Polite Dissent

Supergirl #49 “Death & The Family”
Sterling Gates, writer
Matt Camp, artist

Lana Lang has been found down and bleeding profusely. She is rushed to the emergency room for resuscitation.

There’s a few things wrong with this scene:

First, they’re shocking a flatline. I’m sure I’ve mentioned at least once before that this is not how to treat a flatline.

How should they proceed? Asystole (the fancy, medical word for a flatline) is tough to treat, and the odds are against you from the start, no matter what television tells you. The key to treating asystole is to correct the underlying cause. One concern: Lana’s lost a lot of blood — there’s at least two panels of her laying supine in large puddles of blood and the staff is splattered with blood. As far as the ER staff is aware, this blood loss is a possible cause of her condition, yet they’ve done nothing to treat it. There’s no blood being transfused — in fact, there’s not even a single IV line, which are important in any resuscitation. (As an aside, the defribrillation paddles are also reversed: the upper paddle should be on Lana’s right, and the lower on the left)

Second, as fancy as that face mask is, it’s not going to be any good at getting the air she needs down into her lungs. I appreciate the fact that Cage at least added a breathing tube entering her mouth, but it’s too narrow to be any use (it needs to be about the width of a thumb to work). Plus, if she’s got a breathing tube in place, why does she need a mask?

Third, Lana is bleeding from her mouth, nose, and eyes. If you were the ER staff, what’s one of the first things that would cross your mind? Hemorrhagic fever (Ebola, Marburg, and for the comic-inclined, the Clench). Sure, none of them are endemic to the US, but in this day and age, who’s to say Lana hasn’t been traveling, or exposed to someone who has? The ER staff would be wearing a lot more protective gear.

On the positive side, fzzCHOOMPH is the best sound effect I’ve seen in quite a while.

Tags: comics medicine lana lang supergirl resuscitation sterling gates matt camp

The team in this week’s episode of House followed a more logical approach to the patient, but they were still hampered by bad medicine. But hey, an opossum!

Daryl is a 22 year-old college football player hoping to be spotted by pro scouts. In the middle of practice, he suddenly becomes uncontrollably violent. He grabs his opponent and drags him around by his helmet until it finally comes loose, and then he bashes himself in the face repeatedly with the helmet until he starts bleeding.

He is admitted to the hospital for evaluation, but has no memory of the incident. A head CT scan and a psychiatric evaluation — both obtained in the Emergency Room — were negative. House suspects Daryl’s symptoms are due to steroids, even though he tested clean in the Emergency Room. He believes he is on the “good stuff,” i.e. steroids that don’t show up on tests. The rest of the team suspects a pituitary adenoma (a tumor in the pituitary gland) caused by repeated head trauma. Tests for GnRH (gonadotropin releasing hormone, which controls the gonadotropins, which control the production of testosterone in men) are high, but a pituitary MRI is negative, which lends credence to House’s theory of steroid abuse. He tells the team to start Daryl on a somatostatin-analog (a medication which inhibits the pituitary gland) to block the effects of the elevated GnRH.

Daryl denies any use of steroids and begins to suffer a racing heart rate and chest pain. He has an episode of paroxysmal tachycardia (sudden onset of an abnormally fast heart rate) that requires cardioversion to return it to a normal rhythm (by definition “cardioversion” means returning the patient to a normal heart rhythm. This can be done chemically, such as with adenosine, or electrically). Taub reports that the cardiac symptoms do not fit the diagnosis of steroid abuse, so the team gives Daryl’s heart a further work-up including EKG and sestamibi scan (a test that looks at perfusion of the heart itself), but they are completely normal. The differential diagnosis now consists of a PFO (patent foramen ovale, a hole between the two sides of the heart) or hypertrophic cardiomyopathy (muscular thickening of the heart). House favors the latter and has the team put Daryl on a treadmill to stress him until he develops cardiac symptoms. Unfortunately (or fortunately, really), Daryl is in good enough shape that his heart rate never rises high enough to cause a problem. Going for “plan B”, House decides to chemically induce heart stress by injecting Daryl with a vasodilator (such as adenosine or dipyridamole — they mimic the effects of exercise on the heart). Before he injects the medication, however, he notices that the palms of Daryl’s hands are unusually white.

This new symptom causes the team to reassess their diagnosis. Taub thinks Daryl’s pale hands are due to Raynaud’s phenomenom (spasm of the smooth muscles around the small arteries of the fingers), which he thinks is caused by rheumatoid arthritis. Thirteen suspects that Daryl has plaques in his arteries, and these are breaking off and sending tiny clots blocking the arteries in his hands. Chase believes Daryl has Takayasu arteritis (inflammation of the aorta and other large arteries), and Foreman, ever the optimist, blames lymphoma. House likes the last two ideas the best, and tells Foreman to put Daryl on an ethanol drip. If he develops itchiness, it’s a sign of lymphoma, and if he loses his radial pulses, it’s a sign of Takayasu. Daryl develops itchiness while on the drip, so Foreman’s suspicion of lymphoma appears to be correct. Daryl is taken to surgery for a splenectomy, but during surgery Chase notices that his spleen is fine but his liver is inflamed.

Biopsies reveal no lymphoma and a non-specific liver inflammation. The new differential diagnosis includes polymyositis (a chronic inflammation of the muscles), Felty syndrome (rheumatoid arthritis + splenomegaly, which doesn’t fit at all), and viral hepatitis. Blood is drawn for further testing, but Foreman reports that the blood clotted almost immediately after being drawn. This suggests that Daryl has cryoglobulinemia (abnormal proteins in the blood that thicken with cold temperatures), brought on by football practice on cold days, and needs to be started on anticoagulants (blood thinners). This isn’t good enough for Daryl; he doesn’t want to miss his shot at the pros, so he leaves the hospital, promising to come back the next day. At the exhortation of Daryl’s mother, Foreman tags along to look after him — it was a good thing he did, too, as Daryl starts to experience shortness of breath and blurry vision. He is admitted back to the hospital. As the team begins to evaluate the new symptoms, Foreman admits that their really aren’t any new symptoms. He had dosed Daryl with nitrates (a class of blood pressure medication) to drop his blood pressure so he’d feel bad enough to want to come back to the hospital.

Looking over the chart, House notices that Daryl has only lost one pound during his stay in the hospital and he should have lost more. This lack-of-weight-loss could be due to steroid abuse, or paraneoplastic syndrome — only there’s been no evidence of cancer. The team performs blood test after blood test, and scan after scan, but can find no cancer. House then realizes that the cancer they are looking for is not inside the body, but outside. It turns out that Daryl has melanoma, a skin cancer hard to spot on African-Americans, and this cancer (or course) is causing paraneoplastic syndrome, which explains his symptoms.

(Here’s my take on what’s going on: you may have noticed during the episode that the team gave two different definitions of paraneoplastic syndrome. First, they described a situation where a cancer produces a hormone which can cause systemic effects: in this case, the melanoma is apparently producing GnRH which increased Daryl’s testosterone and gave the appearance and symptoms of steroid abuse including “roid rage,” weight gain, and probably the heart symptoms. Second, House describes paraneoplastic syndrome as a situation where the body is making antibodies against the cancer, and this produces the systemic effects. This would explain the kidney failure and liver inflammation. The apparent cryoglobulinemia may be an effect of the extra paraneoplastic antibodies, or cryoglobulinemia can occur with certain cancers. Both definitions of paraneoplastic syndrome are correct, but I’m not certain if a patient would ever experience both situations.)

I admit that I’m somewhat confused by House’s take on steroids. If Daryl was taking steroids, his GnRH should be suppressed — lower — not higher. Or is House suggesting that Daryl was receiving GnRH itself, or a synthetic substitute — and if that’s the case, the body generally downregulates GnRH receptors when GnRH levels are unusually high, actually leading to hypogonadism and less testosterone.

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

The clotting in cryoglobulinemia resolves at normal temperatures, so why would Daryl be clotting in the presumably warm hospital room. Did Princeton-Plainsboro not pay the electric bill?
Why didn’t he show abnormal clotting during surgery as most operating rooms are kept PDC (pretty damn cold).
Surely they drew blood before surgery, at least a blood type/transfusion panel, and should have notoiced the clotting then.
Blood thinners are not the recommended treatment for cryoglobulinemia.

Giving a patient enough of a nitrate to intentionally cause hypotension (low blood pressure) is dangerous. How did Foreman know he didn’t give too much? I’d also expect Daryl to develop a severe headache — the most common nitrate side effect – before any other symptoms.
I guess he learned it from House, who was trying to induce a cardiac event in a patient without even having him hooked up to any cardiac monitors.

Stress tests aren’t used to test for hypertophic cardiomyopathy, at least not as a first-, second-, or even third-line test. An EKG has already been obtained. A structural test, such as an echocardiogram or MRI is the next logical step. If needed, cardiac catheterization may also be performed.

Sorry Taub, steroid abuse can cause heart problems, including tachycardia.

Is there really a link between repeated trauma and pituitary adenoma, a type of cancer? I haven’t been able to find one, but then again, I’m not a neurologist or sports medicine specialist.
GnRH is released into the pituitary, not from it, so why would a pituitary cancer lead to “leaking” GnRH?

There is a condition known as the “lymphoma itch” that is a severe itching, primarily of the lower extremities. It is most commonly seen in Hodgkin’s lymphoma, but even then it only occurs in 10-25% of patients.
It is not associated with alcohol. A separate condition (severe aches and pains) can be worsened by alcohol intake in certain patients with lymphoma.

I don’t know it alcohol will really shut off blood flow in the radial arteries in patients with Takayasu’s arteritis, but who in the hell would thank that is a good idea. Personally, I like my hands to have full blood flow, thank you.

Return to full contact football a day after abdominal surgery, even a laparoscopic one? Nonsense.

Blood in the urine is really not a sign of kidney failure. It suggests that there is a problem with something farther along in the urinary system. This is especially true in patients on blood thinners, were urinary bleeding is more common – maybe from inserting the catheter in the first place.

Why would a melanoma secrete GnRH?

It is certainly possible to have rheumatoid disease with a negative rheumatoid factor.
Wasn’t Chase the one who shot down Taub’s suggestion of rheumatoid arthritis? So why would he later suggest Felty’s, which requires rheumatoid arthritis?

Paraneoplastic syndrome has become the lupus of this season.

I found the medical mystery interesting this week. Not great, but better than recent episodes. I give it a B+. The final solution clever (hidden melanoma in a black male), but too much of “Been there, got the T-Shirt” feeling (paraneoplastic, again, and a nearly impossible one at that). I give the solution a C-. Overall, the medicine was more driven this week, and followed a logical progression, but too much of it was questionable or downright wrong. Another C-. The soap opera was decent. I liked the Foreman and Foreman scenes, and the Wilson/House scenes were good, but I figures Lucas was the culprit fairly early on as Mark Michael Weston was listed as a guest star, but nowhere to be seen. I give the soap opera a B.

The House Challenge scores have been posted here.

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

I liked the plot of this week’s episode of Fringe — at least for the first two thirds (until Walter was captured, when it started going downhill) — but the “science” and “medicine” was ridiculous.

The Plot: Mysterious men break into a mental health facility and perform some sort of brain operation on one of the patients. They remove some sort of foreign tissue from his brain, but are disturbed before they can finish the operation, so the patient is left with part of his brain exposed. Strangely, the patient has also been completely cured of his schizophrenia.

The Fringe team is called in and it is clear that Walter is uncomfortable with being back in a mental health institution. The security tapes manage to capture the face of the intruders’ leader, and Olivia recognizes him instantly. It was one of the frozen heads that was stolen earlier in the season and belongs to a man named “Newton.”

Looking through the patient’s medical records, Walter finds reference to a mysterious psychiatrist by the name of “Paris.” Astrid can find no records of the mysterious doctor, but with Walter’s help, is able to track down some prescriptions he wrote. They find two other institutionalized patients with prescriptions from Dr. Paris. Visiting these patients, they find that they have also been recently miraculously cured of various psychiatric diseases and show evidence of recent brain surgery. Walter recognizes that one of the drugs they’ve been given is used to prevent tissue rejection in organ transplant patients. He then realizes that the patient’s brains had been used to store the tissue from someone else’s brain.

The team is informed that Walter’s old mental health records show that Dr. Paris visited him six times while he was in the asylum — visits which Walter does not remember. Peter check’s Walter’s scalp and, sure enough, there’s an old surgical scar. An MRI of Walter’s brain is obtained and it shows three missing sections of brain — missing sections that perfectly match the pieces implanted in the other patients. Someone has removed part of Walter’s hippocampus (important in memory storage) and placed it in other people’s brains. And now someone has taken these pieces back.

Meanwhile, Walter has been captured by the Newton and his cohorts. They hook him up through some sort of contraption to the missing pieces of his brain. Once the connection is made, Walter seems suddenly awake for the first time since the show began. Newton is able to get Walter to tell him how to make a door to the other universe. He then injects Walter with some sort of drug before high-tailing it just before Dunham and the rest of the team arrive. While Peter helps Walter, Olivia chases after the bad guys. She manages to shoot the driver of their van (who bleeds silver — one of the shapeshifters), and then the second man (regular blood). Newton is captured — but only for a moment — because he tells Dunham that Walter has been given a neurotoxin, and he’ll only tell her how to administer the antidote after he is allowed to escape. Dunham acquiesces and Walter survives, but she is chided by Newton for her “weakness.”

In a final flashback, we see that the mysterious Dr Paris was actually William Bell and Walter’s brain surgery was done — apparently with Walter’s consent — to remove the knowledge of how to open the cross-dimensional door from his brain and store it someplace “safe.”

1. Lost ‘em Again
That tracking chip didn’t last long, did it?

2. “Iä! Iä! Cthulhu Fhtagn!”
There were a couple of H.P. Lovecraft references this week (purposefully?)
Dr. West (as in Herbert West, Reanimator)
Dunwich Mental Health Facility (as in The Dunwich Horror)

3. Department of Redundancy Department
“Global destruction of biblical proportions.” That’s ridiculously redundant — global destruction, by definition, is of biblical proportions.

4. The AMA Does Not Do What You Seem To Think It Does
A common mistake, but an irritating one. The American Medical Association is really nothing more than a professional organization for doctors, like a union or lobbying group. It has no official sanction. It is not in charge of medical licensing, and keeps no “official list of doctors.” Depending on which source you use, only 15-30% of the physicians in this country are members of the AMA, so someone not being on their roster is no proof that they’re not a doctor or don’t exist. [I've blogged about this several times before, most recently here, in relation to the Beast and Dr. Mid-Nite.]

5. But I Asked For Infinite Refills
You cannot write an “indefinite prescription.” One-year, maximum.

6. I Reject Your Rejection
The four drugs listed on the patient records (Sirolimus, Muromonab CD3, Basiliximab, Azathioprine) are used to prevent rejection in organ transplant patients.
You would think that in their years in the asylum, at least one doctor or nurse would realize the drugs make no sense.

7. Bad Radiology
Those spots on the patients’ brain MRIs were way too big to be thought of as artifacts. The brain tissue was large enough that it would show up on multiple MRI slices (images).
No radiologist ever noticed the three holes in Walter’s brain before?

