crush Syndrome by now; it’s not going to show up suddenly this late). House and Cuddy suspect the high potassium from the crush injury combined with “microvascular occlusion” have caused the heart problem, but luckily, this will show up on an echocardiogram. The echocardiogram is obtained, but it is completely normal. Taking the tachycardia (but normal echocardiogram), sweating, and fever into account, House now decides that Megan is suffering from delirium tremens (alcohol withdrawal). Her boyfriend again objects, saying that he would have noticed if she were an alcoholic. House ignores him and starts her on IV ethanol, which does correct her fever and tachycardia. In real life, IV alcohol is not the recommended treatment for delirium tremens because it doesn’t solve the dependency problem, just prolongs it. Plus, it can lead to electrolyte abnormalities (which Megan already has), gastritis, pancreatitis, and hepatitis. Benzodiazepines (such as Valium, Ativan, or Librium) are the treatment of choice.

When Cuddy visits Megan and her family, she realizes that Megan has been silently screaming in pain for the past 2 hours (but apparently the pain wasn’t enough to raise her blood pressure or heart rate noticeably). Labs show an elevated amylase and lipase, meaning that Megan has developed pancreatitis. The alcohol was the most likely cause for the pancreatitis, but there can be other causes as well. House obtains an MRI which shows a normal pancreas (when it should at least show pancreatitis). The MRI also shows an abnormality around the liver consistent with blood. Sure enough, Megan starts to bleed out both ends and is rushed to surgery with multiple sources of internal bleeding. Watching the surgery, House notices that Megan has an enlarged uterus. He enters the OR and takes a look, realizing that Megan has had a recent abortion. He then hypothesizes that she has been taking birth control pills, which when combined with the Warfarin (a blood thinner) she has been on since hip surgery (which would have been nice to know earlier), led to her bleeding (The effect, if any, oral contraceptives have on Warfarin is not clear. The combination probably does slightly increase the risk of bleeding, so House may be right. Of course, every other medication mentioned in this episode — including MAO inhibitors, ethanol, cephalosporins, tamoxifen, and antipyretics — also increase the chance of bleeding while on Warfarin, only moreso). House puts her on Tamoxifen to block the effects of the birth control pills (this is not a recommended use of Tamoxifen). This revelation that Megan had an abortion is too much for her boyfriend, who leaves the hospital, but he return later to sit by her side.

The bleeding improves, but now Megan develops kidney failure and breathing problems. Her fever returns. House wanders the ER looking for a doctor to bounce ideas off, but discovers that Cuddy has put out a memo prohibiting anyone from talking with him. One young resident decides ignore the memo and talk with him anyway. At first she suggests a fungal infection or haemophilus infection, but House rules these out. She then mentions Crush Syndrome (which House states wouldn’t explain the breathing problems) and ARDS (Adult Respiratory Distress Syndrome — which House complains would only explain the breathing problems). House rethinks the differential diagnoses, and now concludes that the patient is suffering from both Crush Syndrome and ARDS, which is bad news for Megan since these conditions have a poor prognosis. As he is talking with her mother and boyfriend, he notices a large lump in her arm. An MRI shows multiple similar lumps scattered throughout the body which are shown to be Eosinophilic Granulomas, which they say is a sign of an allergic reaction (I don’t know what they are referring to here. Eosinophilic Granuloma is a type of Langerhans Cell Histiocytosis, a rare disease that has nothing to so with allergies. I’m wondering if they are confusing it with feline eosinophilic granuloma, a very different condition.) Apparently Megan is allergic to the antibiotics she was given in the hospital — medications which she has taken before without any problem. Finally, House realizes the solution to this patient’s problems — she isn’t Megan. Both Megan and a similarly appearing girl named Liz survived the explosion. There was a mistaken identification and Megan was identified as Liz and vice versa. Megan died several days ago, and the patient House has been treating is Liz — whose medical records confirm everything House has suspected including the antidepressants, abortion, and use of birth control pills.

---

Overall, House seemed to jump from diagnosis to diagnosis, ignoring almost everything he learned previously, building a precarious (if medical) house of cards. That he was correct was almost entirely luck, not skill. I’m sure most of this was intentional by the writers, to show that House needs a team, but it made for some very disjointed medical care.

For those who may think that the patient mis-identification at the end was a stretch, I know it seems hard to believe that family members wouldn’t recognize their child/significant other, but it has happened more than once. There was a very similar case about a year and a half ago featuring Taylor University students injured in a van crash. I suspect it was the basis for this part of the episode.

---

I give the medical mystery a B+, because it was interesting, if ultimately a little misleading. The final solution I give a B+ (the wrong patient solution, not the allergy solution, that was a D) because it fit the situation well, better than many past solutions. The medicine was sloppy, haphazard, and sometimes just plain wrong. Even if that was intentional, it only deserves a C-. The soap opera was the good, particularly the scenes with Cuudy as well the janitor. I give it another B+.

A list of all prior House reviews

Tags: television medicine house depression crush syndrome ards

This week’s example of a super power-related nose bleed actually has a logical basis in anatomy and physiology. (I know; I’m shocked too.) The scene in question comes from the recent Outsiders Annual #1 (Judd Winick and Scott McDaniels), where the team attempts to bust Black Lightning out of Iron Heights prison. They accidentally start a prison riot, which Warden Gregory Wolfe uses his super-powers to quell.

You’ll notice that several of Warden Wolfe’s victims are bleeding from the mouth. The warden has the super power to make muscles tense up and spasm. A sudden contraction of the jaw muscle could cause a severely bitten tongue and bleeding from the mouth. This doesn’t explain the nosebleed, though as there are no nasal muscles to spasm and cause a nosebleed. On the other hand, if most of the muscles throughout the body were contracted at once, this would lead to an increase in vascular resistance, and a subsequent rise in blood pressure. (If the warden’s powers can affect vascular smooth muscle, the rise in blood pressure would be even worse.) This high blood pressure could be enough to cause the nosebleeds. You would also expect to see an increase in the number of heart attacks and strokes as the blood pressure increased. This may explain the scene at the end of the fight when the warden totally unleashes his powers, killing dozens. Those deaths were probably caused by heart attacks from the incredibly high blood pressure (or the deaths could have been due to a severe spasm of the heart muscle, if the warden’s powers can affect the heart directly).

Final Thought: Shift tries to counter the muscle spasms by creating “a massive gas wave of high-octane muscle relaxant — calcium and magnesium.” While it’s true that certain magnesium compounds have muscle relaxant properties, and calcium ions are involved in muscle contraction and relaxation, I wouldn’t consider them particularly potent muscle relaxants. There’s also the chemistry to consider. Magnesium doesn’t readily become a gas at anything close to room temperature — its boiling point is nearly 2000d F (just over 1000d C). It’s also highly flammable — not a good idea in a firefight.

All previous Psychic and Super-Power Nosebleed Zen posts

Tags: comics medicine nosebleed outsiders

This nice example of a psychic nose bleed — and accompanying eye bleed — comes from Ms. Marvel #16, where S.H.I.E.L.D. psychic Agent Locke fires a “neural blast” to incapacitate the various members of A.I.M. and their monsters that she is fighting. It worked incredibly well, but also knocked her down for the count. I’m a little behind on my S.H.I.E.L.D. history — I remember that there were S.H.I.E.L.D. psychics (“ESPers”) shown during the the original Micronauts series (issues #25-28, the return of Baron Karza), and now Agent Locke and other psychic agents have been introduced recently. Was their any mention of S.H.I.E.L.D. psychics in the intervening twenty-five years? All previous Psychic Nosebleed Zen posts Tags: comics medicine nosebleed ms marvel shield

I love Easter Egg scenes, where half the fun is finding out who (or what) the artist added into the image. This is a good one from Superman #633 (script by Busiek, art by Pacheco) (Top 10 probably holds the record for the most easter eggs).

Back row: Zauriel, the guys from Arrowsmith (coincidentally — I’m sure — also a Busiek/Pacheco creation), the Oblivion bartender (whose name I can’t remember), and Amethyst.

Front row: Dawn and Manitou Raven, Witchfire (another Busiek creation), faux-Arion, and Girl 13 (i.e. Tracy 13).

With spring here, and summer not far behind, it’s time to start thinking about vacation travel plans. In this comic book PSA from Superman’s Pal Jimmy Olsen #24 (October 1957), let Terry the dog tell you how not to have a vacation.

Click on the image for the full PSA ad

I think this PSA also reminds us why not to take a dog on vacation: they always whine and talk about you behind your back. Not to mention that they’re also the worst back seat drivers ever (”You’re going too fast!” “Turn left — no, your other left” “Change the damn radio station” and “You missed that fire hydrant back there”)

Tags: comics psa vacation dog jimmy olsen

There’s been some debate over the earliest appearance of the “psychic nosebleed.” The first reference I’m aware is not from a comic book, but instead from David Cronenberg’s movie Scanners.

Here’s two quick quotes from the film:

I, I must remind you that the, uh, scanning experience is usually a painful one, sometimes resulting in nosebleeds, earaches, stomach cramps, nausea.

and

Cameron: [sees that Kim has had a nosebleed] What happened?
Kim: I was scanned. The woman in the waiting room…
Cameron: She scanned you?
Kim: No, not her. Her child. Her unborn child scanned me.

Scanners is from 1981. Somebody once suggested Stephen King’s Firestarter, published in 1980, but I couldn’t find any occurrences of any sort of psychic bleeding when I read the book. Maybe they meant the movie, which was released in 1984, but I haven’t seen it and Scanners predates it.

For now, I’m going to consider Scanners the earliest psychic nosebleed unless anyone can show me an earlier example.

For comic books, the first example I’m aware of is from the X-Men graphic novel God Loves, Man Kills by Chris Claremont and Brent Anderson, published in 1982, just one year behind Scanners.

For monthly comics, the earliest psychic nosebleed I’ve run across is Adventures of Superman #427 (April 1987) by Wolfman and Ordway, but it wouldn’t surprise me if there are earlier examples.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine psychic nosebleed scanners

If you think the title of this comic sounds familiar, you’d be correct. This comic is simply a reprint of Adventures in Reading starring the Amazing Spider-Man with a new cover slapped on it.

This time the comic is sponsored by Marvel Comics and the soft drink Squirt. The interior consists of the same 32 pages (34 counting the inside covers) and the same lame story: Spider-Man and three inner-city kids are zapped from one book to another without ever being clever enough to realize what’s going on. For a better description of the story, check out my review of the original comic. And yes, the strange Interlac puzzle is in this edition too.