8. Respiratory Depression and Death
Tolerance or no, 50MG of Valium is one helluva dose. That’s two-and-one-half times the maximum daily dose of Valium.
Dr. West is either extremely trusting or extremely naïve to give that much Valium to Walter just on his say so, especially when it’s clear that Walter is not all there.

9. It’s Not a Two-Dimensional Jigsaw Puzzle
The brain is three-dimensional. The tissue cut out was three-dimension. It was inserted into people’s brains (crammed in, basically, because there was no “slot” to put it in), but somehow manages to show up on a two-dimensional MRI as a perfect fit, like a jigsaw puzzle piece. There was no way they could fit the extra piece in the brain so precisely at just the right point and at just the right angle for this to be true. [A similar problem occurred in the infamous autopsy scene in Identity Crisis #6, where Dr. Mid-Nite managed to find just the right slice to find perfect footprints in the brain.]

Good plot but goofy science cancel each other out. The Doomsday Clock stays at 11:55

Tags: television fringe brain schizophrenia door

This week’s episode of Fringe was fairly creepy, and the science wasn’t all that bad

The Plot: A boat from Hong Kong has run aground in the harbor and dozens of illegal Chinese immigrants have washed up on the shore, dead. It turns out it wasn’t the water or cold that killed them, but giant tentacled parasite worms lodged in their gastrointestinal tracts. The Fringe team is called in. One of the immigrants, Mai Lin, managed to survive. She tells the team that all her fellow immigrants were given a strange capsule to treat sea-sickness, but since she was raised in a fishing village and never got sea sick, she didn’t take it. The team suspects these capsules contained the larvae for the giant worms. She tearfully tells the team that her husband and daughter are on the next boat arriving in few days.

The immigrant smugglers are tied to a local Triad gang best known for smuggling and selling illegal drugs. The team initially surmises that the worms secrete some form of opiate, and this is why they’re being smuggled. After being bitten himself, Walter realizes that the worms produce a powerful immune boosting agent. Walter does some research and discovers that the worms are genetically modified Ancylostoma duodenale (hookworm), an intestinal parasite used in traditional Chinese medicine. The genetically modified versions make an immune boosting agent that is stored in their lymph glands.

Some financial documents tie a local woman to the one of the Triad’s front. She tells Agent Dunham that she has no knowledge of any illegal activity and only invested the money where her financial adviser suggested. Peter notices that her house has a surprising number of air filters and hermetically-sealed windows. Once the team learns about the immune-boosting aspect of the worm, they realize this woman knows more than she is telling. This time, Peter approaches her son who tells him that he has a rare immune deficiency. He receives a special monthly treatment of worm-powder delivered surgically, directly into his spleen.

Walter, with some reluctant help from Astrid, heads off to Chinatown to find a herbalist that sells Ancylostoma that is genetically similar to the giant worm. He finds several shops that sell the worms, and inadvertently discloses to one of the shop owners — the wrong one, of course — that he has a giant worm back at the lab. The Triad follow Astrid back to the lab, beat her up, and steal the parasite.

The ship carrying Mai Lin’s family is found and boarded, but it is too late — all the immigrants have already been carted off. Luckily, Peter is spying on the shop in Chinatown where they have been taken. He calls Agent Dunham then decides to do some investigating of his own. He breaks in to the shop and is in the process of freeing one of the immigrants when he is captured. The Triad and their crooked doctor are force feeding Peter one of the larva when the FBI team arrives, just in the nick of time. The villains are shot or captured, Peter is saved, the immigrants are taken to the hospital where they are treated, and everything ends happily.

(Oh, and Walter implanted a tracking chip in his neck.)

Overall, the science — what little there was of it — was passable this episode, so I just have a few nit-picks an observations:

1. As the Worm Turns
Nematodes such as Ancylostoma are too primitive an organism to have a lymphatic system. They don’t even have a circulatory system.
Admittedly, these are “genetically engineered” hookworms, and for a worm to grow as large as those shown, thanks to the square-cube law and other similar concepts, they would have to have some sort of circulatory system.
In the actual worms, the many-tentacled end is the tail, not the head.

2. Glad I Don’t Have to Take Them Out
Matt’s staples should have been removed long ago. He was 3 ½ weeks out from his surgery. By this far out, the incision is healed with 80-90% strength. Leaving in staples or stitches that long serves no purpose, is going to lead to train-track scarring, possible stitch abscesses, and skin-growth around the staples.
Open abdominal surgery is to be avoided whenever possible, especially in immune compromised individuals. Why not just inject the powder into the spleen?
Credit-Where-Credit-Is-Due Dept: That is where an incision for splenic surgery would be made.

3. High is Not Always Better
A high white blood count is a sign of infection (or leukemia, not the sign of a healthy immune system).

4. Ahhh, Just Right
I was starting to have concerns with Walter’s mention of “boosting the immune system” — a common alternative medicine/quackery claim. In reality, the human immune system is finely tuned: too little leaves you open for infection; too much and you get allergy problems and autoimmune disease. If all the alternative “medicine” boosted the immune system like it was claimed, we’d have an epidemic of autoimmune problems in this country. I’ll give the episode credit for having the medication be used by immune-compromised patients — a proper use.

5. What Does the FBI Teach These People?
Walter’s about as good an investigator as Olivia — that is, very bad. The logic of his whole “find a matching worm” plan had more holes than Swiss cheese (though this is Walter we’re talking about). For instance, who’s to say the various different herbalist shops didn’t all use the same importer of worms — which they probably did — so the worms from the various shops would be identical.
And Peter’s not any better. Why would he think breaking into a shop owned by the Triad — known for their brutality — would be a good idea at all?

5. Lions and Tigers and Bears, Oh My!
The song Walter was singing was “The Menagerie“, which was also mentioned in the first season (episode 16, Unleashed).

While there was some errors of scientific-concerned, most of them were minor and could be hand-waved area. Thus, for the second week in a row, there is a one-minute improvement on the Doomsday Clock.

Tags: television fringe parasite ancylostoma worm

The mystery was fairly bland in this week’s episode of House, but the medicine was much better overall. Good bye Cameron. Don’t let the door hit you on the way out.

Hank, a successful porn star is admitted to Princeton Plainsboro Teaching Hospital after developing a severe headache and photophobia (sensitivity to light) while on set. House starts off by ordering a series of tests: an STD panel (to look for sexually transmitted diseases), a toxin screen (to look for common toxins), C-Reactive Protein (”CRP”, a measure of inflammation), ANA (antinuclear antibodies, to look for autoimmune diseases) and a lumbar puncture (to look for viral encephalitis). While the patient is having his spinal tap performed, he develops severe muscle spam and pain (tetany) in his arms. Foreman orders meperidine (Demerol, a strong pain medication).

About this time, House starts hitting up Taub and Thirteen for ideas, trying to lure them back on the team. Taub suggests that Hank must have a brain problem, such as a tumor or seizure. Foreman believes that Hank suffers from cerebral vasculitis (inflammation of the blood vessels in the brain). House agrees with Foreman’s assessment and starts the patient on steroids. He also orders a brain angiogram (an x-ray of the arteries in the brain), as well as an EEG and a nerve biopsy, just to be sure. Foreman convinces Chase to perform the angiogram, but he and Cameron suspect that the patient is suffering from Vitamin D deficiency, so instead of checking the angiogram, they decide to start Hank on light therapy and intravenous vitamin replacement. Unfortunately, while undergoing the light therapy, Hank develops a nosebleed and is found to have petechiae on his legs.

Hank is now diagnosed with disseminated intravascular coagulation (DIC, a weird, but very serious, condition, where the patient is both bleeding too much and clotting too much). Sepsis is suggested as a possible cause, but since he is showing none of the shock associated with sepsis, the idea is discarded. Bacteremia (bacteria in the blood) is suggested, but Cameron shoots it down suggesting instead Meningococcemia (meningococcal bacteria in the blood — really a subset of what Chase suggested). House concurs with Cameron’s diagnosis and Hank is started on heparin (a blood thinner, for the clots) and a broad spectrum antibiotic that covers meningococcus (but if you know which bacteria you’re treating, then you don’t need a broad spectrum antibiotic).

Hank does not improve and he starts to run a fever. Taub suggests that he might have an infection hidden away in his sinuses, where the antibiotics have difficulty reaching, so Chase performs sinus surgery to clear out the sinuses. Now Hank begins to complain of severe abdominal pain and Cameron discovers something on the exam (apparent ascites — fluid in the abdomen) that makes her diagnose liver failure. She suggests a Klatskin tumor (cancer of the bile duct), but it doesn’t quite fit the symptoms. Foreman suggests that Hank has sclerosing cholangitis (a disease that damages the bile ducts). House agrees and an ERCP (an endoscopic exam of the bile duct and pancreas) is ordered — surprisingly it shows a mass in the common bile duct that ends up being a large clump of worms. Hank apparently has strongyloides (”whipworm threadworm”), and is given mebendazole to kill the worms.

Once again, Hank’s condition dramatically worsens. He develops severe pulmonary edema (fluid build up in the lungs). Chase thinks it might be a combination of a hematological (blood) problem and cardiomyopathy (a heart problem). Foremen suspects Hank has lymphoma, with peritoneal carcinomatosis (malignant spread of cancer across the abdomen) and paraneoplastic syndrome explaining his symptoms. House sides with Foreman, and Hank is started on chemotherapy. A short time later, Hank’s condition takes another turn for the worse when he starts urinating blood. Next, his blood pressure and heart rate skyrocket, and he starts to bleed from his mouth. He then suffers a cardiac arrest, but the team is able to stabilize him.

The latest labs are back and show that Hank barely has any red blood cells, white blood cells, or platelets. The differential diagnosis now includes hypopituitarism (an underfunctioning pituitary gland), renal cell carcinoma (a type of kidney cancer), or aleukemic leukemia (a leukemia that is associated with low white blood counts instead of the normally high counts found in leukemia). House tells the team that the latter is the most likely and orders them to ablate (destroy) Hank’s bone marrow in anticipation of a bone marrow transplant. There is a lot of hemming and hawing about whether this is the right thing to do, since it could make Hank sicker or kill him, but at the last moment, Thirteen and Taub call in with the correct diagnosis: extraintestinal Crohn’s disease. According to them, Hank’s exceptionally clean childhood made him more likely to develop diseases such as Crohn’s, and the worms were actually helping him keep the disease in check. Once the worms were killed off, the Crohn’s flared up with a vengeance. With some methylprednisolone (steroids), Hank should get better — but the team wants to give him some worms again, just to make sure.

I found no massive errors in tonight’s episode. There was the usual: jumping randomly between unrelated diagnoses, bizarre test interpretation, and Chase being a specialist surgeon, but nothing horrible. Of course, that’s not to say I have no complaints (as if!). As usual, minor complaints are in blue, nit-picking ones in green:

Where exactly was the extraintestinal focus of the Crohn’s?

Why did he develop a headache and photophobia in the beginning? Was that the Crohn’s? Why did everything suddenly worsen when he got in the hospital? The steroids he was given for the vasculitis should have calmed down the Crohn’s.

The strongyloides worms may not have been the cause of his disease, but their blockage of the bile duct would still cause serious problems for the patient.

Again, no oncologist is going to start chemotherapy for cancer without a tissue diagnosis.

Special precautions are taken for patients who are neutropenic (dangerously low in white blood cells, and thus more susceptible to infection) including gowning and gloving everybody in contact with the patient. You do not roll them down the hospital’s common hallway without a mask and with the wife holding his hand.

The CRP should have been significantly elevated with the Crohn’s disease (and the cerebral vasculitis too).

While the ANA is generally strongly positive for certain types of autoimmune diseases, it is not found in every autoimmune condition (or even most autoimmune conditions), so a negative ANA does not mean there is no autoimmune disease (and positive ANAs in the absence of autoimmune pathology are also possible).

How about checking the vitamin D level — an easy thing to do — before treating the patient.

I noticed how they avoided actually saying the word “ascites” and instead chose a wordier explanation. Probably because of their problem pronouncing it last time.

Cameron shoots down Chase’s idea of bacteremia, but then suggests meningococcemia, a type of bacteremia. The same argument she used against Chase would go against her as well.

Why would you ablate the bone marrow without finding a donor first? (OK, maybe House was never planning on really following through with it, but why would the others go along?)

And now credit where credit is due:
The hygiene hypothesis is a legitimate and controversial scientific theory concerning the rise in asthma and allergy rates in industrialized nations. Some researchers link it to autoimmune diseases as well.
Helminthic therapy — treatment of disease using intentional infestation of parasitic worms — is being tested in a variety of diseases, including Crohn’s/
Shocking ventricular tachycardia, like Foreman did this episode, is the right treatment.

The mystery was okay, but seemed to get lost in the shuffle as the show progressed. I give it a B. The final solution was a stretch, especially when you look back at the original symptoms. It earns a C. Overall, the medicine was better that it has been the past few weeks and earns another B. The soap opera was decent as well. I enjoy Tab and Thirteen, so I’m fine with having them back, though I know many will disagree. The soap opera earns still another B.

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

The House Challenge scores are now up to date here.

Another tale of strange Silver Age medicine, this time from World’s Finest #87:

A new masked and super-powered bank robber appears in Metropolis and Superman tracks him to his lair only to find that the robber had been waiting for him with a chunk of kryptonite.

A few months before, our robber realized that if he wanted to be a successful criminal in Metropolis, he needed to find some kryptonite. He spent months tracking down every meteor¹ that landed nearby, looking for elusive chemical. He lucked out: not only did he find kryptonite, but he also found a box with some pills in the meteor. There is a note with the pills that reads “These radioactive capsules to be used only if needed to renew our super-powers on Earth. [Signed] Jor-El”

The robber took the kryptonite-embedded box back to his lair. He swallowed one of the pills, gained super-powers, and went on a crime spree. Then he lured Superman to his hideout and exposed him to the kryptonite. Leaving the Man of Steel for dead², the criminal flies off to commit more robberies.

Of course, Superman’s not quite dead yet — he takes his last bit of energy and uses his heat vision to break the water pipe in the ceiling, sending water cascading down on the box of pills, washing all the kryptonite away³. Able to stand up again, Superman grabs the box of pills and swallows one, figuring he needs the super-powers they’ll provide since his have been stolen by the kryptonite. Too late, he discovers that some kryptonite dust had gotten in the pills when Krypton exploded — the same explosion which sent the box to Earth. Now he’ll be completely powerless until the chemical leaves his system⁴.

Thinking quickly, Superman calls Batman and Robin. When the duo shows up, he gives them each one of the super-power pills, and they fly off to capture the robber. Since they’re not used to their new powers, not only do they let the villain escape, but they cause some serious property damage. Undeterred, Superman trains them in the use of their powers and they fly off again to capture the robber.

Meanwhile, Superman — using his crafty reporter skills — has discovered the robber’s new lair. Unfortunately, the robber catches Superman in his hideout and pulls out a gun, shooting him in the chest. About this time, Batman and Robin arrive and capture the villain, who is still gloating over Superman’s body. Could the Man of Steel be dead? Of course not. It turns out that while Superman may have been powerless, his suit was still invulnerable and it blocked the bullet, saving Superman’s life. It’s all a moot point now anyway, as the kryptonite has worn off and Superman has regained his powers. He gives the super-power pills to Batman who promises to keep them safely hidden away in the Bat-cave⁵.