The most notable thing about this reprint is the back cover, which contains one of the more egregious examples of crass marketing I’ve ever seen in a PSA comic. Kudos to Squirt for sponsoring this comic, but shame on them for slapping this on its back cover and turning Spider-Man into a commercial pitch man:

Take it from Spidey and Squirt – – reading is a lot more than a school subject. Reading lets you meet new people, go places you’ve never been before. and think things you’ve never thought before. Just open a book and a can of Squirt and find out. Hey, here’s an idea…why not start with the book you’re holding?

Tags: comics psa spider-man squirt interlac

Certain first aid courses, particularly those in the military and the scouts, teach the use of emergency patient transportation such as the “fireman’s carry.” These are quick and dirty maneuvers designed to get the patient out of harm’s way as quickly as possible. As the images show, these don’t provide the patient with any protection and little support and are best for the minimally injured patient. They shouldn’t be used for long term transport. They are ideal for the life or death situation — such as a fire or explosion — where the patient needs to be moved quickly or they will die.

From left to right, the images above show the “Two Person Arm Carry,” the “One Person Arm Carry,” the “Pack-Strap Carry,” the “Fireman’s Carry” (also a noted pro-wrestling move), and the “Two Person Carry by Arms and Legs.” These images were borrowed from the 2001 edition of the US Navy Operational Medicine Course.

So let’s see how our DC super-heroes managed during the freefall that was New Year’s Eve in Metropolis:

	First up is Captain Marvel Jr. He seems to be using a modified version of the One Person Arm Carry. As you see, it provides no spinal protection, so we’ll just have to assume that Freddy used the Wisdom of Solomon to make sure she didn’t have a spinal injury before he picked her up. I do wonder where the girl’s left arm is. I suspect that’s it draped across her chest, just miscolored.
	Hawkgirl is not doing nearly as good a job as Captain Marvel Jr. Her patient, though a snappy dresser, looks like he’s in pain — and I don’t think it’s just from his wound — that just doesn’t look comfortable. And that doesn’t look like it would be comfortable for her either to fly a long distance. We’ll call it the “Hawkgirl One Arm Two Wing Carry” Again, she is providing no spinal support, which is dangerous. Most of these victims suffered impact injuries, either falling from a great height, or being hit by something falling, so spinal injuries are a real possibility.
	Power Girl’s technique is definitely not recommended. She’s the worst of any of the heroes. We’ll just call it the “Power Girl Choke-Hold Carry” and leave it at that.
All images are from the center two-page spread of 52 #35. Breakdowns by Giffen. Pencils by Jimenez and Jurgens

Tags: comics medicine 52 captain marvel junior hawkgirl power girl

In this week’s episode of House, the mystery is good, but the medical treatment is not. There are some good character moments, but this doesn’t stop the Tritter storyline from limping to a weak ending. Spoilers follow!

Derek, a firefighter, becomes short of breath and disoriented while at the scene of a fire. He tells his partner Amy that he is feeling chills. He is brought to the hospital and admitted to House’s service. Cameron notes that he has a fluctuating temperature as well as skin grafts over half his body from bad third-degree burns suffered on the job a year ago. She also discovers that he has had several episodes of disorientation in the past few weeks. Cameron reports that Derek’s tests for hepatitis C, HIV, TB (tuberculosis), Lyme disease are all negative, as is his drug screen. The EKG is said to show an “arrhythmia” (an abnormal rhythm) but House blows it off. Foreman suggests a hypothalamic tumor, while the other doctors are suspicious of a hospital acquired infection — one he picked up when he had his skin graft surgery and which has smoldered since then. They are concerned about MRSA (methacillin-resistant Staph. aureus), a particularly nasty germ.

Because of concern about MRSA, Derek is placed in isolation. He casually reveals to Cameron that everything looks blue. Foreman mentions heavy metal poisoning as a cause of this, particularly thallium. House suspects the patient has “male menopause” (low testosterone, elevated estrogen levels) brought about by burns he has suffered to his genitals. Viagra is known to cause blue color shifts, and House believes he is taking Viagra to make up for the effects of the low testosterone. The next time we see Derek, he is out of isolation (the MRSA tests came back negative) and he is receiving hormone therapy (apparently his levels were low). He suddenly starts screaming that the hormones are causing pain, then he lashes out and starts throttling Cameron. Foreman sedates him with some Lorazepam (brand name: Ativan).

The team tests, but Derek is not allergic to the hormones and they were not contaminated. Additionally, there is no evidence of a pulmonary embolism and his EKG is normal. Foreman, true to form, suspects a neurological cause, either a frontal lobe tumor or meningitis. However, a CT scan and lumbar puncture are normal. Other possible diagnoses mentioned include polyarteritis nodosa (a rare disease caused by inflammation of the arteries) and Legionnaire’s disease. Chase also believes it is unusual that Derek’s drug screen is negative as he must be taking some pain medication to treat the severe pain from his skin grafts.

The Young Guns are paged to Derek’s bedside where they discover that he has become suddenly short of breath and tachycardic (rapid heart rate). His oxygen saturation is 85%. Chase notices ST elevation on the EKG and realizes that Derek is having a heart attack. Elevated cardiac enzymes confirm this diagnosis (a heart damaged by a heart attack will release certain proteins in a predictable pattern over several days. By testing for these proteins, you can discover if a patient has had a heart attack.) The team eventually realizes that the common denominator in all of Derek’s attacks is his partner Amy. It is only when she is around that he has problems. They can find no inciting agents she carries, but Cameron recognizes that Derek is in love with Amy. He explains that she is engaged to his brother and that he can never have a relationship with her. Cameron explains to the rest of the team that Derek is literally dying of a broken heart.

The team starts Derek on beta-blockers and nitroglycerin (common medications for heart attack patients) but they don’t help. The team considers antidepressants, but discards the idea because House believes their side effects will make things worse (which is quite a stretch). Chase suggests propylthiouracil (a drug that is inhibits the thyroid gland), but House feels it would be bad for the heart as well (not to mention a bizarre and incorrect use of the drug). At the end, the team decides to use EST (electroshock therapy) to cause a permanent memory loss so Derek won’t remember Amy or his brother.

The therapy seems to be successful, but in a casual conversation with Amy, Cameron discovers that she was never engaged to Derek’s brother. It turns out that Derek had false memories (I would have first thought of House’s favorite mantra –”patients lie” — rather than jump to the diagnosis of false memories). A brain MRI (now they get an MRI) shows decreased blood flow to one part of the brain. A close look at the blood flow in the spine shows a spinal meningioma (a tumor of the membrane that covers the spinal cord) that is pressing against the blood vessels supplying blood to the brain. When this tumor is removed, Derek will be good to go (well, except for that permanent memory loss).

---

Medically, the two big problems this episode were the EKGs and the ECT.
In the beginning, House ignores an abnormal EKG. You never ignore an abnormal EKG — that’s just asking for trouble, and they would likely have made the diagnosis much sooner (but then the show would be too short). Then later in the episode, Derek had a normal EKG. If he truly had suffered multiple heart attacks, there’s no way he would have had a normal EKG.

The biggest problem was the EST. First, there’s no way EST would ever be used without a psychiatrist’s evaluation and consent, and no psychiatrist would jump straight to EST without attempting other therapies first. A thorough testing, evaluation, and history would reveal the false memories. EST is still used occasionally for depression, schizophrenia, and mania — but the patient is suffering from none of these. EST can certainly cause memory problems, and does cause temporary memory loss in most patients, but it is not a predictable effect and ECT is not used to purposefully block out memories.

For nitpicking, I will point out that the bacterial cultures came back surprisingly fast once again, and that Cameron needs to brush up on her isolation skills. She wasn’t dressed correctly for either contact isolation or drawing blood.

---

On the non-medical side, I liked the scenes with House and Cuddy and House and Wilson — especially the ones with Cuddy; she showed some real teeth. I thought his interactions with Foreman and Chase were good, but wasn’t as impressed with the scenes with Cameron.

Legally, it seemed all wrong. I am certainly not a lawyer, but the show seemed to be confusing grand juries and actual trials. The judge said she was going to determine if there was enough evidence to try House, which suggests a grand jury (or something like that), but House pleaded “Not Guilty” before that. How can he plead if he hasn’t been brought to trial on charges yet?

And the resolution of the whole Tritter storyline? Let’s just say that it ended with a whimper and too much deus ex machina for my taste.

I did like that House had the last laugh after all.

---

The medical mystery was good, so I give it a B+ and the ultimate solution was well-thought out and earns another B+. The actual medical treatment was bad, especially the EST aspect, and drags down the overall medical score to a D+. The character interaction/soap opera was good and earns an A-. Overall, I give the Tritter arc a C-.

The previous House review
A list of all prior House reviews

Tags: television medicine house mrsa electroshock therapy meningioma

A much darker issue of Hawk & Dove than usual, but given that it is dealing with Apokolips — at least in part — that should come as no surprise. The story by the Kesels is up to their usual standards, and I think Karl Kesel is one of the best of the modern comic book creators at handling the legacy of Kirby’s Fourth World. Steve Erwin handles the art this issue and does an excellent job, particularly when you consider that he has to deal with some of those bizarre Apokoliptan outfits.

It’s a girl’s night out. Dawn, Ren, and Donna are skating at the Capitol Skating Rink. Actually, Dawn and Donna are skating, Ren is floundering. There is a loud Boom and two armored women appear and start wreaking havoc at the skating rink and the surrounding parts of Washington D.C..

Across town, it’s also a guy’s night out and Hank, Kyle, and Rodger are at an inner city Boy’s Club. Here, at last, we learn the secret of the Black Russian. Honestly, it’s not much of a secret: Rodger dresses as the Black Russian, a fake super villain, to teach children how to deal with child molesters. Hank and Kyle are along to watch. The act is interrupted by reports of a fire down the street and Hank and the gang run off to investigate.

The villains in both cases are the same. A squad of Female Furies has come to Earth from Apokolips. Two teams of two Furies each are competing to score the most points by claiming prizes from their dead victims. The ultimate prize is the mask of a super hero; whichever team obtains one will win the competition – the other team will be punished by Granny Goodness.

The Female Furies seen here aren’t the main Furies, but instead four junior Furies. There’s Malice Vundabaar and her giant invisible cat, Chessure. Speed Queen is super strong strong and wears roller skates (think an Apokolips version of Dazzler). Bloody Mary is a vampire with telekinetic powers. Finally, there’s Gilotina who has hands which are able to cut through anything. This issue marks the first appearance of these newer Furies, except for Gilotina who appeared briefly in Mister Miracle #8. They have all since shown up a few times including Superboy #24-25 (also written by Karl Kesel) and, if memory serves, at least one episode of Justice League Unlimited.

Dove fights Gilotina and Speed Queen. She tricks Speed Queen into rolling full speed into the Potomac, and then confronts Gilotina. Speed Queen climbs out of the river and grabs Dove. She is able to escape and Speed Queen plows full speed into propane truck. The resulting explosion slows down the Fury, but doesn’t stop her. She is ready to attack Dove again when a Boom Tube appears and Speed Queen and Gilotina are whisked back to Apokolips.

Meanwhile, Hawk battles Malice, Chessure, and Bloody Mary. He is clever enough to use Bloody Mary’s telekinesis against her, but Chessure is strong enough to inflict a great deal of damage on the near invulnerable Hawk. When Hawk is ultimately captured, Rodger tries to distract them so Hawk can escape, but he is in turn targeted by the Furies who see his Black Russian costume and think he is another super-hero. They attack Rodger, grab his mask and then Boom Tube back to Apokolips, the victors in their deadly little competition.

As the issue ends, the Furies have returned to Apokolips but left behind scores of dead and injured, as well as a mortally wounded Rodger.

All Previous Hawk and Dove Reviews

Tags: comics hawk dove apokolips female furies

Continuing a look at nosebleeds caused by psychic powers, with a focus for a second week in a row on the young Emma Frost, later known as the Hellfire Club’s White Queen (and later yet, a member of the X-Men).

This image comes courtesy of Karl Bollers and Carlo Pagulayan and is from Emma Frost #7 and I think is one of the best epistaxis telepathica pictures.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed emma frost

It’s time to resume my chronological look at every Hawk and Dove appearance since their origin in Showcase #75. So far, I’ve covered their original series, their adventures with the Teen Titans, the death of the first Dove during Crisis on Infinite Earths, Hawk’s increasingly insane solo adventures, and then the resurgence of Hawk and Dove with the appearance of the new Dove.

But then real life reared its ugly head and my need for Family Practice recertification trumped Hawk and Dove. However, since discovering that a certain fellow comic blogger lacks the proper appreciation of Hawk and Dove (and passing the recertification exam), I realized it was well past time to resume my postings.

Before returning to the Hawk & Dove comic, let’s take a look at a brief cameo of theirs in Justice League America #42. In this issue from September 1990, Maxwell Lord and John J’onzz decide that the JLA needs a recruitment drive. It should come as little surprise that they seek out the B-level heroes who have their own titles but who aren’t already in the JLA. Blue Beetle and Fire talk with El Diablo, Guy Gardner has a “conversation” with Starman (the otherwise forgettable Will Payton one), and Ice and the Huntress have a chat with Hawk and Dove in an entertaining scene.

Click on the image for the full page

And how did the recruitment go? The answer is below…
Read more…

More on psychic powers, nosebleeds, and Maxwell Lord. This example comes from Justice League America Annual #5 from 1991. This was the “Armageddon 2001″ annual, where Waverider read a possible future for each member of the Justice League. It was a clever issue, and each of the individual stories weaved in and out to make an entire possible future. In this scene, Max is using his powers to talk Bea (Fire) into dropping her lawsuit against Ted (the Stupendous Silverfish — he sold her the rights to the Blue Beetle name, hence the lawsuit). I threw in a nice panel of Guy and Ice just for fun.

Tags: comics medicine nosebleed max lord

An update on the “script your own Dr. Doom panel” meme:

Mike at Progressive Ruin Brandon at Random Panels Sleestak (from Lady, That’s My Skull) Gordon at Blog This, Pal Erich at Fish-Flavored Baseball Bat David at A Work in Progress Dave at his eponymous Long Box Lyle at the Crocodile Caucus

Submitted by Keith Welch:

Time for the bi-monthly post where take a few minutes tolook back at what internet searches brought people to Polite Dissent for July and August. Mostly rather bland searches this time, but then I’m not sure anything will top May and June’s intravenous pumpkins. As always, there were plenty of searches for She-Hulk, Hawk, Dove, Dave Trampier, Wormy, and B’wana Beast. Plenty of House questions too. Then there were the usual searches for sex pictures involving any combination of the following: the Teen Titans (Robin, Starfire, Cyborg, and Beast Boy — but no love for Raven), Kim Possible, Shego, Ron Stoppable, Danny Phantom, and/or Tanith Belbin.

Capitalization has been added to make the searches more readable, but the grammar and spelling are untouched otherwise to give the true flavor. My thoughts are added in green.

Vaguely Medical Searches

• Tiniest bacteria serratia Sounds like a title of a children’s book. [information on Serratia]
• Difference between the circumcision done by a quack doctor and medical doctor? Is this really a question you need to ask?
• Can a blow stop the heart rhythm instantly? Yes, under the right conditions, when the timing of the heart cycle is just right and a blow lands in the right place. This is known as Commotio Cordis and is thought to cause 2-3 deahts per year in Little League baseball.[more information on commotio cordis]
• Kissing fishes skin cure No idea here.
• If you don t test for it you don t have to treat it house of god The actual quote is: “If you don’t take a temperature, you can’t find a fever” and it is Law X from the back of House of God.
• mystery painful rash secreting string You’re probably thinking about Morgellons. [wikipedia entry on Morgellon's Disease]

Supposedly Comic Book Searches

• XY the last man close.
• John Byrne pregnant I doubt it
• Women in the freezer comics Another example of being close but not quite right
• Senseless comics involving the devil Are there any other kind?

Miscellaneous Seaches

• Give me at least 3 valedictorian addressed I don’t know which is more disturbing, that someone is plagiarizing valedictorian speeches, or that they can’t spell “addresses” right. Or maybe it’s just somebody who’s looking for the home addresses of smart people so he can beat them up…
• Hats Somebody searches the internet for “hats”? And found my site? (Several times too, according to the logs).
• How do you spell polite? Just like that.
• I have telescopic vision Good for you.

Adventures in Spelling (presented with few comments)

• Cot having sex on tape
• 37 weeks pregnant cervix is thinning and pressure in Virginia
• Ohno Cryten birth control I assume they meant “Ortho Cyclen” but “Ohno Cryten” evokes much better imagery.

Fan Fiction Want List (presented without comment)

• Airwolf fan fiction
• Fanfiction kim possible giving birth
• Fanfiction kim possible vomit
• Extreme Justice fan fiction

And Last but not Least, the I-Really-Don’t-Want-To-Know Seaches (also presented without comment)

• How can i sudues my sister
• Woman groin picture without obstacle

Finally had time to sit down and read Astonishing X-Men #16. A quick read, but a good one. Particularly nice fight scene between Kitty and Emma…which is as it should be since we’ve been waiting since issue #1 for it (or Uncanny X-Men #151-152, if you really want to know the truth).

As for the revelation of the identity of the secret fifth member of the Hellfire Club. Who would’ve guessed that it was really Ben Casey…but it makes a certain amount of sense.

Seriously, I suspect in one way or another it will come down to Mastermind. He was a key player in the era Whedon seems to draw his inspiration from, not to mention he’s been involved with the Hellfire Club before. Mastermind. You heard it here first.

Tags: comics astonishing x-men ben casey mastermind

Like many pieces of legislation that were rushed through Congress, the recent Superhero Registration Act is vague in certain areas and unexpected questions have cropped up. Luckily the government was able to provide this handy guide to common Registration Act questions:

Q: I used to be a mutant but I recently lost my powers. Do I still have to register?
A: No, you do not need to register, but you do need to fill out form 341-T “Declaration of Cessation of Urban Vigilante Activity”. Fill out the personal information, mark the appropriate box for the reason behind your loss of powers, and drop it off at the nearest FBI or SHIELD office. Farm-based hereos will need to fill out form 341-W, which applies to rural activities.

Q: I have to wear a respirator at work and it covers up most of my face — does this mean I have to register as a masked hero?
A: If your gear obscures your identity, then that qualifies as a mask and you are required to register for the Act. As a rule of thumb, if you have to wear a name tag or have your name stenciled anywhere on you clothes, then you need to register. This means that the following professions are required to register by the Act:
• Firemen
• Scuba divers
• Surgeons
• Dentists and Dental Hygienists
• Painters
• Clowns
• Emo kids with hair over their eyes (The United States v. Death Cab for Cutie)
• Rock singers wearing makeup (The United States v. Simmons, Stanley, Criss, Frehley, et.al)

Q: I work as a professional wrestler and wear a mask, do I need to register?
A: If your role is as a heroic or good-aligned wrestler, then yes, you are expected to register. If you play an evil or villanous wrestler, then you are exempt from registration because due to an inadvertant oversight, the Act as written only applies to heroes. If you foresee your role changing, it would be best to go ahead and register now.

Q: Since I’ve registered, can I now declare my costume and other super hero expenditures as work-related expenses on my tax forms?
A: Yes. You can also declare super-hero based medical care as well, and don’t neglect to deduct for mileage and depreciation on vehicles.

Q: I’ve heard that the divorce rate is higher for super-heroes who register.
A: Nothing could be farther from the truth! In actuality, our very scientific studies have shown that a full 78% of indivduals report improved satisfaction with their marriage after registering*.

Q: What about Halloween? Will the Registration Act affect the wearing of costumes and trick-or-treating?
A: Halloween and all pumpkin-related festivities are now illegal under Section II of the Superhero Registration Act. For reasons not entirely clear, Arbor Day has also been outlawed.

Q: My super powers are granted directly by my deity. Isn’t registering as a superhero with the Federal Government overnment a violation of the Establishement Clause?
Q: I’m the Norse God of Thunder. I thinketh that registering with the government dost be a violation of my First Amendment rights to Freedom of Religion.
A: Under the direction of the President, the Department of Justice has determined that the rights “guaranteed” by the Constitution and subsequent amendments do not necessarily apply to super-powered individuals. The only people who would disagree this decision are clearly communists and/or terrorist sympathizers. You’re not a terrorist sympathizer, are you?