Notes:
1. Yes, technically he was searching for a meteorite, not a meteor, but I’m sticking with what’s written in the comic for this review.
2. If I were a criminal who gained his super-powers through a pill, I would take the pills with me instead of leaving them behind. Sure, leave the kryptonite-encrusted box — just take the pills.
3. Apparently kryptonite is water soluble.
4. Kryptonite or not, shouldn’t the pills have given Superman super-powers? They were developed to give Kryptonians who lost their powers (like Superman) temporary powers. He took one after losing his powers temporarily from kryptonite exposure, so why should more kyrptonite dust in the pills stop them from working? It’s not like they’re affected by kryptonite — Batman and Robin got powers despite the kryptonite in the pills.
5. As far as we know, the pills are still there. Or at least, all but one of the pills…

Tags: comics medicine kryptonite superman batman robin jor-el pills

An interesting premise initially on this week’s episode of House, but a slight episode over all. It was in many ways a rehash of House vs God, only not as clever

Jack Randall is the son of a billionaire. He has been sick for over a week with worsening abdominal pain, fever, dehydration, diarrhea, and weight loss. He has seen a variety of doctors, the last who prescribed intravenous antibiotics for a presumed case of Clostridium dificile (i.e. “C. diff” — a cause of severe antibiotic-related diarrhea). When it became clear that Jack did not have C. diff and was not improving, his father brought him to Princeton-Plainboro Hospital demanding that he be seen by House. Cuddy, as always, acquiesced (she has become the Neville Chamberlain of hospital administrators. Didn’t she used to have a backbone?)

House wants the team to start over from the beginning with the history and physical. While performing the physical exam, Cameron feels a left-sided abdominal mass. This is confirmed by an x-ray and revealed to be a fecal impaction (a big hard ball of poop) revealing that Jack is severely constipated. This is a new finding, as previous x-rays were normal. The team decides that this represents toxic megacolon due to Hirschprung’s Disease (a congenital condition caused by missing nerves in one section of the intestine). They want to perform a barium enema and colon biopsy to confirm. Jack feels much better after the procedure and disimpaction and is laughing and joking. Suddenly he begins staring straight ahead and then breaks into a convulsive seizure. Foreman gives him some diazepam (Valium — among its other uses, it is good at stopping seizures). An examination of the eyes reveals swollen optic discs, a sign of intracranial hypertension. Foreman orders furosemide (Lasix – a diuretic, i.e. “water pill”) and then orders more diazepam and then some phenytoin (Dilantin — another seizure medication). He is worried that Jack’s intracranial pressure will get so high the brain will herniate, so he rushes him into surgery where Chase drills burr holes in the skull to relieve the pressure.

Jack is looking a little better after the operation, but the team notices that he is building up fluid in his brain and abdomen again. Closely examining the head CT, Foreman notices an irregularity in the way the fluid is building up and finds this suspicious for early brain cancer. House concurs. A biopsy is taken, but it is negative. Now House suspects that Jack has adenocarcinoma (cancer) of the stomach, and this is what is causing his symptoms. Jack has another bad seizure, but this time with a normal intracranial pressure. The team gives him some diazepam to stop the seizure and proceeds with the scope — but there is no sign of gastrointestinal cancer either. In the meantime, Jack has fallen into a coma. Chase suggests the cause may be infection caused by an antibiotic resistant germ, but all the cultures have been negative. Cameron suggests that Jack may be having abdominal epilepsy — in other words, he has seizures, but they show up as severe stomach pain, and this then in turn led to his other symptoms. House agrees and Jack is started on gabapentin (Neurontin, an anti-seizure drug). An EEG (brainwave) evaluation is started but reveals no seizure like activity. However, Cameron notices that Jack has developed a rash all over (and I mean all over) his body.

The differential diagnosis of Jack’s condition now includes an allergic reaction to his medications, autoimmune disease (lupus and vasculitis), or polyarteritis nodosa (another type of autoimmune disease). House considers starting Jack on Prednisone to treat the polyarteritis, but when Cameron tells him that the rash is also on the genitals, he deduces that Jack has Degos disease, an incurable terminal disease caused by inflammation and blockage of small and medium sized blood vessels. House breaks the news to Jack’s father and lets him know that Jack has less than a day left to live. Jack’s father decides to invest all his assets in extremely risky ventures, knowing he will lose everything. He has decided that by doing so well in business, he has tempted fate and his family is suffering. Therefore, if he is ruined financially, his karma will even out and Jack will improve. House mocks him, but doesn’t stop him (and apparently makes some money on it). As the financial papers are signed, Jack has a cardiac arrest and flatlines. The team is able to resuscitate him, but it’s touch and go. Talking with Wilson a short time later, House has one of his patented aha! moments and realizes that Jack does not have Degos, but has Primary Antiphospholipid Syndrome. They give him some heparin and immunoglobulin and he miraculously recovers.

The medicine had some problems this week. As usual, major complaints are in red, minor in blue, nit-picking in green:

I’m no neurosurgeon, but I don’t think you just whip out your trusty Ryobi cordless and drill a burr hole like that.
At the very least, clean the skin first — I don’t want any nasty skin bacteria pushed into brain which is what you are drilling into.
Also, a sudden drop in an increased intracranial pressure is likely to cause a brain herniation — the very thing they were trying to avoid.

This is the second episode of the season (and we’re only four episodes into the season) where the misdiagnosis of the patient was made by biopsy.

While writing the script for the classic film noir The Big Sleep, the screenwriters couldn’t figure out who murdered the chauffer. They called up Raymond Chandler, who wrote the original book, and ultimately he admitted the plot was so complex that he didn’t know either. I think this happens in House a lot when the writers get lost in their own plot. Case in point — the seizures: First they suggest the increased intracranial pressure is causing the seizures (could happen). Then they suggest electrolyte imbalances could cause the seizures (could happen) — but if the latter is the case, then what caused the increased intracranial pressure in the first place?
The team kept referring to the abdominal fluid returning or recurring. What did they do to remove it in the first place?

Furosemide is, at best, a second-line agent for treating increased intracranial pressure. If you’re going to use a diuretic, acetazolamide is the best choice. Mannitol is a good choice as well.
Cameron’s suggestion of intubation and hyperventilation was another good option.

Phenytoin 500MG is not an unreasonable dose to break a seizure in patient who weighs 60-80 pounds.
I notice Cameron only ended up giving 50MG. Was this a continuity error in the script, or willful disobedience on her part? And 50MG would be an appropriate dose for an 6-10 pound child, way too little for this kid.

If your patient with C.diff is a previously healthy kid, with no recent antibiotic use, and no record of C.diff exposure, and he requires oxygen, then your C.diff case does not have C.diff.

I defy anyone to get a good fundoscopic exam on a seizing patient in the middle of a brightly lit room. Can’t be done.

You’d think after six years, Jennifer Morrison would know how to pronounce ascites.

Labs don’t run extra blood tests without an order. Especially tests that require prep, like fasting before a cholesterol test.
Here is another example of the writer’s trying to have it both ways. If the lab ran the tests, then there would be a computer file with results, not just a single piece of paper. But if Chase ran the test himself so there was not a full computer record, then who ran the extra tests?

I thought the medical mystery was interesting this week and deserves a B. The final solution fit fairly well, though I think Degos fit better. I give it another B. The medicine overall was average, though there were some positive signs — like the team actually performing a history and physical. I give it a C+. The soap opera was okay. Nothing great, but nothing out of character either. It earns a C.

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

House Challenge scores have been posted. Yeah lupus!

This was purely a character episode for House, and a pretty good one, at least until it became ridiculously sappy at the end — sappy enough to put a soap opera to shame. There wasn’t that much medicine, which is probably good, because this is a long enough review already.

The episode starts out with a montage of scenes of House locked in a room and undergoing Vicodin withdrawal. Not a very pleasant experience, but he comes through it unscathed.

Now that he has detoxed from the Vicodin, wants to check out of the clinic and resume his previous life. Dr. Nolan, the head psychiatrist of the clinic, confronts House and tells him that he is free to leave, but if he wants the letter of clearance he needs to regain his medical license, he’ll have to attend inpatient therapy. Dr. Nolan points out that it wasn’t the Vicodin that was causing his hallucination, but other deeper problems. Reluctantly, House allows himself to be admitted to Ward Six, the inpatient psychiatric unit.

Dr. Beasley is the young psychiatrist in charge of the unit. Point blank, House tells her that he’s only there until he gets the clearance letter he needs. He threatens to “turn the ward upside down” if he doesn’t get what he wants. He is shown his room and soon meets his roommate, Alvie, a manic depressive (in modern parlance: bipolar) who is in a full manic state because he doesn’t like to take his medications which “bring him down.” (Alvie is a pretty good example of someone who is manic. If anything, he’s more subdued than most manics I’ve encountered.) Alvie introduces him to the other patient including Annie (a mute), Hal (an anorexic), Jay (a claustrophobic) and Richter (a paranoid schizophrenic — probably because he was in all those Revenge of the Nerds movies). They all meet for the first group therapy session, which doesn’t go well, and House finds himself confined to a locked room as punishment.

House rejoins the rest of the patients when they’re outside playing basketball, and quickly turns their psychoses and neuroses against them in order to win the game. House goes back to the ward and encounters Lydia, the sister-in-law of Annie, playing the piano for her. About this time, the orderlies arrive to take him back to the locked room for his behavior on the basketball court.

This time, when House comes out of punishment, he leads a vocal patient rebellion until Dr. Nolan steps in. After things calm down, Steve, a new patient, joins the group. Steve believes that he is a superhero and goes by the name “Freedom Master.” House decides his best bet to get the clearance letter he needs is to find something incriminating on Dr. Nolan and blackmail him. He sends Alvie up to his office, but he can’t find anything. He sneaks a phone call to Wilson, but he refuses to help him.

Now House’s plan is to cooperate, or at least to fake it. He pretends to take his pills and is, to all appearances, getting better and more social. A third psychiatrist, Dr. Medina, wants House to provide a urine sample to prove he is taking his medication. House is ready, though, and has Hal waiting in one of the bathroom stalls to provide a sample. Sure enough, the sample shows evidence of psychiatric medication and Dr. Medina is satisfied.

A little while later, Dr. Medina strolls onto the Ward and confronts Steve about his delusions and the fact that he doesn’t really have superpowers. His extremely confrontational approach angers House, and he becomes even more concerned finding Steve medicated to the gills a short while later. Dr. Nolan steps in. He pulls House into his office and reveals that he knows House has been faking. He had only been getting sugar pills, so his urine should have been clean. Having a positive drug test was proof that he was faking.

Lydia visits later that day, bringing Annie’s old cello. House has Steve help her get the heavy instrument from the car, hoping it will bring back his old super-heroic feelings. Next, he decides that he and Steve should take a ride and he “borrows” Lydia’s car. He takes Steve to a nearby carnival where they have one of those “skydiving over a giant fan” rides (would that really work out in the open like that?). Both he and Steve have fun soaring, and it seems to bring Steve out of his funk — so much so that once again he believes that he has superpowers, and he jumps off the parking garage to prove it.

Steve survives his plummet, but just barely. He has a lacerated spleen and multiple bone fractures. Nolan confronts House and tells him that he is going to transfer him to another psychiatric facility. House is shocked by what happened to Steve and clearly feels guilty. He asks Nolan not to transfer him and promises to comply with his therapy.

House and Nolan start regular one-on-one counseling sessions. He is also started on an antidepressant (an SSRI — serotonin specific reuptake inhibitor. This is a class of antidepressant/antianxiety drug that includes Prozac, Paxil, Zoloft, Celexa, and Lexapro). Nolan takes him to a charity dinner so he can mingle and learn to trust people. Lydia is there, and the two of them have a good time lying and pulling pranks on the other attendees. At the end of the night, she kisses him. Nolan tells House that the night was a success because no one tattled on House’s lies, therefore he can trust other people– which seems a painful stretch of logic to me.

Lydia comes back to visit the next day, but the return of the severely injured and now catatonic Steve to the floor puts a damper on whatever may have happened between her and House. Nolan tells House he needs to apologize to Steve, but he can’t bring himself to do it.

Meanwhile, Dr. Beasley announces that there is going to be a talent show and wants everyone to participate. During group session, House receives an urgent note from Nolan. He meets him at the hospital where Nolan’s father lies in a coma. Nolan tells House that the doctors have told him there is no chance of recovery, but he wants a second opinion. House looks at the CT scans and tells Nolan that his father has had a catastrophic hemorrhagic stroke and agrees that there is no chance of recovery. After being confrontational at first, he pulls up a chair and sits by Nolan as he holds his father’s hands.

Returning to the ward, he finds Lydia by herself crying. One thing leads to another and they end up having mad passionate sex in the office. (Ask anyone: locked ward insane asylum love making is the best kind.) At the talent show, House ends up helping his roommate Alvie rap by stepping in and helping when he starts to stumble over words.

House finally finds the strength to apologize to Steve. He starts to wheel him to group therapy when he notices that Annie is looking down at a music box Steve is holding. He slows down and Steve hands the box to her. She accepts it and opens it.
“Thank you,” she says — the first words she has spoken in ten years.
“You’re welcome,” replies Steve. His first words since the accident.
(And this ridiculously maudlin moment is where all forward plot momentum was lost and along with it, most of the good feelings I had about the story).

Since she is no longer mute, Annie is discharged to an out of state rehabilitation facility. The rest of her family, including Lydia, is going with her. House gets a pass from the hospital and goes to confront Lydia. She tells him that she doesn’t want to leave, but she must because she doesn’t want to break up her family. Nearly broken, House returns to the psychiatric hospital where he encounters Dr. Nolan. Nolan offers to write him the clearance letter he needs — not out of pity — but because House has shown he can change: he cared enough about somebody else to get hurt, and he turned to Dr. Nolan for help when this happened, not Vicodin. The next day, House leaves the hospital and hops on a bus back to his old life.

Not much non-psychiatric medicine this episode, so no major complaints. Minor ones are in blue, nit-picking in green:

Confronting someone with a delusion as strong as Steve’s the way Dr. Medine did is not going to work. Logically, you would think that showing someone that their beliefs are wrong would break the delusion — but by definition, delusions aren’t logical. The mind is very facile and will find a way to keep the delusion despite the evidence. For instance, Steve might now say, “My powers didn’t work because no one was in danger. They only work if there is a lady in distress.” Dr. Medina should know this.
And if you do choose to confront him that way, you don’t do it in public.

Why on earth would you give oral Haldol (a strong anti-psychotic medication. Also a tranquilizer) to someone who’s agitated. First you’ve got to get them to swallow the pills, then you have to wait for them to take effect. It’s much faster just to use injectable Haldol.
And that brings up the ethical question of whether this is an appropriate use of Haldol (my answer: no).