Q: As a foreign operative and/or alien and/or time-displaced individual and/or artifical lifeform**, am I still required to register for the Act?
A: Yes you are. Any super-powered or masked individual who operates on American Soil — including outlying territories, helicarriers, and assorted secret moon bases — are required to register with the Federal Government.
In addition to the standard registration form, you may be required to submit one or more of the following forms as well: 338-A (Declaration of Residency in a Foreign Nation), 338-AN (Declaration of Residency in a Non-Recognized Foreign Nation), 338-AX (Declaration of Residency in a Foreign Nation, Since Destroyed or Re-Zoned), 338-C (Declaration of Residency in a Future Timeline), 338-CX (Declaration of Residency in a Future Timeline Which Can No Longer Exist), 338-D (Declaration of Residency in the Past), 338-DS (Declaration of Residency in the Distant Past), 338-DW (Declaration of Residency in an Alternate Past), 338-E (Declaration of Residency on a Planet or Moon within the Solar System), 338-F (Declaration of Residency on an Extra-Solar Planet or Moon), 338-FX (Declaration of Residency on an Extra-Solar Planet or Moon, Since Destroyed), 338-G (Declaration of Residency on an Artifical Planetary Object), 338-GX (Declaration of Residency on an Artificial Planetary Object, Since Destroyed), 338-J (Declaration of Residency in a Parallel Dimension or Alternate Reality, Accessible), 338-JT (Declaration of Residency in a Parallel Dimension or Alternate Reality, Not Accessible), 338-JX (Declaration of Residency in a Parallel Dimension or Alternate Reality, Since Destroyed), 338-K (Declaration of Residency in a Magical or Fictional World), 325-B (Declaration of Individual as an Artificial Lifeform, Biological), 325-E (Declaration of Individual as an Artifical Lifeform, Electronic)**, 325-M (Declaration of Individual as an Articfical Lifeform, Mechanical)**, or 325-S (Declaration of Individual as an Artifical Lifeform, Magical).

Excerpted from “So You Have Questions About the Superhero Registration Act,” a government pamphlet
scheduled for general release August 2006 October 2006.

---

* Statistics provided by the Statistical Heuristic Interpretation Evaluation and Logic Department. Margin of error ±75%
**All Mechanical and Electronic Artifical Lifeforms are required to have a compliance chip implanted.

Tags: comics politics civil war superhero registration act shield

For those of you too young to remember (including me), Ben Casey was television show that ran on ABC from 1961 to 1966. It starred Vince Edwards as Dr. Ben Casey, a neurosergery resident at the hospital 59 West. Dell published ten issues of a Ben Casey comic book from 1962 through 1965. Today’s topic is Ben Casey #3 from December, 1962.

Dr. Ben Casey and his co-worker Dr. Maggie Graham take their boss Dr. Zorba out to dinner for his birthday to the Periscope, an expensive seafood restaurant. Also dining at the Periscope that night is the famous actor Brent Calhoon. An obnoxious drunk spills some food on Calhoon’s wife and then picks a fight with Calhoon. It’s a vicious fight and both combatants end up down for the count. The drunk has been knocked unconscious and Calhoon has multiple facial lacerations and fractures.

Ben Casey examines the drunk and realizes that he’s in bad shape with a probable subdural hematoma. The ambulance arrives and both patients are rushed to the hospital. Casey operates on the drunk, drilling several burr holes to drain the hematomas. It’s a tough operation and the patient survives — at first, but dies from his injuries about an hour later.

Dr. Casey then goes to evaluate Calhoon. As he surmised at the restaurant, Calhoon has suffered a couple of jaw fractures, something easy for good oral surgeon to fix. When Casey informs him that the other patient died, Calhoon becomes hysterical. It takes an injection of a sedative before he finally calms down.

Outside Calhoon’s room, Casey encounters the press corps who want to know about Calhoon and the other patient. Casey starts to explain the situation, but a reporter accuses him of covering up the fact that Calhoon is guilty of murdering the other fighter. That doesn’t sit well with Casey who is ready to start a fight of his own, but luckily at just that moment he is called to Dr. Zorba’s office.

Inside the office, Dr. Casey finds the District Attorney waiting for him. The DA is ready to charge Calhoon with murder, but wants Dr. Casey’s opinion on the case as he operated on the dead man. Casey informs the DA that the operation revealed that the patient had suffered multiple head traumas over the years that had weakened his blood vessels. Thus while Calhoon may have struck the fatal blow, the previous injuries had contributed to the death as well. Furthermore, Casey points out that he recognized the patient as a local professional boxer. That means that his fists are considered lethal weapons and according to the law, Calhoon was merely acting in self defense. After his talk with Dr. Casey, the DA drops all charges against Calhoon.

Meanwhile, Calhoon has become paralyzed and is unable to walk. He is convinced that he has suffered some brain damage in the fight and he needs immediate brain surgery. He knows this because he once played a doctor on TV. Casey has a different opinion. He recognizes that Calhoon is suffering from hysterical paralysis from guilt over the death of the drunk. Casey recommends a psychiatrist, but Calhoon refuses, demanding surgery.

Eventually Dr. Casey relents and Calhoon is wheeled off to surgery. Once the patient is anesthetized and the surgery started, Casey hands the scalpel off to another doctor. A few hours later, Calhoon is wheeled back to his room for recovery. The next day, miraculously, Calhoon is no longer paralyzed and can walk again. Talking privately to Calhoon’s wife, Casey tells her that they never performed any brain surgery on her husband, they just repaired his jaw fractures. They lied to him about the brain surgery so he would think he could walk again. Casey tells Calhoon’s wife to keep this a secret, and then he, Maggie, and Dr. Zorba head off to the hospital cafeteria to finish Dr. Zorba’s birthday dinner.

This was an entertaining story with a couple of clever plot twists. The “hands are lethal weapons” was a nice way out for Calhoon, though I wonder if that’s true legally or just an urban legend. Calhoon’s hysterical paralysis added another dimension to the story though the sham operation was more than a little unethical and is likely to backfire when (and if) Calhoon realizes the truth. While not quite unethical (at least according to the 1960s), you’ll notice Dr. Casey was freely sharing a great deal more of his patients’ medical information than he should have been

In addition to the Ben Casey main story, the comic contains a four page Dr. Dan Dazzler backup story as well as a one page text story about Dr. Lester Dingwall and a pet monkey. The inside covers concern the history of medical inventions and the founding of the county’s first tissue bank. The back cover piece is about Florence Nightingale.

Tags: comics medicine ben casey flashback week

Continuing the medical annotation of Naoki Urasawa’s Monster. This time, I’ll take a look at the first half of the recently released Volume 3, chapters one through four.

Nothing medical happens in the first chapter, so the annotation begins with:

Chapter Two
Tenma is taken to treat a terrorist injured in a gunfight with the police. He realizes that the man was shot through his axillary artery and is bleeding to death.

The axillary artery is an important artery. It starts off as the subclavian artery, coming off the aorta. As it dives under the shoulder it is known as the axillary artery. It then becomes the brachial artery (the main artery of the arm) as it leaves the shoulder. It’s a large enough artery that an injury to it could lead to death from blood loss, and fairly quickly.

Tenma apparently* stops the arterial bleeding with direct pressure, a valid approach, but he succeeds conveniently quickly. Next he announces that he needs to close the injury to the skin which he proceeds to due with a handy stapler. This makes little sense. I have no problem with the use of the stapler — it’s nearby and it works — I’m just not clear on why he closed the wound in the first place. Tenma knows the patient will require a surgical repair of the artery, so the doctors will just have to open the wound up again. The closed skin may provide a little pressure which will help keep the artery from bleeding, but a simple pressure dressing would do the job much better.

After closing the wound, Tenma places the injured arm in a sling, picks the man up fairly roughly (especially considering he is nearly dead already) and moves him outside for the police to find.

Read more…

This is a comic that was produced by the United States Forest Service and the Ad Council during the 1960s and early ’70s. I remember owning it when I was a preschooler. It was always one of my favorites. It tells the true story (more or less) of Smokey Bear, who went on to become Smokey The Bear and the forest fire prevention mascot of the U.S. Forest Service.

As the comic starts, a forest fire rips through Lincoln National Forest in New Mexico. Most of the forest animals flee, but many perish in the flames. One lone animal survives the fire: a badly burned bear cub stuck in a tree. The firefighters rescued him and he was bandaged up and his burns treated. The rangers called him Smokey and he became the mascot used to remind the public that “Only You Can Prevent Forest Fires.”

Smokey lived out his days at the National Zoo in Washington D.C. I remember seeing him as a youngster in the ’70s, so I’m sure he has long since passed on. I just remember that I could care less about the pandas and the other exotic animals, it was Smokey that my sister and I desperately wanted to see on our visit to the zoo.

• Thanks to the Minnesota Department Department of National Resources, you can download your very own copy of this comic. About 3/5 of the way down the page, under the “Smokey comic book audio CD” heading is a link to a pdf file of the comic (though the last four pages seem to be the same in my copy).
• In addition to this freebie comic, Smokey had Gold Key comic book series that ran for 13 issues from 1970 to 1973. Not to be outdone, Woodsy Owl (”Give a Hoot, Don’t Pollute”) had a ten issue series, also from Gold Key, from 1973-1976.
• Wikipedia tells a slightly different origin of Smokey the Bear. I’m sure theirs is correct as it is more politically expedient, but I prefer the comic book version.
• Why should you, as a comic reader, care about forest fires? From the comic book:
  Smokey tells them how he hates forest fires!
  How they destroy his animal friends…
  How they burned up timber that could have been used to make homes — perhaps a new home for you…
  How they waste wood that could have gone into furniture…
  

Tags: comics psa smokey the bear forest fires

A real world case this time: Michael Swango’s troubles were first noticeable during medical school at Southern Illinois University. Swango’s demeanor was brusque and he had no bedside manners to speak of. He seemed to have a peculiar fascination with dying patients. He also liked to take the easy way out, and was nearly expelled after being caught cheating during his OB/GYN rotation. In the end, the school let him graduate if he repeated the course work.

Despite a poor recommendation from the dean at the SIU School of Medicine, Swango was selected for a surgical internship at Ohio State University. That’s where the trouble really started. Nurses noticed that healthy patients on the floors where he was assigned happened to die…frequently. One nurse even caught him injecting some medicine into a patient who later became ill. The nurses reported their concerns to the administration, but they were brushed aside and only a superficial investigation was carried out. Despite being cleared by this investigation, Swango was not asked back to OSU because there were concerns about his skills as a physician and surgeon.

Swango returned home to Illinois and started working as a paramedic. Within a few months, the rest of the paramedics noticed that they would get violently ill whenever Swango brought any food in, or prepared the coffee. They investigated and found arsenic and other poisons in his possession, along with a book about poisoning. He was arrested, tried, and imprisoned for these poisonings.

After being released from prison, Swango worked various medical related odd jobs for a while, but eventually managed to bluff his way into a residency program in Sioux Falls. Things went well at first, but then he tried to join the American Medical Association. Unlike the hospital, the AMA performed a background check and discovered that Swango had no medical license and had a past felony conviction. About the same time, the ABC television show 20/20 aired a segment on Swangoand his poisoning conviction. When these were reported to the Dean of the University of South Dakota, Swango was summarily dismissed.

A short time later, Swango surfaced in New York at Stony Brook Medical School where he had been admitted as a psychiatry resident. Once again, his patients started dying for no apparent reason. When the dean at South Dakota heard that Swango had moved to New York, he called the administration at Stony Brook and Swango’s full history came to light. He was fired from yet another residency position. This time, the residency director learned from past mistakes and mailed a warning about Swango to every other residency in the nation.