A nitpick here, but House is shown to be receiving 15MG of an unnamed SSRI. It seemed that House was only taking a single pill, but no SSRI comes in that strength. It could be Lexapro, which comes in 10MG, and 15 is a common dose, but that would take a pill and a half

No medical mystery this week, so no grade for it or the final solution. The medicine overall was pretty good, at least until the miraculous cures in the end. I’ll give it a solid B. The soap opera was good — at leas the House part — because it wasn’t as maudlin as Annie, Steve, and Alvie. House’s soap opera gets an A- (everyone else gets a C).

A list of all prior House reviews

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

Marvel Zombies 4 #1 “Midnight Sons, part 1″
Fred Van Lente, writer
Kev Walker, penciler

Morbius may be a snappy dresser and a brilliant biochemist, but he is clearly clueless about vaccines.

Generally speaking, there are five types of vaccines in common use:

Live attenuated vaccines
These are the only vaccines that could possibly cause a disease — but only certain vaccines, and only in certain rare instances. As the name suggests, these vaccines use live, but weakened, germs. The measles, mumps, and rubella vaccine (MMR) falls in this category. It might cause a slight fever or body aches, but it will not cause measles, mumps or rubella.
The varicella (chicken pox) vaccine is also in this category. One in 20 of the recipients of this vaccine will develop a mild rash (usually 1 or 2 pox near the injection site), and a few children with a compromised immune system have developed a full chicken pox infection after vaccination, but there have been no reported deaths associated with the vaccine (unlike actual chicken pox, which prior to the use of the vaccine, killed about 100 people per year in the US).
The vaccine with the highest risk is the oral polio vaccine (OPV), which reverts to the wild-type fully infectious polio virus in about one in a million recipients. Luckily, the OPV hasn’t been used in the United States in nearly a decade (and realistically, before the vaccine, many more than one in a million children contracted polio).

Killed virus vaccines
These vaccines used dead germs to induce an immune response. Since the germs are dead, they can’t cause a disease. Killed vaccines include polio (the current injectable vaccine, not the oral one), hepatitis A, and the flu.

Subunit vaccines
In these vaccines, only a small part of the infectious organism is used — generally a surface protein. Since the entire organism is not present, there’s no way this type of vaccine can cause an infectious disease. Hepatitis B and the HPV vaccine (Gardasil) are examples of this kind of vaccine.

Similar is the conjugate vaccine. In these vaccines, part of the outer coat of an infectious bacteria is combined with a larger protein to make it more susceptible to the immune system. Again, since only part of the germ is used in the vaccine, it cannot cause disease.

Finally, there’s the toxoid vaccines, which are used to protect against toxins put out by certain bacteria such as Clostridium tetani (tetanus) and Corynebacterium diphtheriae (diptheria). Since no germ is used in the vaccine, there is no zero chance of developing a “full blown” infection.

So out of all the vaccines we routinely give, only two even have the “slight chance” Morbius mentions of causing the actual disease. But even that is overstating it: the varicella vaccine has only been shown to cause full blown chicken pox in immune compromised individuals, and the oral polio vaccine hasn’t been used in the United States since 2000. (And you’ll notice that both those diseases are viral, while Morbius specifically mentions bacteria [never mind, see comment #8 below]).

I hope you’re a better zombie fighter than immunologist, Morbius.

Today’s comic book public service ad is “Get a Grip on Your Gripes,” or as I like to call it: Junior High Psychotherapy.

Fred is angry because he lost his race at the track meet the day before. Now, he’s taking it out on those around him. Luckily his friend Joe steps in and commiserates with him about his loss and encourages him to do better next time, right? Wrong! Joe steps in and tells Fred to suck it up — it’s his own fault he lost, and to stop taking it out on other people. Sure, there’s some validity in what Joe is saying, but would it hurt to show a little sympathy? This is a comic book after all, and we all know what happens to people like Fred: they become super-villains.

Click on the image for the full ad

This PSA is found in DC comics from January 1961. Jack Schiff handles the scripting of this ad, with Bernard Baily providing the art.

More PSAs

Tags: comics psa psychoanalysis anger jack schiff bernard baily

In the Motto Grosso region of Brazil, a strange and deadly new plague has arisen: the Green Death! Its symptoms really aren’t mentioned — other than the obvious key words “green” and “death” — though one scientists refers to it as a “terrible body wasting disease.” Judging from the pictures, it turns people into green hippy zombies. As the rural farmers flee from the disease, they spread it to the larger towns and cities of Brazil until a full epidemic of Green Death has broken out.

Luckily, scientists from the Grant Institute of Medical Research have sent a team into the jungle to find the cause of the disease and develop a cure. Unfortunately, their native porter betrays them and they are captured by a local tribe of headhunters and imprisoned. The head scientist meets an unfortunate end, but the beautiful-female-scientist-hiding-under-a-mousy-façade and her hunky fellow scientist survive. Something to be said for being a good looking junior scientist, I guess.

All is not lost though, as one of the members of the expedition is really the Golden Age hero “The Hurricane” in disguise. He rescues the scientists and kills the evil witch doctor who was behind the Green Death. He also managed to “convince” the witch doctor to hand over the cure to the plague. As the remaining scientists are flown to safety, Hurricane unleashes his fury on the tribe of headhunters, destroying the whole town — if not the entire populace. Such is the vengeance of the Golden Age.

The Green Death resembles two plagues we’ve seen before: the Yellow Death from Superman and the Red Death from Doc Savage. Of course, this story predates the Yellow Death by three months, and the Red Death by nearly fifty years.

Motto Grosso is an actual region of Brazil, but the tribe mentioned, the Jivaro, live in Peru and Ecuador, not Brazil. I don’t think there are any Mayan ruins in Brazil, either.

This Hurricane story is from Captain America Comics #2 (June 1941), by Joe Simon and Jack Kirby.

While Team 7 is looking for abandoned nuclear weapons deep in the Cambodian jungle, they are ambushed by a pair of Soviet psychics. Here, Jackson Dane (later the leader of Wetworks) is under psychic attack by one of the Soviets.

Team 7: Operation Hell #3, by Chuck Dixon and Chris Warner

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed team 7 chuck dixon

Here’s Gabriel — Miles Craven’s pet psychic — again. This time he’s the victim of a psychic nosebleed when he visits the mysterious ninth floor, where IO looks locks up their failed psychic genetic experiments.

Team 7 #2, by Chuck Dixon and Aron Wiesenfeld

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed gabriel chuck dixon

Black Lightning Year One #4
Jen Van Meter, writer
Cully Hamner, penciler

Black Lightning (Jeff Pierce) comes home and finds his friend Peter shot and dying on his front steps. When he cannot detect a pulse, Jeff gives him a large shock.

Not really the best idea.

For once, I’m not going to lecture about “don’t shock a flatline” because that’s precisely the problem — we don’t know what the heart rhythm is. Jeff checked the pulse, but Peter’s lost an awful lot of blood (check the comic for yourself to see, I can’t reprint every panel) — there’s probably not enough left to give any sort of pulse, even if the heart were beating normally. Jeff may be shocking a heart beating normally, or one in ventricular fibrillation, or a flatline — the point is he doesn’t know, and so it’s not a good idea to blindly shock.

Peter’s problems are his massive blood loss and his gunshot wounds. Any heart issues are secondary to these. It’s fine to treat the heart, but it’s not going to do any good if the hemorrhage isn’t dealt with quickly — or if one of the bullets wounded the heart.

Other Thoughts:
1. Now in real life, a situation like this isn’t going to happen: if you have access to a modern defibrillator or an AED, you have access to a basic heart monitor because they are built into the machine. Sure, the monitor’s not usually fancy, but it’s enough get the job done.

2. The reason two paddles are used in defibrillation is to make an electrical circuit with the heart in the middle. Is that what’s happening here? Is current flowing from one of Jeff’s hands into the other? (His hand position’s a little off too, unless he meant to defibrillate the sternum.)

3. Admittedly, Black Lightning’s reaction here is more emotional than medical, and I can’t really fault him for that — but I can use him as a teaching point.

4. Kudos to Jeff for remembering to open up Peter’s shirt before shocking him.

5. If it were me in this scenario? While the electrical powers may look cool, they don’t really change the treatment: I’d keep the airway open, stop the bleeding as much as possible, and provide CPR until properly equipped help arrived.

6. As cliché would have it, despite being found down and pulseless, Peter is able to revive enough to whisper his last words to Jeff.

Tags: comics medicine black lightning defibrillation

They almost made it for a complete episode without screwing up the science…almost.

The Plot: Strange murders have been occurring in Boston, murders where the victim has their spinal column ripped open and have been drained of spinal fluid. Agent Dunham and her team are called in after the second murder. While examining the body, Walter finds traces of Treponema pallidum, the bacteria that causes syphilis — only it’s a variety of syphilis that has been extinct for decades. They trace the syphilis to the CDC who note that they recently sent a sample of that very syphilis to Lubov Pharmaceuticals. The CDC also mentions that the same research lab ordered RND-390, a component of the rapid skin growth bioweapon seen previously.

Olivia and her team raid the lab — only it’s not a real lab, just a split-level house in a residential area. They arrest a wheelchair-bound scientist named Boone and bring him in for questioning. He admits to working for the ZTF and having developed the rapid skin growth weapon, as well as playing a role in whatever is terrorizing the city now. He tells Dunham that he will help her, only they need to rescue his wife who was kidnapped by the ZTF to ensure he keeps working for them. Eventually, Boone admits that his wife is not a hostage, but has been dosed with a contagion that has turned her into the killer stalking the city. If Dunham and her team can capture his wife, he will concoct an antidote and then tell Dunham everything he knows about the ZTF.

Dunham, Peter, and Charlie capture the wife and brings her back to the lab where Walter and Boone have concocted an antidote. The cure is a success, unfortunately Boone died of a stroke while making it. He leaves a videotape for Dunham naming names. He doesn’t know much, but reveals to her that the money man behind ZTF is William Bell.

1. Free Samples
The CDC is a little free with their germ samples, aren’t they? Particularly the bioweapon ones.
And they know the lab is in a residential area, but don’t seem to think twice about it.

2. It Goes to Eleven
How does giving cerebral spinal fluid to his wife going to cause Boone to become paralyzed? If that’s the case, then everyone who ever had a spinal tap would be in a wheelchair.

3. FBwhat?
Astrid gets the “Only Agent Actually Investigating” Award for her finding-the-club-stamp moment.

4. Billy Squire
Taking too much spinal fluid is not going to cause a stroke; if anything, it’s going to cause a herniation (the brainstem is pushed downward over sharp bony prominences and damaged — and not in a good way). At the least, it’ll give him a nasty spinal headache.
Because it’s not a stroke, the medication tPA (tissue plasminogen activator, a “clot busting” drug) is not going to do any good. And even if it were a stroke, tPA is not necessarily a good idea. If it is a stroke caused by a clot, then tPA is indicated, but if it is a stroke caused by bleeding in the brain, then tPA will make it worse. There are very specific rules about giving tPA to minimize the risk of bad outcomes.
Regardless, you don’t stab someone in the neck with a syringe of the medication.

5. K.I.S.S.
Why inject the antidote into the spinal column at the cervical spine (neck level)? It’s a tough shot, and runs a risk of injuring the cord. Since the CSF circulates throughout the spinal column as a whole, injecting the medication at the lumbar level will have the same effect, only be easier and less risky.

Everything was going for this episode, and I was going to move the clock back again, but then they started talking about stroke and tPA and lost all benefits. The clock stays in place this week.

This episode seemed to have potential — strange creature from lab released by animal rights activists that proceeds to terrorize the countryside. But then the bad science and awkward storyline kicked in.

The Plot: A group of animal activists break into a research lab and frees all the animals from their cages. They also release a particularly nasty creature hidden in the back of the lab. The monster shows its gratitude by promptly killing one of the activists and a scientist who tried to stop them. It then hunts down and kills the other activists as they are fleeing in an SUV.

Agent Dunham and her team are called in the next morning when the wrecked car and shredded bodies are found. One of the dead bodies is moved back to the lab where Walter performs and autopsy and finds a stinger of some sort buried in the body. He also finds hundreds of larval worms in the body, apparently implanted by the creature. Unfortunately, by this time Charlie has encountered the monster and been attacked. He survived, but has become implanted with the larvae as well.

Walter has deduced that the monster is a transgenic animal — composed of the genes and attributes of multiple species. He is worried that it may be based on his work because he experimented with transgenics years before. For once, the “science” turns out to be unrelated to his research.

Walter theorizes that the only way to kill the larvae inside of Charlie is to transfuse him with some of the monster’s blood so that the larvae will get confused and stop feeding on him. The team traps the monster in the sewers and kills it, but they collect enough blood to transfuse Charlie and save his life.

1. Worry Wart
After all the other episodes where the plot was based on Walter’s research, why is he suddenly worried about the morality of it. Plenty of people have died because of his work already this season.

2. Blue Genes
Transgenic animals have been used in research for years. They are animals that express genes from other sources, or express specially modified genes. Walter seemed to be talking about transgenics taken to a whole new level — plus he was confusing it with xenografting (transplanting parts from different animals) with his talk about rejection.

“Accelerated Darwinism”
A nonsense phrase and a particularly stupid one at that. The theory of evolution applies to natural selection, and the selection here was man-made, pretty much the opposite of natural..

3. Keep the Needle Away From Me
Astrid is told to draw 25cc of blood from Charlie and she sticks the needle in the belly? She might get some peritoneal fluid, but the big blood vessels are deep in the abdomen. Why not just draw blood from the arm like a normal person?

4. Lucky Shot
Where was the incendiary part of the incendiary 50 caliber rounds? And wouldn’t incendiary rounds have made it that much more difficult to get blood from it.

5. Ultra-Special
That was impressive resolution on that out of date ultrasound machine. Even more impressive was how the picture stayed perfectly still despite Walter waving the wand all over Charlie’s chest. (That last sentence should get some interesting Google searches)

6. The Belly of the Beast
So the idea was that by giving Charlie some of Mama Monster’s blood, the baby monsters would get confused (in that “can’t tell self versus non-self” way), and thus miraculously die off (cause of death? Confusion.) So how did the proteins on Mama’s blood cells get into Charlie’s peritoneal fluid so fast, if at all? Why not just inject an anti-parasitic into the peritoneal fluid, thus bypassing most of the side effects Charlie would suffer.

7. Random Thoughts
Apparently the monster has either blue curaçao or Windex for blood.
Johnathan Swift?
Clearly Walter missed Aliens when he was in the asylum or he would have known to look up.

Another week of bad science, and characters acting, well, out of character. The Fringe Doomsday Clock gains another minute and stands at 11:57 (meaning that all the gains from the good episodes before the break have been lost).

Despite the barely above average medicine, I enjoyed this episode of House. Probably because it focused more on House himself than on Foreteen.

Jackson is a teenager born with genetic mosaicism whose parents have chosen to raise him as a male. He is playing on the school’s basketball team and he has just made the winning basket when he collapses to the ground with severe abdominal pain. He is later admitted to House’s service for treatment of this “chronic pelvic pain”. An issue is that his parents have never told him about his underlying genetic condition and have been giving him testosterone shots under the fiction that they are vitamins. They don’t want House or his team to tell him the truth, a situation that doesn’t sit well with some of the team, particularly Thirteen.

The team’s initial differential includes dehydration, congenital adrenal hyperplasia, PMDS (Persistent Mullerian Duct Syndrome), a blind uterus, or problems from the surgical reconstruction of his penis. House wants to perform a urethroscopy, but the parents want an MRI to look for a blind uterus. House gives into their suggestion and an MRI is ordered. The results are negative, so Jackson is prepared for the urethroscopy. As they start the procedure he starts to complain of chest pain and shortness of breath. Thirteen only hears muffled heart sounds on exam and notices jugular venous distention. He appears to be in cardiac tamponade so she jabs a syringe blindly into his chest to remove the extra fluid from around the heart.

The team’s second attempt at a differential diagnosis only yields the generalities of “drugs, toxins or infection.” Then autoimmune disease related to the testosterone injections is mentioned, especially polyarteritis or SLE (lupus). House has the team start Jackson on corticosteroids for the suspected autoimmune condition and finasteride to block the effects of the testosterone. (It’s not made clear at this point, but the testosterone injections are stopped as well). As Thirteen is administering the medicine, she notices red palms on Jackson. She takes this to mean that 1) he has does not have an autoimmune disease, and 2) his liver and kidneys are failing. Blood tests back this up (her second point, at least).

The third version of a differential diagnosis contains amyloidosis or drug/alcohol abuse due to depression. A search of his room yields some dismal and morbid poetry that Thirteen takes as proof that Jackson is depressed. She feels this depression is related to his sexual identity issues and wants his parents to tell him the truth, but his mother refuses. Meanwhile, Taub finds evidence of toxoplasmosis on Jackson’s water bottle, so infection is a possibility as well. He is started on pyrimethamine to treat the suspected toxoplasmosis. His parents ask that his testosterone be restarted as well. When Thirteen is injecting the medicine into Jackson, she confesses that it isn’t a vitamin shot like he’d been told — though she doesn’t tell him what it is, just tells him to ask his parents. This triggers a showdown with her and the parents in Cuddy’s office. Cuddy backs Thirteen, but lets her know it is for Jackson’s sake, not her own. When told the truth, Jackson understandably becomes angry and refuses to speak with his parents anymore. Thirteen comes back in to talk with him and lets him know about finding the poem. He tells her it was for a class assignment (”write a poem in the style of Sylvia Plath”), and was not about his feeling at all. He tells her that he doesn’t feel depressed — or at least he didn’t until his parents told him the truth about his genetics. He becomes suddenly nauseated and begins to vomit blood.

Jackson is found to have a gastric fistula due to necrotizing pancreatitis. Thirteen suggests Zollinger-Ellison Syndrome, but Taub believes it is systemic scleroderma. Foreman decides to treat the possible Zollinger-Ellison first and if that doesn’t work, then to treat the scleroderma. He and the rest of the team know that sclerodema is more likely, but also has a worse outcome, so they are treating the Zollinger Ellison and hoping for the best. It doesn’t work, so Jackson is started on anti-inflammatory medication to treat the scleroderma. The next morning, Foreman tells Thirteen that it is having some effect as Jackson’s liver enzymes are improving. Through some convoluted logic, they deduce that this means it cannot be sclerodema since he is getting better too fast. About this time, House reappears on the scene, hears about the case and instantly makes the diagnosis: it all started with dehydration; that’s what caused the collapse. The ER gave him some IV fluids, but because of his use if energy drinks (which apparently also caused his abdominal pain), his kidneys were slow to respond. When Jackson was then given the contrast for the MRI, the already dehydration/energy drink-strained kidneys could not filter the contrast fast enough so it cycled throughout the body, causing problems wherever it went. It was this contrast that caused the heart disease, the liver failure, the kidney failure, and the pancreatitis.

Methadone is a potent narcotic, and has more respiratory depression than more common narcotics, but it’s not that life threatening. Particularly in a patient with such a heavy previous use of narcotics.

I did like House’s realization that he can’t be the brilliant diagnostician he wants to be if he’s not in pain.

Mosaicism occurs when one person has two genetically distinct lines of cells. Some of their cells have one set of genes, and the other cells have a different set. Mosaicism generally occurs early in development, often from a mutation or nondisjunction. In Jackson’s case, one cell line is genotypically male (XY) and the other female (XX). This is a known, but rare, cause of intersexuality.

As usual, minor complaints are in blue, and nit-picking in green. My main complaint this week, the red one, I’d characterize as a “moderate” complaints — more than minor, but less than major. It’s theoretically possible, but extremely unlikely.

Intravenous contrast can certainly cause renal problems, my kidneys are proof of that. Contrast material can cause acute renal failure (contrast-induced nephropathy). There have also been isolated cases of pancreatitis and pericardial effusion thought to be linked to contrast material, but the patients involved all had significant other co-morbidities (such as AIDS). For Jackson to have had such problems with contrast, his kidneys must have been in bad shape, which should have shown up on simple blood tests — blood tests which radiologists are maniacal about ordering and avoiding the use of contrast if they looks even a little off.
I guess this sort of complication is what happens when you act as your own radiologist.
And seriously, how many energy drinks was this kid downing to cause these problems?

Notice how vague the writers were being when treating the scleroderma: repeatedly using the term “anti-inflammatories” instead of naming a specific drug. This is usually a sign that they’re trying to skirt around a known plot inconsistency.
Such as the fact the anti-inflammatory that they’d use would likely be a corticosteroid, the same type of drug they gave Jackson for a suspected autoimmune condition in the first half of the show. In fact, scleroderma is an autoimmune condition.

I like how psychic the team can be. Thirteen automatically knows it’s an exudate causing Jackson’s tamponade instead of the more common (and seen just two episodes ago) blood.
That’s incredibly fast for an exudate to form.
Blindly jamming a needle in the chest is still not a good idea. It wouldn’t take that much longer the properly position it, and just a little more time to attach it to a cardiac monitor.

Finasteride is not approved for use in children. It blocks the breakdown of testosterone into dihydrotestosterone (DHT), which I guess might help if it is the DHT causing the lupus reaction and not the testosterone itself. Otherwise, you’ve just made things worse by increasing the levels of testosterone.

Toxoplasmosis is a common parasitic disease, but does not typically cause problems in people with healthy immune systems. It is a worry in patients with compromised immune systems and in pregnant patients, because it is one of the diseases that can be passed from mother to fetus.
Symptoms don’t match at all.
Pyrimethamine is not used alone to treat toxoplasmosis. It is given with a sulfonamide.

I suspect a pelvic U/S would be a better choice than MRI when looking for a blind uterus, but then you’d avoid that whole contrast material concept.

Several hours of pelvic pain is not chronic.

The medical mystery was good. The mosaicism was a red herring in terms of the mystery itself — though it did add to the family dynamics issues. I give the mystery a B+. The final diagnosis was logical, but would have required a perfect storm of events to occur. I give it a B. The medicine overall remained haphazard, but at least it was more focused than previous weeks (except for the toxoplasmosis, that came out of left field), and earns a C+. The soap opera was fairly good, both the “House is happy” and “Mother avoids the issue” aspects. I give it a B.

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The second good episode of Fringe in a row. Maybe my Doomsday Clock threat is working

The Plot:The episode starts with Mr. Jones, the enigmatic villain who escaped from a German prison several episodes ago through the use of Dr. Bishop’s teleport machine. He was shoved in a decompression chamber the minute he arrived, and now he finally emerges 2 weeks later. Everything should be fine, but he notices a distinct tremor of his hands.

Meanwhile, a newspaper vendor in the city dies in a particularly gruesome way. In a matter of seconds, his skin grows over his eyes, nose, and mouth and he suffocates to death. On first hearing about the case, Bishop suspects ceramides were involved. Agent Dunham, on her part, suspects that Mr. Jones is behind the death and is determined to find him.

One of the junior FBI agents determines that Jones’ late lawyer had access to a warehouse in Texas that, after years of lying dormant, had its power switched back on the same day Jones escaped from prison. Broyles is just about to order a raid on the warehouse when Mr. Jones turns himself in to the FBI at the Boston office. He refuses to speak to anyone but Agent Dunham.

For once making sense, new head honcho Harris refuses to let Dunham talk to Jones, telling her that doing so would be giving in to a terrorist’s demands. Instead he sends Dunham on the raid on the Texas warehouse. The raid turns up evidence that Jones had been there, and when one of the FBI agents (coincidentally, the same one who located the warehouse in the first place) dies of the same weird condition, the team knows Jones is responsible for the strange disease.

Dunham and Peter Bishop track down the manifesto of the ZTF, the group Jones is associated with. It tells of a coming war between two realities with only one surviving. By now, Dr. Bishop has discovered that the strange disease is caused by toxin absorbed through the skin that causes hyperactivity of the “protein responsible for scar tissue.”

Back in Boston, Jones refuses to talk to Harris, but does give him a list of supplies he requires. Dunham returns from Texas and meets with Jones. She hands him the supplies he requested and he promptly uses them to make an anti-surveillance device so no one can overhear their conversation. He admits that he is responsible for the two deaths, but tells her he wants to prevent any more. Before giving her anymore information, he tells her that she must take the key he brought with him and take it to an abandoned amusement part. Once there, she finds what appears to be a box of old children’s games. A note tells her that she must pass the “first test” — mentally turn off all the lights in a box — with her mind alone before Jones will tell her anything else.

Dunham tries the test, fails, and is convinced it is nothing but a game Jones is playing. She confronts him again, and he tells her it is not a game, but reality. He then tells her that she is special because she received treatment with the drug Cortexiphan. It turns out that this is a drug designed by Massive Dynamics — by Dr. Bell himself in fact — which is supposed to “remove limitations” from the mind. During their conversation, Jones collapses, suffering from after effects of teleportation; effects which are hinted at, but never explained. He is rushed to Bishop’s lab where Dr. Bishop manages to resuscitate him. Dunham has Peter Bishop rewire the light board so it looks like she passed the test. Jones relents and tells her the location of a bomb containing the compound that causes the disease. The FBI rushes there to find that the bomb is wired with an array of lights, just like the “test” Dunham was given. The only way to defuse the bomb is turn out all the lights without touching the device. Olivia decides she has to try and manages to mentally turn off all the lights with just seconds to spare.

Afterward, when she goes to talk with Jones, she discovers he has escaped the hospital where he was transferred by punching an enormous hole in the wall. The words “You Pass” are scrawled on the wall. Meanwhile, Walter has been reading the ZTF manifesto and discovers that its typewritten pages exactly match the print produced by his old typewriter.

1. Would a Fat-Free Diet Help?
Ceramides are lipid molecules common in cell membranes. As Walter says, they play a role in cell differentiation. On the other hand, he’s mostly wrong when he also mentions cell growth. Ceramides don’t seem to play a role in overactive cell growth — just the opposite actually — they appear to inhibit cell growth. (And being a lipid – a fatty molecule — it has nothing to do with the scar tissue protein implicated later).

2. Not Quite Far Enough
Performing her emergency tracheotomy, Agent Dunham successfully cut through the skin, but neglected to actually cut into the trachea — the key part of the procedure. She just slid the tube into the loose tissue in front of the trachea — though it ended up being a moot point.

3. Rescue Me
Unexplained bradycardia. An EKG is a good call.
They confused cardiac arrest (the heart stopping) and heart attack (lack of blood flow to the heart causing damage). Nitroglycerin is good for a heart attack, but won’t do any good for a cardiac arrest.
50cc is not enough saline to resuscitate anyone; it’s only about 1 ½ shot glasses of salt water. A normal resuscitation required liters of fluid. Though to be fair, Walter orders the saline and never states why; it is Peter who tells us it is for resuscitation, and he might not know what he’s talking about.

4. Lying or Stupid?
Mr Jones didn’t tell Olivia “where or when” the bomb was going to go off? He may have neglected the where, but he certainly told us the when — 16 hours.

5. Elementary, My Dear Watson
Some interesting choices for the movies and book mentioned in this episode. I’m suspicious they may be clues, or at least hints.
The Land of Laughs. I actually have the book in my library (but not the edition shown). A very good book. Among other themes, it deals with reality versus fantasy. Since they explicitly singled out the book by name, I suspect it’s important. I’ll have to reread it.
Charade. Good movie. Cary Grant, Audrey Hepburn. Deals with people who aren’t what they seem. Good guys are bad guys and bad guys are good guys.
Rear Window, the only Jimmy Stewart/Grace Kelly movie. A classic Hitchcock suspense thriller.

There were hokey aspects (Dunham’s psychic powers, alternate realities) and questionable medicine, but there was enough cleverness in this week’s plot to allow me to overlook them. I particularly liked the manifesto and the twist that the bomb had to be deactivated just like the test she only beat by cheating. I’m moving back the clock another minute, and the Doomsday Clock now stands at 11:55. (Of course, now we have to wait until April for new episodes, and I will have forgotten all the clues and the show will have lost all its building momentum.)

A much better episode of House this week. While it wasn’t quite up to the standards of the first two seasons, there were definite that classic House was trying to break through.

Sarah is a 29 year old teacher of special needs children who suddenly begins to cough up blood during class and then collapses. She is admitted to the hospital under House’s care. The team’s initial differential diagnosis includes ulcer, leukemia, von Willebrand’s disease (a blood clotting disorder), or a thoracic tumor. House agrees with Foreman that the problem is likely within the patient’s blood and orders a bleeding time test. The test is abnormal, showing that her blood is not clotting correcting. A check of her clotting factors is normal, but her platelets turn up abnormal. The differential diagnosis now includes lymphoma and ITP (idiopathic thrombocytopenic purpura), with the latter being more likely. House elects to start her on methotrexate (which really isn’t a recommended treatment for ITP), but he also wants to treat her with total body irradiation (which is also not a recommended treatment for ITP, only it can have even nastier side effects than methrotrexate). In actuality, House has no intention of using the radiation but is just trying to test Cameron’s limits. She calls his bluff and allows the procedure, so now House and his team pretend have to pretend to use it. In the meantime, the methotrexate has shown no benefit, so House doubles the dose and adds Prednisone (a steroid, and the actual recommended treatment for treating ITP). During the (fake) radiation treatment, Sarah mentions that she has to pee. When she tries to get off the table, she collapses and is found to be pulseless. Thirteen and Taub rapidly pull out the defibrillator and shock her back into a normal rhythm.

The team meets again to discuss the latest findings. Tests, including a transthoracic echocardigram and a bubble test, show no structural defects of Sarah’s heart. Thirteen suggests a high vagal tone from urinating may have caused her to develop an arrhythmia and collapse. The rest of the team half-heartedly suggest heavy metal poisoning, toxin exposure, drug use, or alcohol use. Thirteen then mentions cold agglutinin disease, which seem to fit the case. House wants to put Sarah in an ice bath to test the diagnosis, but Cameron wants him to test some of the blood first. Reluctantly House agrees. The blood clots when exposed to the cold, confirming the presence of cold agglutinins, so Sarah is put into a three minute ice bath. The test, though uncomfortable, is normal (so while she may have some cold agglutinins — and most people do at various levels — she doesn’t have the disease; but please note this is not the recommended way to diagnose the condition).