A year later, Swango surfaced in Africa working as a physician in a rural hospital in Zimbabwe. True to form, his patients again started dying mysteriously. This time the police stepped in and he was arrested, but he skipped town before his trial date came. He hid out elsewhere in Africa and Europe and was close to taking another job as a doctor in Saudi Arabia when he was arrested at O’Hare Airport in Chicago.

Swango was extradited to New York where he was charged and convicted of practicing medicine without a license and fraud. While in prison for those charges, police were building other cases and he ultimately pled guilty to four counts of first-degree murder and was sentenced to life in prison with no possibility of parole. This plea bargain allowed him to avoid the death penalty and extradition to Zimbabwe. All told, it is estimated that Michael Swango killed thirty to sixty patients.

• The Crime Library report on Michael Swango (like all Crime Library articles I’ve read, this one is full of hypebole and trips over its own attempts at flowerly language. Still it’s chock full of good information.)
• Timeline and Documents of the Michael Swango case from CourtTV
• CNN article on Michael Swango.
• An AMA Op-Ed about Swango.

Tags:medicine news michael swango.

Dr. Harleen Quinzel was a psychiatrist who managed to make it through both college and medical school relying on her personal charms and womanly wiles rather than any actual skill or ability. She applied for an internship at Arkham Asylum with the plan of turning her experiences into a best-selling tell-all book later. However, upon arriving at the Asylum, she found herself attracted to the Joker. She managed to persuade her boss into letting her conduct therapy sessions with him, but she was the one who underwent therapy. These were far from normal counseling sessions, and the Joker manipulated Harleen, tugging at her heartstrings and telling her waht she wanted to hear. After one of his escapes and post-pumelling return by Batman, she snapped, stole greasepaint and a costume and became Harley Quinn (This is according to the excellent one-shot comic Mad Love — set in the Batman Adventures continuity — by Paul Dini and Bruce Timm. The regular continuity Harley Quinn has a slightly different origin, but the key points are all the same. All images in this post are from Mad Love.)

Harley Quinn orignated on the Batman Adventures television cartoon (in episode #22, to be exact), but proved so popular she quickly appeared in the regular continuity comics as well. She even had her own 38 issue series from 2000 to 2004.

Since becoming Harley Quinn, Dr. Quinzel has rarely been shown to use her psychiatric skills and training. I recall one storyline (in Catwoman #89) where she used them in an attempt to brainwash Catwoman, but that was about it. Well, it’s not like she really paid attention in class anyway.

Remember what I said in an ealier post about psychiatrists — that they’re comic book shorthand for characters who are “off,” “creepy,” and “up to something.” As far as I’m concerned, this applies to Harley as well. She can be a fun character, but when you get right down to it, there’s something unnerving and more than a little creepy about the her.

• The Wikipedia entry on Harley Quinn.
• Harley Quinn fansites: Harley’s Haven and Harley’s Heaven.
• Gotham Girls, online WB Dini-verse cartoon starring Catwoman, Poison Ivy, and Harley Quinn.
• Funny, she doesn’t look Jewish.
• Harley Quinn in Batman: the Animated Series.
• Arleen Sorkin, the voice of Harley Quinn
• The Birds of Prey TV series, with Mia Sara as Dr. Harleen Quinzel. (Mia Sara is probably best known for her role as Sloane Peterson, Ferris Bueller’s girlfriend in the classic ’80s movie.)
• Harley Quinn Micro-Heroes (scroll to the bottom of the page) and Thrillkiller Micro-Heroes, including that version of Harley.
• The IMDB entry on Harley Quinn Smith, daughter of director and alleged comic book writer (Whatever happened to the Bullseye miniseries? Three and a half years and counting) Kevin Smith.

Tags: comics medicine harleen quinzel harley quinn joker batman psychiatrist .

DC got a great deal of use out of their AIDS PSA ads, and recycled a few of them in the 1990s.

First, there’s the JLA PSA with Booster Gold, Fire, and Blue Beetle (R.I.P.). The ad I originally highlighted was actually the revised ad (I found it in Flash #87, February 1994). The first one is nearly identical except that it features Booster’s classic uniform and Fire still has her powers (found in Hammerlocke #6, February 1993). In between the two ads, the JLA fought Doomsday with a disastrous outcome.

Click on the images for the full page ads

In these next ads, they didn’t update the costumes — instead they swapped characters. The ad I posted featured Hal Jordan. The revision replaces him with John Stewart. (Though I’m not sure which is the re-do. Looking at the art, I suspect Stewart was the original and Jordan the revision. The John Stewart PSA is from an older book — Darkstars #4, January 1993 — while the Hal Jordan PSA is from Catwoman #6, January 1994)

Click on the images for the full page ads

Tags: comics medicine psa hiv aids jla booster gold blue beetle fire green lantern john stewart hal jordan

Tonight’s House episodes are repeats of the ninth and tenth episodes of the second season of House. Both are average at best.

The first, Deception, is about a woman House meets at an off-track betting parlor when she has a seizure. Despite the inclusion of the ubiquitous (on TV medical dramas, anyway) Muchausen’s Syndrome, the medicine in this episode is dismal. Go watch fireworks instead.

The second episode, Failure to Communicate, is about a journalist who suffers aphasia after a sudden fall. House and Stacey are in Baltimore, so he is only able to assist the Young Guns by phone. Another episode with poor medicine. You really should be outside watching fireworks, or at least watching the Tour de France on OLN instead. Trust me.

---

Instead of two less-than-stellar episodes of House, how about some good medicine? Grand Rounds is the weekly collection of the best medical blogging on the web. It always features fascinating stories, advice, and insight into the medical field. Check it out this week at Rangel MD.

Tags: television medicine house grand rounds.

What would Independence Day be without a nod to one of America’s greatest families?

Happy Independence Day!
And for Heaven’s sake, keep those fireworks away from your eyes.

Tags: comics independence day partridge family

I’m going to end “PSA Classic Weekend” with one of my favorite PSA comics of all time: Superman For the Animals. Produced by DC Comics and the Doris Day Animal Foundation, this book features the artistic stylings of Tom Grummet and a script by a young Mark Millar. Originally posted 5 August 2004, take it away, Mark and Tom:

Before he wrote such compassionate comics as Wanted and Chosen, Mark Millar honed his writing skills on Superman for the Animals, a free comic published by DC Comics in January 2000 and co-sponsored by the Doris Day Animal Foundation. The story, entitled “Dear Superman…”, was written by Millar with art by comic book veterans Tom Grummet and Dick Giordano.

The comic tells the story of Tommy, a twelve year-old who moves to a new city and falls in with the wrong crowd. How do we know they’re the wrong crowd? Because they discuss comic books, of course (“Batman can beat Superman?! Man you need a shrink to take a look inside that crazy head of yours.”) Seriously, we know they’re a bad crowd because they’re cruel to animals. When we first meet gang leader Ballser, he is teasing a caged squirrel. This is followed by kicking pigeons, torturing goldfish, shooting junkyard dogs and throwing a kitten off an overpass onto a busy freeway below.

Luckily, Superman happens along just then (you knew he had to be in this comic eventually, after all his name is on the cover) and catches the kitten. Next, he stops a fire at the local chemical plant and manages to save Tommy’s dad. Watching Superman, Tommy realizes that it’s wrong to “pick on anyone weaker than you.”

Meanwhile, Ballser and the rest of the gang (Charlie, Donuts, and Eightball — no, really, that’s their names) have killed the science teacher’s pet squirrel. Tommy confronts Ballser and a fight breaks out between the two of them. Tommy lands the first punch, but then Ballser punches him repeatedly, first with his fists and then with a handy CD rack. Finally, he throws a small suitcase at Tommy. This suitcase conveniently breaks open, spilling out dozens of collars of local pets that had gone missing or been killed. Horrified, the rest of the group finally realized that hurting animals is bad (well, except for Ballser who attempts to go after Tommy with a baseball bat.) Tommy, Donuts, Charlie and Eightball fess up to the science teacher, and to make amends Tommy and Donuts volunteer at the local animal shelter. Ballser meanwhile finds himself dealing with the police and “sent into heavy duty therapy with a psychologist.” Tommy adopts the cat Superman saved, and then he and Donuts discover something better than maiming innocent animals: girls.

Besides the story and five pages of DC house ads, Superman for the Animals also contains a the alliterative Comics for Compassion Coloring Contest, where children 8-12 got to color a picture of Superman and tell DC Comics how they would help animals if they had super powers. The winner got the chance to appear in a DC comic along with their favorite pet. Sadly, I don’t know if this ever came to pass.

Other Interesting Facts about Superman for the Animals:

• The New England Anti-Vivisection Society (NEAVS) was originally scheduled to run a full color ad in the comic, but DC got cold feet at the last minute and canceled the ad “faster than a speeding bullet” NEAVS’s website tells us. The ad was then scheduled to run in the first issue of Bongo’s Bart Comics. (I can find no listing of any Bart Comics, I assume they mean Simpsons Comics Present Bart Simpson).
• Being cruel to animals is one of the diagnostic criteria for conduct disorder.
• 67,000 copies of the comic were released to comic book stores, packaged with copies of Batman: Gotham Adventures, Superman Adventures, Stars and S.T.R.I.P.E., Impulse, and Hourman (where I found my copy). I don’t think any of these titles still being published today. Not a good sign.
• An additional 6,500 copies were distributed by the Doris Day Animal Foundation to scout troops, social workers, school teachers, and social workers. Sadly, their supply is now exhausted and the comic remains out of print. However, it seems that their second Comics for Compassion, X-Men Unlimited #44, is still available.
• A vegetarian activist site proudly proclaims that “Mark Millar, author of Superman for the Animals, is a vegetarian.”
• Superman for the Animals can currently be found on eBay for $1-2, X-Men Unlimited #44 for 99?, and Simpson Comics present Bart Simpson can usually be found for 99? as well. Collector’s items each and every one. But them, save them, and send your kids to college.

Tags: comics psa superman mark millar tom grummet

Roughly half of this week’s 52 takes place in a hospital. I’m going to take a brief look at those scenes from a medical point of view. There are plenty of spoilers below, so be warned.

As always, I find the the concept of a hospital devoted to superheroes fascinating. It’s been done before in the small press (Antarctic’s Metadocs most notably), but this is the first time I remember seeing it in one of the “big two.” Plus it’s always nice to see Dr. Midnite. Douglas over at 52 Pickup does a nice job explaining who St. Camillus was (and he’s right about the art as well — I think the majority of the problems I noticed were art related).