House now decides that Sarah’s offhand story of transposing the digits of her room number, combined with her need to urinate during the radiation treatment, are signs of a brain lesion — a left hippocampal lesion to be precise. He thinks it is most likely multiple sclerosis (MS), and wants to perform a brain biopsy to confirm his diagnosis. Kutner thinks she has a pancreatic tumor and wants to perform an ERCP instead, but House wins — sort of. Cameron won’t let him go through with a brain biopsy, wanting an MRI first. Reluctantly, House orders the MRI, but it is normal, so Sarah doesn’t have MS. Kutner performs his ERCP and it is normal, but Sarah starts to have problems breathing during the test. She is found to have pleural effusions (fluid build up around the lungs), which are drained (off camera). House now decides that Sarah has equine encephalitis, a mosquito-borne disease caused by a picornavirus (there are actually several types of equine encephalitis, but none that I can find are caused by a picornavirus), which is causing conduction problems in her brain. He wants to test nerve conduction tests along the surface of her brain. This, of course, requires removing the top of her skull and thus needs approval from Cameron. She declines. Meanwhile, Kutner now thinks that she has a lymphoma of her spleen and wants to perform a splenectomy (surgically remove the spleen). House has Thirteen and Foreman search the classroom for evidence of encephalitis, but they turn up nothing significant. Nevertheless, Cameron allows him to perform the nerve conduction study and even assists. The test is going smoothly until Kutner tattles by calling Cuddy. She demands to speak with House and is placed on speakerphone. In the background, her baby Rachel is crying, and the sound is annoying Sarah quite a bit. Her reaction is paradoxical, though, in that her blood pressure drops while she is annoyed (it should rise). The team ends the test and puts her skull back together. House is puzzled and cannot figure out what is going on with Sarah. Puzzled, that is, until Cuddy and Rachel stop by. The baby spits up on House which leads him to start a monologue about evolution which leads him to have his Eureka! moment and diagnose Sarah with a PDA (patent ductus arteriosus).

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

Even though the PDA may not have been open when the heart was scanned, the fact that the duct still existed (it should have withered away) should have been evident.
Why would only the left part of her brain been affected?

Apparently no one in the hospital likes to run CT scans or MRIs (this week anyway). Most of the diagnoses mentioned (MS, lymphoma, tumor) would have shown up and not required brain biopsy, ERCP, etc.

A blood test for cold agglutinins is not simply a “cool the blood and see if it clots” test, but a test to see how much it clots.
An ice bath is by no stretch of the imagination a good test for cold agglutinin disease, if they have it, you’ve just done the patient a major disservice as systemic clotting is not a good thing.

ITP, by definition, has low platelet numbers — which were never mentioned, just abnormal looking platelets (though her red blood cells should have looked chewed up as well).
MTX is not a treatment for ITP. It has been investigated, and continues to be investigated, but hasn’t shown a lot of promise. IV steroids are first line.

There seems to be confusion among the team about heart attacks (myocardial infarctions) and cardiac arrest. The terms are not synonymous.
Shocking a pulseless patient? How about — at least — some CPR first, if not checking the rhythm before shocking?

If I were the doctors I would have taken a closer look at the vitals during the test. Her resting oxygen saturation was 97% — on oxygen. That’s not normal. Nor is a heart rate of 116 , even though they called it “normal”. It didn’t change at all during her ice bath, when it should have shot up. Sure, I know the fancy vital sign machine was just there as a prop, but at least put in a little effort to make it authentic, prop people.

It would have been nice if they had run labs on the fluid they pulled out of the effusion. It would have helped to rule out cancer and pancreatic disease at least.

On another note, parent/baby bonding is often delayed in adoption situations and post-adoption depression in common, so what Cuddy was feeling was fairly normal. I’m glad to see she did not give up Rachel because of it.

The medical mystery started out weak (coughing up blood? That’s it?), but got better earns a B. The final solution was a stretch, but at least it fits more symptoms and seems more logical than usual and thus deserves a B+. The medicine had too much jumping from diagnosis to diagnosis while overlooking the most common and useful testing, so can’t really be considered anything more than average: C. The soap opera was subdued this week, but that felt appropriate, and earns a B.

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This week’s House Challenge results have been posted.

An enjoyable episode of House; one of the better of the season. A good mystery, and the medicine was generally decent. Some nice battle of wits soap opera as well.

Emmy, a thirty year-old fitness instruction, is filming an infomercial when she experiences sudden difficulty breathing and collapses, breaking her ankle in the fall. She is admitted to House’s service for evaluation and all the initial tests were normal. Taub suspects her of steroid use, Kutner mentions environmental allergies, and Cuddy suspects exercise induced asthma. The last seems the most likely, so the team sets about to recreate Emmy’s episode, the best they can with her broken ankle. Sure enough, while in the middle of exercising, she once again collapses and is found to be pulseless.

Kutner suggests she may have Carcinoid syndrome. A CT is obtained which shows no carcinoid tumor, but does reveal that she has had gastric bypass surgery in the past. This catches the team by surprise, and has them rethinking their differential diagnosis: now diabetic neuropathy (nerve damage caused by diabetes) and sleep apnea are added. Thirteen suggests gastrointestinal malabsorption leading to a low potassium, but Kutner takes it one step further and thinks Emmy may have SIBO (small intestine bacterial overgrowth) in a blind loop of bowel, and that these bacteria are making their way into her blood stream causing her symptoms. They test her stool, but there is no evidence for bacterial overgrowth or fat malabsorption.

House decides to rethink sleep apnea, and has Kutner and Taub run a sleep study. During the test she sneaks out, and the pair find her exercising on a treadmill, her ankle still in a splint. They also notice she is bleeding from the ankle and never noticed — she has lost sensation in her foot. The differential now includes multiple sclerosis, Parkinson’s Disease, and transverse myelitis (a crosswise inflammation of the spinal cord). House orders a nerve conduction velocity test (NCV), but while setting it up, Taub realizes that she is losing muscle strength in her arms. This again changes the differential, and the team considers myasthenia gravis, botulinum toxin exposure, other toxins, or heavy metal poisoning. House has them start her on chelation to treat her suspected heavy metal toxicity, but there is no change in her condition. The latest differential consists of a corornary-cardiac fistula (an abnormal connection between the coronary arteries — which supply blood to the heart muscle — and the interior of the heart), Austrian syndrome (meningitis, pneumonia and endocarditis caused by the Pneumococcus bacteria), or Guillain-Barre Syndrome (an autoimmune disease of the peripheral nervous system). The latter fits the symptoms the best, so she is started on the treatment for Guillain-Barre, plasmaphersis.

When Emmy starts hallucinating, the team realizes that the Guillain-Barre diagnosis is wrong as well. Thirteen favors a diagnosis of CNS lymphoma, but Taub is suspicious she has a prion disease (a rare type of disease caused by infectious protein particles. The best known example is probably mad cow disease). House wants a brain biopsy, but Cuddy won’t let him until they’ve ruled out other brain tumors by non-invasive means. The initial tests come back negative and House decides to perform the brain biopsy himself. However, when he and Taub enters the room, they find Emmy up and about, feeling good. Taub informs House that there have not been any new drugs, but that she did eat a piece of chocolate cake from the cafeteria. House now realizes the cause of her condition — she has hereditary coproporphyria. This is an inherited disease that House tells her can be controlled by a high carbohydrate diet. When she was fat, she ate that type of food all the time, so suffered no ill effects, but now that she is slender and eating healthy, the symptoms have caught up with her. He recommends resuming the high carbohydrate diet, but she chooses to continue her low calorie diet and take medication to control her symptoms.

Major complaints are in red, minor in blue, nit-picking in green. Overall, not too many big errors this week, but many of the diagnoses were quite a stretch.

You don’t test for SIBO with a stool study. You need an aspiration of fluid from the small intestine to evaluate or a hydrogen breath test. Plus, if she has a blind loop of bowel, how are the bacteria from it going to end up in the stool to be tested?

She was pulseless, but they never specifically said what her rhythm was. If it was asystole or PEA, then defibrillation was wrong. Otherwise, it was probably right. (And I’m still not too clear on why she coded in the first place).

The time course was off again, but in different way than usual. Emmy must have been several years out from her surgery — she had the weight to lose, the muscles to tone, the fitness guru-ness to obtain, and the informercials to produce and distribute — and only now does she start to have symptoms?
And she never had symptoms with a low carb diet while trying to lose weight before her surgery.

Diet alone is not the best treatment for severe CHP attacks. A drug known as Hemitin also helps.
A high carbohydrate diet is recommended by some physicians. Most doctors recommend a healthy balanced diet with high carbs only during acutre attacks.
Abdominal pain is a key symptom of coproporphyria.

Several episodes this season where diagnoses are made by looking at the urine color and they miss the classic purple urine in this one?

The medical mystery was good this week and deserves an A. The final solution was fairly clever, though a bit of a stretch, and earns a B. The medicine, though again quite a stretch at points, was good overall and also earns a B. The soap opera was well done, both in terms of House/Cuddy and Thirteen. I give it an A, with extra credit for Cuddy’s comment about House’s balls.

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Nightwing #148 “The Great Leap, part 2″
Peter J. Tomasi, writer
Rags Morales, penciler

After being shot with a bullet in the right shoulder, Nightwing makes it to the Batcave where Alfred performs arthroscopic surgery to remove the bullet fragments.

Arthroscopic Surgery (also called arthroscopy) is a type of joint surgery which uses a special fiberoptic scope that allows the surgeon to explore and repair the injured joint while minimizing the trauma from the surgery itself. The scope is attached to a camera and the surgeon follows the action on a video screen. Arthroscopy can be used on a variety of joints (shoulder, knee, spine, etc.) and for a variety of procedures — in this case, removal of a foreign body.

A small incision is made for the arthroscope and another small incision is made for any additional instruments (a blunt probe is commonly used; A pair of forceps to remove the bullet is used here). The surgeon watches the video screen as he manipulates the arthroscope and other instruments. The joint is explored, bullet fragments are found and then removed. The instruments are then withdrawn and dressings applied to the incisions. Healing time is quicker than traditional open shoulder surgery — athletes can usually return to action within a few weeks to a month. On the other hand, I think it’s fair to say that Nightwing running off an hour or two later to resume the good fight is not one of his better ideas. He must not be particularly fond of using that shoulder.

Depending on the location and extent of the surgery, general, epidural, or local anesthesia can be used. Alfred is grousing because Nightwing asked only to use lidocaine — a local anesthetic — for the surgery. Given the wound location, this is actually a reasonable choice. The lidocaine could be used as a local anesthetic or to provide a brachial plexus block (the brachial plexus is a collection of nerves in the shoulder that contains all the nerves of the arm). The latter would be the best option, but as it affects the entire arm and takes several hours to wear off, it would limit Nightwing’s ability to go gallivanting across the rooftops later that night.

Other thoughts:
Nightwing tells Alfred to avoid nicking a nerve, which is an unusual request as there are no nerves in the shoulder joint. He might be referring to the incision into the shoulder, but at the time he says it, Alfred’s already well into the operation.

The arthroscope doesn’t provide any advantage in removing the bullet from the wound in Nightwing’s side. It’s not a bullet lost in a wide-open joint, but instead one lodged in the abdominal muscles. A standard surgical exploration would be best.

I see that Alfred is not wearing eye protection or wearing a full surgical gown. Given that he considers Nightwing “family,” he might feel that these aren’t necessary. Anyway, I doubt OSHA is likely to spring an inspection on the Batcave.

I suspect Alfred reads the journal Arthoscopy. From the June 2007 issue of the journal, in the abstract of an article entitled Acute Arthroscopic Removal of a Bullet from the Shoulder:

“Bullets and lead particles in synovial fluid dissolve in time and cause periarticular fibrosis, chondrolysis, hypertrophic arthropathy, and sometimes chronic lead intoxication.”

Here’s what our favorite surgeon/butler tells Nightwing:

“…otherwise the lead particles in the synovial fluid could dissolve in time and cause periarticular fibrosis, chondolysis, even hypertrophic arthropathy.”

As usual, Rags Morales provides solid medical-related art. However, if I, if I really wanted to nick-pit, I would point out that arthoscopic images are always round (because the camera looks through the round scope — and speaking of cameras, there doesn’t seem to be one attached to the scope. It should fit over the eyepiece).

One last thought: Alfred’s priorities and sense of timing are horrible. Nightwing showed up to the Batcave bleeding from a bullet wound. Alfred’s first priority was to stop the bleeding. After accomplishing that, there was little need for him to perform joint surgery and remove the bullets at that time. The complications he describes are all chronic conditions and would take weeks, if not months, to occur. If he knew Nightwing was going to finish his mission as soon as possible (and you know he did), then Alfred should have postponed the surgery until later and spare Nightwing any surgical complications and need for recovery while fighting crime that night.

Black Jack is a famous manga character written by Osamu Tezuka. He is a supremely skilled surgeon, though an unlicensed one. Often he is the only surgeon skilled enough — or even willing to — perform a particular lifesaving operation. He will operate on the rich and the poor alike, and lives by his own code of ethics.

Tezuka was a medical school graduate and did his best to add medical accuracy to his stories, though he never let that stand in the way of a good plot — you’ll notice that many of the stories contain implausible fantasy or science-fiction elements. The stories were published over a ten-year period, from 1973-1983, so it’s also important to remember that they were written 20-30 years ago and medicine has come a long way in that period of time. There is sometimes a difference in the approach to certain patients and conditions between Western and Eastern medicine, and that occasionally shows up in the stories as well.

Vertical has recently started releasing a very nice collection of Black Jack stories. These volumes present the stories chronologically as they occur in Black Jack’s life. (This is different than the order in which the stories were originally published). My copy of Black Jack: Volume 1 is the limited edition hardbound and the pages references below match that edition. Hopefully, the pages numbers are the same in the softcover edition as well.

In my annotations below, I’ve added the year the story was first published. Consider this a strong Spoiler Warning as well. Click “Read More” to read the rest of the post.

Read more…

Eleventh Hour is yet another science/action/mystery show. This one is about the overly brilliant Dr. Jason Hood, biophysicist and “Special Science Advisor” to the FBI, along with Rachel, the attractive yet hard-as-nails FBI agent who accompanies him. Cloning is the subject of the first episode, as Jacob and Rachel hunt the mysterious Gepetto, a scientist who is trying to clone humans using innocent women as surrogate mothers.

The science is definitely better than Fringe, though the characters aren’t as interesting. The plot was compelling, despite a few plot holes (such as…how stupid is the surrogate mother not to realize something isn’t kosher? Or does she really think it is normal to have an obstetrical examination in an abandoned warehouse?)

If you missed it Thursday night, you can still catch it on the CBS website for the show.

1. Cloning
As Science not Fiction points out in their review, the science is reasonable, and the explanation of cloning given is fairly straight-forward and easy to understand. It’s easily the best depiction of cloning in a television show that I can recall.
For the record, the worst I can remember are the clone storylines in The Flash (Episode 18: Twin Streaks) and the live action The Amazing Spider-Man from the ’70s (Episode 5: Night of the Clones).
Why are the police running a DNA lab in a tent in the forest? It’s a delicate procedure and that’s just asking for contamination. (”The DNA appears to be half human and half oak. So let’s get the team out there looking for an Ent!”)