I genuinely enjoyed the hospital scenes. Please remember that as I proceed to nit-pick them to death.

1. Cyborg/Firestorm

• “Time-Freezing Drugs” — must be nice. (page 7)

2. Mal Duncan

• Why does he have cardiac electrodes on his abdomen and none on his chest? (page 8)
• Septicemia means that there are infectious bacteria running rampant in his blood stream. (page 8)
• Pseudocytes. Sounds like they’d work, in a science-fiction kind of way. Otherwise it probably wouldn’t be a good idea to give Mal standard transplant drugs to resist rejection since they’d lower his immune system, and he already has a nasty infection. (pages 8, 9)
• That’s sure a screwed up rhythm on the bed monitor. It looks like a nasty ventricular tachycardia. Regardless, it sure is convenient the way it starts and stops precisely within the confines of the monitor. (page 13, upper left)
• Counseling. Good call, Steel. It’s nice to see someone address the fact that healing is not always just physical. (page 13)
• It would be nice to know what kind of arrest Mal is in. It could be cardiac arrest, respiratory arrest, or both. His heart rhythm was nasty, but remember Dr. Cross “didn’t like the sound of this young man’s breathing” (and why’s he complaining to the nurse rather than doing something about it?). If it is a cardiac arrest, it would be nice to know more, such as what kind of rhythm – if any – the heart is showing. The treatment varies depending the rhythm. (pages 13, 16)
• It looks like Mal’s gone into flash pulmonary edema, where the lungs quickly fill with fluid; this would explain the frothing at the mouth. (page 13, lower right)
• Full credit to the team for remembering the ABCs. Not only are they treating the heart (C = cardiac), but also the A and B (airway and breathing). (page 16, upper left)
• I was going to say that it’s nice to see Dr. Cross remembered to perform CPR, but then I noticed his hands: they’re in the wrong position and on the wrong part of the body. Also notice that the heart rhythm on the monitor looks good in this panel. At first I assumed that was the monitor of the next patient over, but page 8 shows no patient on that side of Mal. (page 16)
• Defibrillating (shocking) a patient in ventricular fibrilation or ventricular tachycardia is reasonable. It is not a good treatment for a patient in asystole (no heart rhythm). Defibrillation is a controlled application of direct current – enough to capture the heart rhythm, but not enough to fry the heart. I’m assuming Steel’s armor has all sorts of fancy equipment in it, because otherwise trying to restart someone’s heart using the AC current directly from a junction box would be foolish at best, but more likely lethal. (pages 16, 17)

3. Hawkgirl

• So she’s now 25 feet tall. This is the perfect example of the Square-Cube Law I mentioned last fall. She is now 4 times her normal size, but would weight 4³, or 64, times normal. Hawkgirl would barely be able to breath or pump blood. (page 6)
• I’m not sure what they’re doing with that giant electrical device on her chest — maybe it’s an external pump for her heart/lungs (?) – but I sure would have kept a twenty-five foot patient tied down. (page 16)

Tags: comics medicine 52 dr midnite steel ventricular tachycardia ventricular fibrillation asystole abc

It’s been a year since I took my last look at pregnancy in comics so I think it’s time to take an updated look. In the past few months alone, Selina had her baby, and unlike Jessica Jones, managed to have a pregnancy of less than a year (how long was Jessica pregnant anyway, 2 or 3 years?). As always, comments, corrections, and suggestions are appreciated. Thanks to everyone who has contributed in past years.

Heroes:
ADAM STRANGE
1. Alanna dies during childbirth.

ANIMAL MAN
1. Annie was pregnant and gave birth in the last issues of the series.

AQUAMAN
1. Dolphin and Garth (Tempest) had a son, Cerridan.
2. Mera’s pregnancy happened “off camera.
3. In the Atlantis Chronicles: Cora was raped by her cousin Dardanus and gave birth to Kordax (pregnancy not shown). Also Atlanna had a tryst with her ancestor Atlan and gave birth to Orin (Aquaman). This pregnancy was shown.

AVENGERS
1. Ms. Marvel was pregnant*
2. Scarlet Witch’s pregnancy was shown in the Scarlet Witch and the Vision mini-series, though her twins were later ret-conned out of existence. This led her to become murderously insane and then crossover-miniseries-murderously insane**. Apparently, the children have now shown up as characters in Young Avengers.
3. Jessica Jones was pregnant for what seems like years, and delivered a healthy baby.

BATMAN COMICS
1. Spoiler was pregnant and gave her child up for adoption in Robin; she later died during Wargames.
2. Francine (Man-Bat’s wife) was pregnant in the Batman titles in the 1970s and gave birth in Batman Family #17.
3. Batman and Talia had a son in the more-or-less non-canon Son of the Demon (though the pregnancy was pretty much “off screen”

CATWOMAN:
1. Selina gave birth in the first “One Year Later” issue of Catwoman. The pregnancy has not been shown (it was in that one year time gap) and the identity of the father is unclear at this point.

FALLEN ANGEL
1. Lee conceived a child with Juris. She let him think that she had miscarried after a fight with Boxer, but instead handed her son over to a nun.

FANTASTIC FOUR
1. Sue Richards had Franklin, and then lost her second pregnancy. A magical/time-stream induced third pregnancy gave the Richards a daughter, Valeria.
2. Lyja Storm was pregnant and gave birth to an egg.
3. Crystal and Pietro (Quicksilver) have a daughter Luna. Reed Richards (apparently an obstetrician in his spare time) delivered the baby.

FLASH
1. Iris was pregnant with twins at the time that the silver age Flash (Barry Allen) died.
2. Linda West lost twins due to an attack by Zoom. There was some question as to whether she would be able to become pregnant again. However, after another melee involving the timestream, Linda suddenly found herself very pregnant (from 0 – 9 months in seconds) and delivered a healthy set of twins.

HARBINGERS:
1. Kris Hathaway was pregnant and gave birth to the child who would be sent to the future to become Magnus, Robot Fighter.

INCREDIBLE HULK
1. Betty Banner was pregnant, but miscarried.

IRON MAN
1. Pepper Potts was pregnant, but miscarried.

JLA
1. Sue Dibny was pregnant when she was killedin Identity Crisis #1

JSA
1. Hawkgirl was pregnant as a teenager and gave the child up for adoption.
2. Dove was raped by Hank Hall (Hawk) and later gave birth to a child who ultimately ended up housing the soul of the new Dr. Fate, Hector Hall.
3. Power Girl was mystically impregnated by her grandfather Arion so she could give birth to the prophesied demon fighter Equinox.

INFINITY INC.
1. Hippolyta Hall was pregnant a long time, and ultimately gave birth to Daniel (who was taken from her by Morpheus to become the new Sandman).

KILLRAVEN
1. Carmilla Frost discovered she was pregnant in the Killraven graphic novel.

LOSH (1)
1. Garth Ranzz (Lightning Lad) and Irma Ranz (Saturn Girl) had twins. (Twins are the usual on Garth’s home planet of Winath; however, twins are determined maternally and Irma come from Titan. Plus are the twins fraternal or identical? Both have been shown on Winath in the series.)

LOSH (2)
1. In the “five years later” Legion, Night Girl was not only married to Cosmic Boy, but also pregnant.
2. Laurel Gand had a child by Rond Vidar.
3. The Ranzzs had a second set of twins during the five year gap.

LOSH (3)
1. Apparition (Tinya Wazzo) and Ultra Boy (Jo Nah) have married and had a child (Cub).

L.E.G.I.O.N.
1. Stealth had a child by Vril Dox.

MANHUNTER
1. Kate Spencer miscarried after a fight. She had not been aware she was pregnant.

MIRACLEMAN
1. Liz Moran gave birth in Miracleman #9.

MR. MIRACLE
1. Beautiful Dreamer was pregnant and gave birth.

NOBLE FAMILY
1. Zephyr became pregnant after a spiteful “night of passion” with her family’s greatest enemy. She delivered a healthy child, but it was stolen and she informed that her child had been stillborn.

SABRE
1. Melissa Siren was pregnant and gave birth in Sabre.

SQUADRON SUPREME:
1. Arcanna Jones was pregnant for most of the limited series, and gave birth sucessfully.

STARMAN
1. Jack fathered children with the Mist (see below) and his significant other, Sadie.

SPIDER-MAN
1. Mary Jane was pregnant but miscarried when one of Norman Osborne’s flunkies poisoned her before she gave birth (there is some debate online about whether she actually miscarried or the baby was stolen by Osborn).
2. Gwen Stacy had twins after an ill-advised tryst with Spider-Man’s greatest enemy: Norman Osborn (the Green Goblin).
3. In the Spider-Girl universe, Mary Jane’s second pregnancy was shown in detail.

TEAM TITANS
1. Donna Troy was pregnant at the beginning of this series. Her husband and child died in a car accident, and then she died in Graduation Day. She came back (again), but has yet to mention her family.
2. Mirage was pregnant at the end of the series and has since been shown with her infant daughter Julianna (Refresh my memory: was the father of Julianna the evil future Nightwing? And was it consensual?).

X-MEN
1. Madelynne Prior was pregnant with Scott Summer’s child (and gave birth to him) in the Uncanny X-Men. This child later went on through a very convoluted storyline to become Cable.
2. Wolverine left a pregnant lover behind in the Savage Land in the one-shot Wolverine: The Jungle Adventure (though it’s not 100% certain that he’s the father).
3. According to one of the tales in Classic X-Men, Colossus also fathered a child during a visit to the Savage Land (pregnancy off camera).
4. Angel Salvadore and Beak had a brood of flying beaked kids. Angel laid eggs, so I’m not sure you would necessarily call her pregnant.

Villains:
Punch & Jewlee
1. During their time inSuicide Squad, Jewlee suffered morning sickness and discovered she was pregnant. She and Punchh left the team soon thereafter and the pregnancy and delivery were “off camera.” They later showed up in Hawk & Dove toting a toddler.

Chesire
1. Gave birth to Lian, fathered by Speedy/Arsenal (Roy Harper). The pregnany was entirely off-camera, and Roy didn’t know he was a father until well after the fact.
2. She seduced Thomas Blake (Cat Man) in Villains United, allegedly for him to father a child for her.

Mist
1. Had a child by Jack (Starman). Pregnancy was entirely off camera.

Star-Sapphire
1. Raped by Predator (another of Carol Fenris’s alternate personalities) and impregnated in Green Lantern #43. Gave birth sometime during Extreme Justice.

Non-Super-Hero:
FABLES: Snow White became pregnant after a drug-induced night with Bigby. She later gave birth to a litter of wolf/human hybrids.

Y: THE LAST MAN:
1. Beth is pregnant with Yorrick’s daughter (note that this is not fiancee Beth, but another one)
2. The female astronaut conceived a child with one of her fellow astronauts and has delivered a healthy son

HELLBLAZER:
John Constantine’s birth was shown in detail, including the death of his mother and twin.

LUCIFER:
Jill Presto is mystically impregnanted by a magic deck of cards.

SWAMP THING:
Swamp thing used the body of John Constantine to father a child on Abby, unaware that John was tained with demon’s blood. Abby ultimately gave birth to Tefe. Not sure if pregnancy was “on camera” or not.

STRANGERS in PARADISE:
Francine miscarried.

ELFQUEST is chock-full of pregnancies and births. I’m not conversant enough with the series to comment.

Characters UNABLE to become Pregnant:
1. Black Canary – Sustained tortue injuries in Green Arrow: Longbow Hunters that rendered her sterile. Her recent dip in a Lazarus pit may have reversed this.

2. Firestar – Using her powers will cause her to become sterile. Hank Pym developed a costume for her that repairs the damage.

*Explanation per Matt Rossi: “Ms. Marvel was impregnated originally by Immortus’ son, who used the devices of Limbo to draw her to him, make her fall in love with him, and then implanted himself into her via some freaky Limbo technology. She then was sent back to Avengers mansion where she gave birth in an extremely short amount of time and the baby was Marcus, Immortus’ son (the one who impregnated her, remember) and then the baby, too, grew up rather remarkably quickly while time itself went ape because Marcus, concieved and born in Limbo, was a being out of time and his mere presence, not to mention the twisted nature of his self-conception into our world and the rapid time displacement, was shattering causality. Eventually Marcus agreed to go back to Limbo but pledged his love for Ms Marvel and asked her to come with him to Limbo, which she agreed to do and the Avengers let her (this was later pointed out to have been a really dumb move.) …I’ve simplified this immensely.”

**Explanation per Chris Arndt: “At first they were magically concieved from the Vision and Scarlet Witch’s love. I mean, how else could they do it? The Vision may be a synthezoid, but I bet he lacks swimmers. Heck, in Avengers West Coast, John Byrne revealed that the Vision didn’t even have external equipment, so to speak. Anyway, eventually it was revealed that the kids souls were re-allocated chunks of the major WCA villain at the time, Master Pandemonium. Mephisto stole his soul, broke it in five chunks, and Scarlet Witch accidentily made off with two of them when she started concieving babies; turns out creating life was beyond her; she still housed souls but later the housing disappeared when her thoughts were not specifically on her children. Raw deal. Her memories of the kids were erased to remove the trauma. All in all it turned out to be a good story but definitely something too dark for an all-ages comic. The worst part is that it was part of Byrne’s de-construction of the Scarlet Witch. She made up her children; she forgot her children; most readers assumed that the Vision was anatomically on-model and as Star Trek’s Data puts it “fully functional” and then Byrne revealed that the synthezoid lacked a male member (and based on dialogue the sudden absence wasn’t a noticeable change) which would essentially de-humanize the character to the greatest degree and thus make the Scarlet Witch the sickest she’s ever appeared to her fans. You can fool a legion of nerds, geeks, sci-fi fans, and whatnot into thinking she married a man if they’re given the impression that the Vision is a man but for his origins. It’’s harder to achieve the idea that she married anything but a robot, something with a life value or even a sexual value equevalent “to a toaster oven” when the robot in question has no Mr. Happy!”

Tags: comics medicine pregnancy

Some more thoughts on the concept of the über-doctor. As far as I’m concerned, to be considered an über-doctor, a character must meet three criteria:

1. Hold a doctorate, a medical degree, or the equivalent.
2. Multiple instances of demonstrated expertise outside their stated field of study (or expertise in everything if no specific field of study is mentioned)
3. The ability to build wicked-cool gadgets

Tags: comics medicine über-doctor

The Sunday before Memorial Day is one of my favorite days of the year. Friends come over, the barbecue is fire up, and we settle in for 1100 miles of racing good news.

My family’s originally from Indianapolis, so we’ve always watched the Indianapolis 500. I did my Family Practice residency in Indianapolis and lived a little over a half-mile from the track; every May I loved the fact that from my back porch I could here the cars practicing. I was hoping Michael Andretti would finally have his chance to win, and while he was leading with four laps to go, it was mostly due to pit-stop timing and he clearly didn’t have a car that stood a realistic chance of winning. It looked like his son Marco would be able to pull it off, but Sam Hornish was able to pass him in the last few hundred yards. While it would have been nice for an Andretti to win, Hornish has had his own problems in past Indianapolis 500s, so he deserved a win too.

In the evening is the Coca-Cola 600, the longest — and usually one of the best — NASCAR races. Kasey Kahne’s speed is impressive this year, both in qualifying and race day. Tony Stewart looked like he was in a great deal of pain, particularly arm pain, and I would not be surprised to find out he’s got more of an injury than they’re letting on — probably a rotator cuff injury. And Kyle Busch – what a complete ass! He’s worse than his brother ever was.

(I managed to slip in watching some Giro d’Italia between the car races. The Giro is the premier Italian bicycle race. From what I’ve seen so far in the Giro and earlier races, Ivan Basso looks like the man to beat for this year’s Tour de France).

In between the two races, I fire up the grill. This year, I cooked several racks of my special spare ribs, some authentic smoked sausage from the local butcher’s, and some ginger/wasabi chicken for the Polite-Wife. I also cooked up a surprisingly sweet black bean and roasted pepper relish. We topped it all off with a Tortuga rum cake.

All in all, a satisfying, if calorie-laden, day.

Tags: indianapolis 500 nascar barbecue

The American Way #3 “Book Three: Let the Word Go Forth”
John Ridley, writer
Georgen Jeanty, penciler

In the middle of the issue, the super hero Secret Agent confronts a murderer at the site of his crime. The killer is holding a young boy hostage, but that doesn’t slow down the Secret Agent: he fires a bullet that ricochets around the room before clipping the murderer in his back.

Narration by Secret Agent: I crease the guy easy. Hit him right in the T7 vertebra. He’ll be a quadriplegic for the rest of his sorry life.

Just one problem there, Secret Agent: a spinal cord injury at T7 leads to paraplegia, not quadriplegia.

The spinal column is made up of 5 sets of vertebrae. The cervical vertebrae (C1-C7) are in the neck, the thoracic vertebrae (T1-T12) are in the upper back, the lumbar vertebrae (L1-L5) are in the lower back, followed by the 5 sacral vertebrae (which in most people are fused together), and finally the coccyx (or tailbone).

The spinal column protects the spinal cord. As the cord moves down from the brain, a pair of spinal nerves split off at the level of each vertebra. These nerves innervate different parts of the body depending on which level they are from. For instance, the C2 – C5 nerves innervate the neck and the back of the head. C5 also supplies some of the nerves to the hand and arm, as do C6, C7, C8, and T1. The thoracic nerves innervate the chest and abdomen. The lumbar nerves innervate the lower back and along with the first two sacral nerves (S1 and S2), supply nerves to the legs.

When a spinal cord injury occurs, it wipes out everything below the injury, but does not affect nerves that split off higher than the injury. A T7 injury would lead to paralysis of the legs and lower trunk and loss of feeling below the rib cage, but it would not cause quadriplegia.

*There are seven cervical vertebrae but eight cervical spinal nerves. Why? Because that’s how they were named. Just one of those wonderful bits of knowledge you learn in medical school.

Tags: comics medicine american way spinal cord paraplegia quadriplegia

I will be hosting Grand Rounds next Tuesday, May 2nd. Please e-mail any submissions to me no later than 8PM central time, Monday May 1st.

Submissions should be sent to: grand@politedissent.com.

When I receive your submission, I’ll fire back an e-mail so you know I’ve gotten it. If you haven’t received a confirmation note in 24 hours, it’s probably best to send you submission again. Thanks.

It’s another in the series of HIV and AIDS public service ads that DC ran in their comics in the early ’90s. This particular ad features Blue Beetle (the late Blue Beetle), Booster Gold (in what must be the ugliest costume ever), and Fire (though now that I look at it, her costume is pretty ugly too). It was found in Flash #87 (February 1994).

Brazil, Fire’s home country, has been hit hard by the AIDS epidemic. It saw its first case of AIDS in 1983 and now has over 600,000 individuals living with AIDS or HIV. Brazil accounts for 57% of the AIDS cases in Latin America and the Caribbean. Despite this, or because of this, Brazil has one of the world’s most aggressive HIV treatment and prevention programs in the world.

Click on the image to the left for the full size ad.

Tags: comics medicine psa hiv aids

Having trouble getting girls to dance with you? It could be that you’re too Brainy, Emotional, or Muscular. Girls don’t want any of that! What they want is a BEM (which surprisingly does not stand for Bug-Eyed Monster).

Click here or on the panel to the right to see the full PSA

This helpful 1967 PSA is from Superman’s Girl Friend Lois Lane #74 (as well as Superboy #138 and The Inferior Five #2). The art is by Sheldon Moldoff working from a script by Jack Schiff.

This PSA was provided by the National Social Welfare Assembly, the same group that not only brought us the Mysterious Unnamed Doctor™ PSA, but also seemed to sponsor most of the Silver Age single page PSAs.

Tags: comics psa national social welfare assembly jack schiff sheldon moldoff

UPDATE: Error found and fixed. The pop-up image should now work in both IE and Firefox.

[This post marks the beginning of an occasional series on various medical diagnoses that are -- if not unique to comic books (particularly super hero books) -- generally restricted to comics and related genres and media. While most of these diagnoses are entirely imaginary, some are genuine conditions -- only re-imagined in a way only comic book writers can.]

I’ll start off with an oldie but goodie: Frozen Solid.

Classically, villains (and sometimes heroes) encased their victims and opponents in ice. They were trapped for a time, and undoubtedly very cold, but otherwise unharmed.

Medically, the largest risks involved were frostbite on exposed skin and hypothermia. Also, looking at some of these images, I think suffocation would have been a significant concern because it is damn hard to breathe through ice (Go ahead — try it. Get an ice cube from the freezer and just try to breathe through it).

Even in today’s comics, this remains the preferred use of ice:

In recent years, things have gotten more dangerous. Some villains are no longer content to just immobilize their opponents, but instead freeze them through. This can prove fatal as shown in one of the early Gotham Central storylines and the sadly overlooked one-shot Firebirds.

Medically speaking, the rapid freezing of body tissue is extremely damaging because it disrupts cell membranes and kills the cells. That’s the main reason we use liquid nitrogen to treat warts. Frankly, even if the frozen victim wasn’t shattered, they would never survive being frozen solid.