2. Placenta Previa
When the placenta covers the internal os (the opening between the uterus and birth canal), it is known as placenta previa. The condition is graded by how much of the os is covered. In Grade III placenta previa (mentioned on the show) — which is also known as partial placenta previa — the os is partially covered by the placenta. As you can imagine, this makes it a challenge to give birth vaginally. C-sections are the recommended delivery method in this situation*.

The classic symptom of placenta previa is painless vaginal bleeding during pregnancy, which is not what was shown on the show. Painful vaginal bleeding is more indicative of a placental abruption (when the placenta pulls away from the wall of the uterus), a much more dangerous condition**.

3. CPR
While I applaud the show for resisting the temptation to defibrillate a flatline, that has to be one of the worst examples of Hollywood CPR ever.

Television and movie CPR is almost always done incorrectly, with bent elbows instead of straight arms — but there’s a good reason for this because you don’t want to injure the actor portraying the victim. This scene was worse than that, with nearly everything done wrong, such as — in addition to the bent elbows — improperly placed hands, a patient who was up too high for good CPR, and too rapid a pace. In the end, to show he was really trying hard, Dr. Hood increased the speed of his compressions even more — but this is the worst thing he could have done. You have to give the heart time to fill with blood between compressions; faster compression means the heart doesn’t have time to fill, and the resulting CPR is worse, not better***.

Notes:
*Bear in mind that a placenta previa is fairly common in early pregnancy, and will usually shift away from the os as the uterus grows during pregnancy. So, delivery-wise, placenta previa is only a concern when it occurs late in pregnancy.

**Admittedly, placenta previa can sometimes stimulate premature contractions, which can be quite painful, but that doesn’t seem to be what was shown here.

***Though they saved the patient in this situation, it would not have worked like this in real life. She had flatlined because she had hemorrhaged and lost a tremendous amount of blood. Until that blood loss is corrected, it’s going to be impossible to get her heart restarted (especially with bad CPR).
Speaking of blood, why would there still be blood in a closed-down clinic?

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

This comic can best be described as “medicine done wrong — very wrong.” It features some of the worst medicine (the worst medical decision making, anyway) that I have ever seen, and that includes four seasons of Grey’s Anatomy.

The Young Doctors was a series published by Charlton comics at the same time Dell was publishing Ben Casey and Dr. Kildare and clearly designed to taget the same audience. It featured two senior residents, Doctor Martin Burke and Doctor Cliff Landon, and their exploits at Metro Hospital. Dr. Landon was a stuck-up surgeon and Dr. Burke was a stuck-up psychiatrist. They couldn’t stand each other, and apparently no other doctors could stand them either since they always seemed to be the only two doctors in the entire hospital.

In the first story, Doctor Burke and Doctor Landon have reluctantly agreed to attend a fund raising dinner hosted by one the local big wig politicians in preparation for the upcoming election. In the middle of his speech, the politician suddenly loses his voice and develops difficulty swallowing and breathing. He is admitted to the hospital and placed under the care of Dr. Landon. Landon performs a thorough examination including lab work and x-rays and can find nothing wrong with the patient. He suspects it is a psychosomatic illness and he brings in Dr Burke, the psychiatry resident. Dr. Burke evaluates the patient then talks to his family and finds that the politician has these symptoms before every election. Dr. Burke agrees with Dr. Landon: the problem is not physical, but psychological. The two of them attempt to discuss their diagnosis with the patient, but he will hear none of it. The two residents run for cover and repeat the tests, but everything comes out the same. It is a psychological problem.

So what do Dr. Landon and Dr. Burke do? In the end, the two residents take the easy way out and lie to the patient. They inform him that his tonsils are giving him problems. Dr. Landon removes the tonsils and the politician returns home, satisfied.

But should he be satisfied? No, he received poor and deceptive medical care. Rather that address the actual problem — and admittedly that would have been difficult — the doctors chose to perform an unnecessary and potentially dangerous surgery on healthy tissue. A tonsillectomy is not always an easy surgery; it can be risky, particularly in adults. And in the end, the politician’s problem still exists. He needs therapy, no surgery. When he develops the same symptoms at the next election, what are they going to blame and remove then?

In the second story, Dr. Emile Braddock, a famous surgeon who was Dr. Landon’s mentor, comes to Metro Hospital. Dr. Landon is shocked to learn that Dr. Braddock has given up surgery and is now a researcher. He confronts his former teacher, who tells him that he was involved in a traffic accident that injured his hands. After recovering, Dr. Braddock returned to surgery, but his first patient after the accident died on the table, so he now believes he no longer has what it takes to be a good surgeon. Dr. Landon cannot believe what he is hearing. How can his mentor give up surgery? He decides that Dr. Braddock has simply lost his confidence, and that there is nothing physically wrong with him. Enlisting the help of Dr. Burke, he decides that tricking Dr. Braddock is the best way for him to regain his confidence. Late one night, Dr. Landon put his plan into action. A patient with a head injury and subdural hematoma needs emergency surgery and Landon asks Braddock to assist him since all the other doctors have gone home for the day. Braddock reluctantly agrees and scrubs in. Shortly after the surgery starts, Dr. Landon feigns feeling ill and Dr. Braddock has to finish the case by himself. He finishes the surgery and the patient survives (this is a code approved comic after all), and in the end he thanks Dr Landon for showing him that he still has the “eye of the tiger.”

This all ended well, but I really cannot stress this point enough: purposefully and deceitfully placing the life of a patient at the hands of a potentially impaired doctor is never a good idea. There are many better ways to help Dr. Braddock get his mojo back that don’t involve a scalpel blade poised millimeters above an innocent man’s brain.

One last word of advice: if you discover that the Young Doctors #5 inspired someone to become a physician, find yourself a new doctor quickly.

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

Nightwing #145 “Freefall”
Peter J. Tomasi, writer
Rags Morales, penciler

At the end of the Resurrection of Ra’s Al Ghul storyline, Al Ghul had been defeated by Batman and locked in Arkham Asylum. Batman had the asylum staff convinced that Al Ghul was a dangerously psychotic schizophrenic who required constant heavy sedation with multiple drugs. This way Batman figured it would be a long time before Al Ghul was a threat to anyone again. This may come as a surprise — but he was wrong.

In the recent Nightwing #145, Al Ghul surreptitiously grabs a pen dropped by a guard and uses it to lacerate his “brachial, ulnar, and radial arteries.” By the time the wounds are noticed, he’s already lost a tremendous amount of blood. The doctors at Arkham work feverishly to fix the lacerations and stop the bleeding, and they pump Al Ghul full of multiple units of blood to replace what he has bled out. This basically acts as an exchange transfusion. His drug-tainted blood has been lost and been replaced with fresh blood, eliminating the psychiatric drugs from his system. This allows Al Ghul to overcome the residual effects of the medication, slay the helpful doctors and nurses, and escape Arkham.

I give full credit to Al Ghul (and to writer Tomasi) for developing such a fiendishly clever plan. Assuming one ignores that fact that Al Ghul would have been too drugged up to conceive it — let alone carry it out — the plan should work well. The blood he lost would have been the blood carrying whatever drugs he’d been given, and the new blood transfused into him would have been drug free. For all intents and purposes, this would have purged the sedatives from his system — though probably not as fast as shown in the comic.

Al Ghul’s exchange transfusion plan wouldn’t work for every drug. For instance, drugs that are strongly bound to their receptors are likely to stay bound even with a transfusion. Additionally, drugs that are injected into the muscle and then slowly absorbed by the body (Depo Provera or Depo Medrol, for example), would see their levels drop right after the transfusion and then build back up as more drug is released into the circulation. Neither of these seem to apply in this case. While it’s never clear exactly what drugs Al Ghul has been given, the guards mention that he’s receiving them five times a day, suggesting that they are very short acting and should flush from his system quickly in an exchange transfusion.

A few nit-picks:
The brachial artery splits into the radial and ulnar artery, so it seems a bit redundant for Al Ghul to cut all three.

You don’t suture with your hands, you use instruments. But that could explain why the doctor seems to be so slow. He should have been long finished with his suturing by the time the seventh unit is transfused. Then again, he’s probably a psychiatrist who hasn’t sutured since medical school.

If the patient has lost that much blood, there should be multiple IVs running, not just a single bag of blood.

A unit of blood is 450cc. It looks like the nurse is just hanging the seventh unit, so he should have received only 2.7 liters by then, not 5.6

There are 5 liters of blood in the human body. That means it takes just over 11 units to completely replace someone’s blood. The doctor should have repaired the wounds in time for some of Al Ghul’s blood to remain, so he shouldn’t have needed the full 11 units (meaning some of the sedative would still be in his system, just very less concentrated). On the other hand, the doctor is clearly very slow, so Al Ghul might have needed more than the 11 units if he was still bleeding while they were transfusing more in.

What kind of asylum has their own blood bank? Wait, no need to answer that, it’s Arkham.

More Comic Book Transfusions

With a couple of big auto races coming up this weekend, I thought it would be a good time to take a look at NASCAR Heroes #3, the final part of the “origin” story of the eponymous NASCAR Heroes.

First, be warned: this is a bad comic — even worse than the first issue. Admittedly, the second issue was a little better, but with the third issue the quality slips and the publisher has finally reached that elusive goal: the car crash comic — a comic so bad, you just have to read it.

For those of you coming in late, the villainous Jack Diesel (NASCAR’s top driver — who also just happens to be an evil scientist) was running secret experiments when a lab explosion took place, exposing himself — as well as his rival team next door — to a mysterious purple radiation. Thanks to the physics of comic book radiation, everyone involved gained a super-power of one sort or another, and our hero James Dashiell, once a lowly janitor, becomes the mysterious masked racer “Dash” and savior of the previously last place Team Flatstock Racing (actually, it’s the “Team Kung Fu Grip” this time around, but I can’t type that with a straight face).

The first two issues showcased various races between Dash and Diesel as they competed for the NASCAR title. At each race, Diesel would pull some underhanded trick in an attempt to win, and each and every time, Dash would still manage to triumph. Not unexpectedly — given Diesel’s overly melodramatic personality — these losses did not sit well and at the end of issue #2 he decided to take revenge by trapping Team Flatstock in an old junkyard, kidnapping their boss Astor, and throwing their race car into orbit.

Through judicious use of their super-powers, Team Flatstock manages to cage the giant radioactive junkyard dog (seriously), escape the trap, and make it back to the race track just in time to compete in the final and deciding race of the season. Meanwhile, Diesel has stashed Astor in his car’s trunk, and taunts Dash as the race progresses. Luckily, Astor uses her powers to escape (apparently Diesel failed Super-Villains 101: Hostages With Super-Powers Can Easily Escape. Also, race cars don’t have trunks). This doesn’t stop Diesel: he uses a special magnet (conveniently labeled “Diesel Industries Magnetic Disruptor”) to rip the tire off Dash’s car. Of course, he hadn’t counted on Zip, Dash’s super-fast team-mate, who runs out on the track to fix the tire (without anyone noticing, of course. Or without any tools). Frustrated, Diesel informs Dash that he’s hidden a bomb in the stands. Dash and his teammates stop to look for the bomb only to discover it was just a trick to lure Dash out of his car so that Diesel can win the race. No such luck, however. Astor has climbed into the car and passes Diesel on the last lap, taking delight in informing him that not only has he lost the race and the championship, but that he was beaten by a girl.

Later, as Team Kung-Fu Grip is relaxing, savoring their success, and lamenting the loss of their orbiting race car, a strange and futuristic-looking scientist suddenly appears and returns their missing car. And with this abrupt and unexplained entrance, the story ends.

As before, the story is an uncomfortable mix of super-hero cliches and racing action that is sure to satisfy fans of neither. The super-hero aspect takes the worst excesses of the Silver Age (Giant animals! Power-giving radiation! Mad scientists!) and the ’90s (facial tattoos) but does nothing new or interesting with them. The racing scenes are so far removed from reality that one suspects the writers have never actually watched a NASCAR race. The art shows a noticeable decline in quality this issue, most likely because the publisher was hurrying to get the comic out the door in time for this years 50th anniversary of the Daytona 500 (and to be fair, they succeeded; I’m just late in reviewing it).

The last few pages of the comic is a surprisingly well done and nicely illustrated history of the inaugural running of the Daytona 500, famous for a photo finish that took officials three days to decide on a winner (Lee Petty, by the way).

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

Tags: comics nascar nascar heroes daytona

I’m finding fewer psychic nosebleeds in comic books recently (or maybe I’m reading the wrong books), but on the other hand, more seem to be making their way into other media, especially television and the occasional movie.

For example, here are couple of psychic trauma/time travel related nosebleeds (and Spoiler Alert, by the way) from a recent episode of Lost (“The Constant” — episode 5, season 4).

George

Desmond

All previous Psychic Nosebleed Zen posts

(I meant to post this a while back, but it somehow got lost in the ether. It’s a follow-up to January’s posts on Tony Stark’s heart.)

So what’s the status of Tony’s heart now? Good question.
In Iron Man #30 (1998 series), Tony suffers (yet another) heart attack while fighting a sentient version of his armor. Instead of kicking him while he was down, the armor rips out its own heart and implants it into Tony’s chest (that’s what the second panel shows, though the action is far from clear).

The fact that Tony now has a purely mechanical heart was confirmed in the following issue:

This was the status quo as Iron Man, Volume 3 continued for 58 more issues. As Iron Man, Volume 4 — the one initially written by Warren Ellis — begins, the story changes. In this version, the shrapnel never actually penetrated or injured the heart, but would have if the magnetic fields of the Iron Man armor hadn’t kept it trapped 2 cm from the heart. Tony then goes on to say that medical science was finally able to remove the shrapnel. So in current continuity, until his recent takeover by Ultron, Tony never had an injured heart.

One last scene, which may or may not be relevant, occurs in Iron Man #5. After being injected with Extremis to save his life after a severe beating, fellow scientist Maya mentions his damaged internal organs. “Grew new ones,” is Stark’s reply.

Tags: comics medicine iron man tony stark heart heart attack

Ultimate Spider-Man #30 “Emergency”
Brian Michael Bendis, writer
Mark Bagley, penciler

Spider-Man has been shot in the shoulder by an overzealous police officer. With some help from Mary Jane, Peter Parker arrives at a nearby Emergency Room and collapses on the floor.

There’s clearly a little confusion in the scene, as the doctor is asking for the blood pressure just after the nurse tells him what it is, but you can chalk that up to the stress of the resuscitation, or maybe misplaced speech balloons.

Let’s take a look at what everyone is saying:
Number 8 ET tube — the doctor is considering intubating Peter and is ordering a 8.0 endotracheal tube, a normal size for an adult male. There’s no indication that Peter is having trouble breathing or protecting his airway, but the doctor is probably just being prepared. After all, “Airway” is the A in the ABCs of trauma.