In the real world, I’m not aware of any cases of anyone every being rapidly frozen (fatally or otherwise) similar to comic book scenarios. Forozen bodies are common though; it seems that not a year goes by without a dead frozen body being found somewhere in the world, here a two recent examples:

• The Iceman of the Alps
• Frozen WWII Flier

You’ll notice that in all these cases the person ended up frozen after death.

---

FINAL NOTE: Don’t ask me to explain Captain America other than the fact that it was a fairly slow freeze and he had the benefit of the Super Soldier Serum

Tags: comics medicine ice frozen mr. freeze iceman icicle

It’s time for my bimonthly look at what search terms brought people to Polite Dissent over the past two months. Sure, it’s a lzay post — but a fun one.

Common search terms:

• Weird n Wild creatures, Scottie from Mythbusters, and D&D module X2 (Castle Amber)

Trivia (Some people are clearly entering trivia questions verbatim as search terms. This is particularly evident in the last question as it starts out with the category. Click and drag the mouse to reveal the answer.)

• What cable hit is introduced by the voice over what happens when people stop being polite and start being real? Answer: The Real World
• Drs Kildare and Gillespie could be found in which hospital? Answer: Blair General
• gen x tv before coming to WKRP johnny fever got fired for saying what word on the air? Answer:Booger

Medical Concerns:

• Humorous spiral fracture Spiral fractures are rarely funny, at least to the people who have them. I suspect you want information on a spiral fracture of the humerus.
• Strep throat involving blisters on plate of mouth Blisters on the roof of the mouth are more suggestive of a viral sore throat than a strep throat.
• How many vials of csf are take during lumbar puncture? Usually four.
• What can I do to lower my blood pressure besides medicine? The big three: Healthy diet (low sodium), weight loss, and aerobic exercise — lots of it.

Alternative Medicine:

• Blood type O personality traits I hope I don’t have to tell you that any connection between blood types and personality is nonsense. Still, it is a common concept in many Eastern cultures and shows up in manga from time to time.
• Homeopathic remedy scaphoid fractures First, homeopathy is a ridiculous concept and doesn’t work. Second, no medicine can fix a scaphoid fracture. Third, scaphoid fractures can have long-term consequences if not repaired, so I’d suggest going to see an actual medical doctor.
• Incurable autoimmune disease natural cures Anyone else see the logical error here?

• Mistletoe side effects homeopathy Homeopathic remedies are nothing more than water, so there should be no side effects.

You People Are Sick (presented without comment):

• Wonder girl chloroform
• Sarah sutton dr who nyssa bondage
• How many seasons of Full House are there on DVD
• Self-circumcision clamp

I’d be Interested to Know What They Were Thinking:

• nuns & comics
• comic books with sodium involved
• sputum fantastic 4

Miscellaneous:

• Hostess cupcakes. For some reason, it pleases me to know that my site turns up in a search for “Hostess Cupcakes.”
• Playlists for depressing songs. I suspect it depends a great deal on your taste in music. I consider Billy Joel’s Captain Jack to be one of the most depressing songs ever. And one of my friends in college felt that if you could listen to the Pink Floyd album The Final Cut all the way through and not contemplate suicide, then you were uncommonly stable (or in denial)
• Bode Miller fanfiction. You can tell it’s fiction because Bode actually wins.
• Digital Fortress is the worst book ever. I agree it’s not a good book, but there are worse books out there. I mean, I actually finished this book and there are many books so bad I couldn’t finish them (one that springs to mind as an overly praised work I could never finish is A Confederacy a Dunces.) Digital Fortress does follow the same plot Dan Brown uses in every book.
• inttel inside idiot outside What’s funny is that they spelled Intel wrong

Batman: Gotham Knights #73 “Payback”
A.J. Lieberman, writer
Diego Olmas, penciler

The Set-Up: Three people in Gotham City suffer sudden cardiac death: a traffic copter pilot, a business woman, and a train engineer. Autopsies showed that not only did all three of these people die of a heart attack, but that they all had a particular model of pacemaker made by WayneTech. Batman deduces that somehow someone is overriding the pacemaker’s frequency leading to a rapid heart rate which causes a heart attack. He accuses Hush, but he knows nothing about the pacemakers.
It turns out that the Joker has taken up bird training and has been using a clicker to train his birds. Coincidentally, he has discovered that this clicker causes WayneTech pacemakers to speed up so much that they cause heart attacks. He decides to use this information to get back at Hush and Batman.

Topic One: A big typo. This is one of those typos that strikes me as funny because it actually changes the meaning of the sentence significantly.

Medical examiner: “…Each one of these people died of amyocardial infarction.”

It should be a myocardial infarction, not amyocardial infarction. Myocardial infarction is the medical term for a heart attack. There is a blockage in one of the arteries that supplies the heart with blood and consequently part of the heart dies from lack of oxygen. If a big enough portion of the heart dies, the patient will too.

Amyocardial is not a word. But bear in mind that the prefix “a-” when added to medical terms means “without” or “absence of” — for example asplenia refers to someone who is lacking a spleen. Therefore amyocardial infarction would be an infarction not involving the heart.

Topic Two: The autopsies. Sloppy, sloppy work. Autopsies use a Y incision, not the chainsaw-style down the middle incision shown here. The medical examiner is also mixing specimens up. The three pacemakers should be kept separate and labeled, not all kept in one bin.

Topic Three: The pacemakers. Well drawn. Good job.

Topic Four: Could the Joker’s plan really work? Could you increase a pacemaker’s rate enought that it would be fast enough to kill someone? Theoretically yes, but death would probably be from a fatal rhythm, not a heart attack.

There is a rare phenomenon known as runaway pacemaker. In these instances, the pacemaker’s rate increases to an incredibly rapid level. In the early days of pacemakers (the 1970s), this led to a few deaths from a lethal arrhythmia known as ventricular fibrillation. In today’s modern pacemakers, runaway pacing can happen, but only very rarely, and there have been no deaths associated with it for many years. There are two main reasons for this: 1) pacemakers have a programmed upper limit to their rate, and 2) the faster the pacemaker fires, the lower the voltage, so at high rates it doesn’t give off enough electricity to start a contraction. The most common symptoms of runaway pacing are dizziness, light-headedness, and the sensation of an irregular heart beat.

Theoretically, I could imagine that a rapid heart rate from a malfunctioning pacemaker might cause a heart attack in a susceptible individual, but there have never been any recorded cases of this happening. If a malfunctioning pacemaker were to cause a rapid heart rate leading to death (a very big if), it would be more likely from a fatal heart rhythm than from a heart attack.

Tags: comics medicine joker hush batman autopsy pacemaker heart attack ventricular fibrillation

A Monday episode of House brings us a young model and an interesting diagnosis. By the way, this medical review contains a few spoilers, so don’t say I didn’t warn you…

Alex, a 15 year old super-model, complains of feeling nauseous and is profusely sweating. Her father gives her a Valium and a drink of his champagne to calm her down. She heads on down the catwalk but stumbles. She experiences double vision and punches another model who tries to help. Finally, she collapses on the runway.

Alex is admitted to the hospital for evaluation of her collapse (though she describes it as more of a cataplectic attack). She admits to feeling sweaty and nauseous for a while. A history also reveals that she has yet to start menstruating. Lab tests are drawn and all are normal except for drug screen which comes back positive for “Valium” and “heroin.” The Valium can be explained by the pill her father gave her, but the heroin suggests to the team that she is suffering heroin withdrawal (I should point out that these tests are not that specific, so would have come up “benzodiazepine positive” and “opiate positive”, without identifying the specific drugs. For all we know, Alex could have been taking Xanax on her own in addition to the Valium her father gave her…)

The differential diagnosis includes heroin withdrawal, juvenile multiple sclerosis, and Parkinson’s syndrome. House suspects most of her symptoms are due to the withdrawal, but he wants her completely free from heroin so he can ensure that just the withdrawal was causing her problems. He decides to pursue a rapid detox. Basically, Alex is placed in a medically-induced coma and fed naltrexone. Naltrexone blocks the opioid receptors and sends the patient into a complete and immediate withdrawal. It is a risky procedure, but a real one and there are centers that specialize in it.

Alex suffers some sort of cardiac arrest during the coma. They refer to it several times as a “heart attack,” but it seemed more a rhythm problem than an actual heart attack (and if it was a heart attack, they did absolutely nothing to treat it or to prevent the next one). After she comes out of the coma, she has a problem with her short term memory, repeating the same questions over and over. The team is concerned that Alex may have suffered brain damage due to oxygen deprivation from her “heart attack.” House isn’t convinced. He feels she wasn’t without oxygen long enough to cause a problem; he suspects Post-Traumatic Stress Disorder (PTSD) because he thinks her father sexually abuses her. He orders an MRI and an LP (lumbar puncture) and he goes to have a chat with her father. The team tries to get an MRI, but Alex develops an uncontrollable muscle twitch so they can’t proceed with the test. They are able to perform a lumbar puncture which shows increased protein in her cerebrospinal fluid.

The doctors are now concerned about that Alex may have any one of a number of brain diseases including viral encephalitis, CMV (cytomegalovirus), and CJD (Creutzfeldt-Jakob Disease). House wants to proceed straight to a brain biopsy (instead of getting a CT scan, or sedating her for an MRI). The brain biopsy shows no white matter disease, so the team now starts to focus on the grey matter. Foreman lists off a whole string of rare neurological diseases and House suggests that it may be paraneoplastic syndrome. Paraneoplastic Syndrome is a rare disease that occurs when a person has cancer and their body attempts to make antibodies against the tumor. These antibodies misfire, and affect the person instead, causing a whole range or symptoms including weakness, memory loss, and problems with coordination.

Alex is given IV immunoglobulin and she stops twitching. This supports the diagnosis of paraneoplastic disease because the immune globulin is thought to block the antibodies causing the problems. She is now subjected to test after test trying to find the tumor House knows must be there. Small ovaries seen on a pelvic ultrasound, but every other test is normal.

House is still convinced there is cancer somewhere. The rest of the team are still thinking it may be PTSD since her father did admit that he had slept with her. House has a burst of insight and gets an MRI of Alex’s pelvic area. He discovers that Alex has “male pseudohermaphrodism” and has testes instead of ovaries. A tumor on one of these testes is what has given Alex her paraneoplastic syndrome and explains away all her symptoms. The tumor can be removed surgically, but what can be done for Alex who thought she was a she but may be a he (depending on how strictly you choose to define the terms). I think the psych consult was a good idea.

---

The mystery was interesting and the final solution clever. I have only one major complaint about the final diagnosis (or rather, how they missed it), which I’ll get into