Pulse Ox is Low, 82 — The Pulse Ox gives a quick approximation of the how oxygenated a patient’s arterial blood is. A normal reading is 99-100%. A reading of 82% is very low, and could be caused by a couple of things: First, it suggests that Peter may have lost much more blood than his other vitals show. Second, given the location of the wound, I’d be very suspicious that the bullet may have clipped the lung and given Peter a pneumothorax (collapsed lung), explaining the low oxygenation. Finally, a Pulse Ox machine fits over the finger and uses light shined through the nailbed to work, so anything that obscures light can cause bad readings — maybe Peter has web fluid or blood under his nails.

BP’s 132 over 82 — That’s a blood pressure in the normal range, or at most slightly elevated for a patient Peter’s age and size. A moderate blood loss should give a low diastolic reading (the second number), and a more severe blood loss would show up in the systolic (top number) as well. Certainly pain and stress can raise the blood pressure, but at this point he’s 1) passed out, and 2) has had the wound for quite some time so their effect should be minimized.

Pulse 110 — A slightly elevated heart rate, could be related to blood loss or stress.

A and O times four — Here’s the problem: this result is impossible. “A” stands for “Alert” and “O times four” means that Peter is oriented to person, place, time, and situation. It’s a quick neurological test. The difficulty is that peter is unconscious, and thus by definition in not alert, or able to talk to answer the nurse’s questions about orientation. Oops.

Fed up with always being overshadowed by fellow DC comics hipster Buzzy, Binky finally makes an appearance in a PSA — though he’s basically a passive observer, with Tim and nameless-grocery-delivery-boy getting the attention.

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

This is at least the second PSA with a “stay in school” theme (the other was “Not Wanted: High School Dropouts“). I guess DC Comics and the National Social Welfare Assembly felt that this was a major problem among comic book readers in the ’50s and ’60s.

This particular PSA is from The Brave and the Bold #20, though it can be found in other DC comics from October 1958. It’s actually the second go around of this PSA, which first appeared in some October 1951 comics. It was printed yet a third time, in November 1966 comics. 15 years off a single PSA — that’s not too shabby. As usual, the script is by Jack Schiff (of course), with Win Mortimer on pencils and inks.

More PSAs

Tags: comics psa binky buzzy jack schiff win mortimer

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.

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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.

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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.

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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.

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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.

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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 relative weak episode of House, medically. Foreman returned, and it was good, but the mind-reading/mimicking patient blew my suspension of disbelief.
All in all, while Mirror Mirror was one of the best Star Trek episodes, the same cannot be said of House (it’s not an awful episode , just mediocre). Anyway, spoilers below!!

A man walking down the street is mugged and starts coughing and wheezing during the attack. As he falls to his knees in respiratory distress, one of the muggers feels bad enough to call for an ambulance (but not bad enough to return his wallet). The patient, who identifies himself as Martin Harris, is admitted to House’s team for evaluation of his respiratory collapse.

The initial differential diagnosis includes asthma (not supported by the x-ray), food allergy (no skin findings), and pulmonary embolism (a blood clot in the lungs — but radiology studies were normal). Foreman suggests laryngospasm (a sudden tightening of the vocal cords) as a diagnosis. Though he is not happy about Foreman being present, he recognizes that his suggestion has merit and orders a methacholine challenge. The test is negative, though now the patient complains of numbness in his extremities and abdominal pain. The differential diagnosis now consists of dissecting aortic aneurysm, a spinal cord lesion, or multiple marantic emboli (clots from growths on the heart valves). None of them seem to fit the symptoms well, but the team is interrupted mid-discussion with the news that the patient has had a syncopal episode and collapsed.

As they are evaluating Martin, Foreman begins to suspect Munchausen’s Syndrome because the patient “borrowed” the name of one of the paramedics and his new symptoms match the exact symptoms of his neighbors. House, instead, suspects Giovanni’s Giovannini’s Mirror Syndrome, where a patient who has lost his memory mimics those he sees around him. House brings Martin into the operating room where Wilson is performing a procedure. Sure enough, Martin begins to mimic Wilson, confirming the Mirror Syndrome diagnosis.

A short time later, House and the team notice that Martin has a lace-like rash over his arms and legs (livedo reticularis), which House decides is due to cold agglutinins (antibodies that clot in the cold, blocking capillaries and blood flow) caused by infection. Blood cultures are ordered as well as an ultrasound. House sends Dr. 13 and Big Love to search for the patient’s car to find out who he really is. A solid liver lesion turns up on the ultrasound — the thought is either an abscess or a vascular hemangioma (a clump of dilated capillaries). Frat Guy performs a needle aspiration and gets a dark substance he believes is pus. He suggests that Martin has a tropical fungal infection and the patient is started on Amphotericin. The livedo reticularis returns and Martin is placed in a heated whirlpool. The Amphotericin does not help and what was felt to be pus ends up just being coagulated blood. The differential remains infection, but most likely viral or some rare bacteria. Because the patient has no memory, they can’t get a good history, but House suggests they run antibody tests on Martin’s blood and cerebrospinal fluid (CSF) because this will give them some idea what diseases he’s been exposed to in the past and a general idea of where he is from and where he’s been. His antibodies are high for histoplasmosis (common in the Ohio River Valley) and weak for coccidiomycosis (found in the San Joaquin Valley) and Chagas Disease (common in Mexico and Central and South America).

The livedo reticularis has returned despite aggressive hot water baths. House starts Martin on lipopolysaccharide (a toxin found on the cell wall of certain infectious bacteria) to induce a fever to raise his temperature and keep his blood flowing. While in the tub, Martin goes into cardiac arrest. Kumar defibrillates Martin before he is completely dry. This returns Martin to a normal heart rhythm, but also knocks Kumar out.

House orders a re-check of the blood cultures and Foreman recommends a heart biopsy. As Dr. 13 completes the heart biopsy, Kumar drops a hint to House that Martin regained some of his old memories while in the hot tub. Taking the items found in the patient’s car by Big Love and Dr. 13, House pretends to be Robert Elliot (the patient’s real name) in an attempt to jog the patient’s memory. With the help of vaporub, he succeeds and discovers that Robert/Martin is a traveling farm equipment salesman and has developed an Eperythrozoon infection from pig feces (a type of bacteria found in certain animals, including pigs and ruminants. It has been known to infection humans on occasion, though I can find no listing of serious infections).

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There was too much bad reasoning in this episode for the medicine to be very good. Everything magically clicked into place when it shouldn’t have. Sure, methacholine can be used to detect laryngospasm, but it is better for inducing asthma – also on the differential diagnosis list. Sure, infection can cause cold agglutination, but so can many, many other things including vasculitis, autoimmune diseases (Lupus!), cancer, and tuberculosis, just to name a few.

I don’t have much to say about Giovannini’s Mirror Syndrome, because I can’t find any information about it. Whether it exists or not (and I suspect it does in some manner), the way it was presented was too unbelievable. A patient would take on characteristics of those around him, but not be magically able to see deep into their psyche; they wouldn’t become omniscient. And if patients with Mirror Syndrome do mimic the strongest personality about them, why would he copy Wilson in the ER and not House, who is clearly the dominant personality. Why did he pick one name and stay with it? Wouldn’t he pick a new name every time he encountered someone dominant? Shouldn’t he be Gregory House?

The temperature of cold agglutination does not increase as the patient becomes sicker, certainly not to over 100 degrees. Anyway, giving someone a bacterial endotoxin to cause a fever is not a good idea because it causes other serious effects besides just fever.

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Funniest Line (intentional):

House (to Cuddy): I know when my Vicodin isn’t Vicodin. Do you know when your birth control pills aren’t birth control pills?

Funniest Line (unintentional):

House: He’s got Mirror Syndrome.
Foreman: Giovannini’s?
House: Do you know another Mirror Syndrome?

(um, how about Maternal Mirror Syndrome from last season?)

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The medical mystery was interesting, though the symptoms were stretching incredulity — I give it a B. The medical aspect forgot the whole idea of differential diagnosis, and chose certain causes without reason. It wasn’t wrong, per se, as incompletely thought out. The Giovanni’s Mirror Syndrome seemed a little too convenient, too. It earns a C. The solution was yet another strange zoonotic disease, but not one really considered as dangerous as the show suggested; I give it a B-. The soap opera with Foreman and House and Cuddy was good (as was Chase running a betting pool), but Martin reading everyone’s mind was too much of a stretch: B.

The previous House review
A list of all prior House reviews

Challenge scores are in the post immediately beneath this one (or click here)

Tags: television medicine house mirror syndrome livedo reticularis cold agglutinins eperythrozoon

No House tonight because Fox is broadcasting the American League Championship Series (Go National League!). Instead, I thought I’d make some predictions about what diagnoses will show up on House this season. I didn’t do so well last time I tried to predict, but failure has rarely stopped me before (you’ll notice a lot of similarities between my two lists, I added some new predictions and lost a few.)

• Herpes Encephalitis.
• Kawasaki Disease.
• Delusional Parasitosis.
• Post-pregnancy Eclampsia.
• Dengue Fever
• Toxic Shock Syndrome
• Strep Throat (but mostly its rare but dangerous sequelae).
• Hanta.
• Oleander poisoning.
• Zoonotic diseases such as Babesiois, Ehrlichiosis, Tularemia, and Orf (and here’s a page on “Emerging Zoonoses“)
• cryptococcus gattii infection
• Commotio Cordis

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“The Challenge”
Make a list of ten conditions or diseases you think will show up on House. Be as specific as possible: no categories (like “cancer” or “autoimmune disease”), and no overly broad descriptions (”liver failure”or “cardiac arrest”, for instance). The list you make will last the remainder of the season — no addition, subtractions, or swaps. Put your list in the comments section.

Each week, your list will be compared against the show. Scoring is as follows: 1 point for a brief mention or one-liner. 3 points if the team actually tests for the condition. 5 points if the team treats the condition (or supposed condition). 12 points if it’s actually the correct final answer (or one of the answers) of the episode.

Scores will be collated each week and a running total will be kept. After the final episode of the season, a winner will be crowned!

My list: Herpes infection, Parvovirus infection, Lupus, Tularemia, Addison’s disease, Klinefelter syndrome, Cushing’s disease, Toxic Shock Syndrome, Cryptococcus gattii infection, Clostridium difficile infection.

Tags: television medicine house challenge

It’s time once again for one of my favorite holidays of the year: Talk Like A Pirate Day!
Being the good buccaneer that I am, I looted last year’s post (which was itself plundered from the year before that), and I’m reposting and updating it — and new additions are always welcome!

Comic-book pirates (and pirate comic books) off the top of me head (to be updated as I think of more):

• Crossbones
• The Psycho Pirate
• Occulus from Fantastic Four
• And in the Fantastic Four’s first encounter with Dr. Doom (FF #5), The Thing ended up becoming Blackbeard.
• Pirate Club
• The evil pirates from My Monkey’s Name is Jennifer
• The Starjammers
• The hilarious Scurvy Dogs (”The cow says moo…”)
• The abandoned Barbarossa and the Lost Corsairs
• El Cazador
• Street Angel #2
• Long John Silver and the Pirates (Charlton comic from the 1950s)
• Belit (and Conan, for a time) from the Conan comics (older Marvel volumes)
• The Black Pirate appeared in some of the 1940s issues of Action Comics
• There was the pirate comic-within-a-comic in Watchmen (Tales of Black Freighter)
• Buccaneers from the 1950s
• The similarly named Buccaneer, also from the 1950s
• The Golden Medallion, a pirate comic book put out by LEGO
• The Pirates of Dark Water A kids comic put out by Marvel based on the Hanna-Barbera cartoon.
• Terry and the Pirates. Sure it was a comic strip, but it’s been reprinted in comic book form several times
• Then of course there’s Colonia (pointed out to me last year by Laura, the “Scourge of the Seattle Seas”)
• Pirate Corp$
• Even Mickey Mouse is getting in on the act: Air Pirates Funnies
• Metrokitty (the “Feline Felon”) reminded me that there was a pirate as a suporting character in the Starman series (and in one of the Talking with David issues).
• Speaking of Disney, we can’t forget air pirate Don Carnage from Talespin
• Pirates appeares in at least one Spirit story
• EC’s Piracy
• Indiana Jones and the Sargasso Pirates
• Some pirates appeared (briefly, before being slaughtered) in Grendel: War Child #4
• Polly and the Pirates
• The Aquaman villains Cutlas Charlie, Captain Squid, and Captain Blackjack
• The subway pirates from Seven Soldiers: Manhattan Guardian
• Air Pirates appeared in CrossGen’s Meridian.
• An evil pirate appeared in Leave it to Chance
• Pirate Jean Loring, from the early adventures of the Atom (as reviewed by The Comic Treadmill)
• A pirate memorably appears in the Dr. 13 story from the recent Tales of the Unexpected mini-series.
• Pirates play a major role in the origin and adventures of The Phantom
• Captain Fear appears in the Ostrander/Mandrake Spectre series
• Freefall and Burnout sign up with pirates for a time in Gen13
• Ghost pirate Captain Fate appeared in Man-Thing.
• European comic pirates include Barbe-Rouge (Redbeard) and Ouwe Niek en Zwartbaard (Old Nick and Blackbeard)

Tags: comics pirates talk like a pirate day

Scene from Countdown #35

I thought one of the big plot points from the current Justice League of America series was that Vixen had lost her animal powers. Pity somebody forget to tell that to the Countdown team — it could’ve save Jimmy a lot of pain.

Tags: comics countdown justice league of america vixen jimmy olsen

The same time that Dell Comics was seeing success with licensed medical properties such as Ben Casey and Dr. Kildare, Charlton Comics started publishing its own medical titles. The Young Doctors was one of these series. It starred Drs. Landon and Burke, residents in surgery and psychiatry (respectively), at Metro Hospital. There is no love lost between the two residents and they often come to blows, but when a crisis occurs they always pull together and help each other. Apparently they are the only two residents in the entire hospital because they are the only two we ever see (there was an intern, Tom Brent, but he graduated to his own series and was rarely seen in The Young Doctors after that).

Because these weren’t licensed properties, the writers faced fewer restrictions and could be more imaginative with the characters and stories. The art was generally better as well (but then the art on Ben Casey was pretty bad). The medicine wasn’t as accurate as Dell’s comics, but the stories were more engaging.

The first story finds Dr. Landon helping a tropical disease specialist doing research at Metro Hospital. When the specialist becomes feverish and collapses, Dr. Carlson is quick to recognize the symptoms of smallpox and the hospital is locked down under quarantine. A mini-epidemic breaks out in the community, but the hospital (and by the hospital, I mean Drs. Landon and Burke) are able to rein it in and restore order. This hospital quarantine is a common medical drama theme — just off the top my head, I remember seeing it in first season episodes of St. Elsewhere and Chicago Hope and a second season episode of House — but it is pulled off well here (and considering when this story was published, the idea had yet to become the cliché it is now).

The second story features Tom Brent. It’s another common medical storyline: When the famous surgeon Tom is assisting suddenly falls ill, it is up to Tom to finish the complex operation. This story is just mediocre because it lacks any real drama — there’s no way Tom’s patient is going to die.

The final story concerns a patient with a case of complete amnesia. Dr. Landon and Dr. Burke have to work together to solve the mystery of the patient’s identity. The story is well done and the clues are there for the reader to solve the mystery along with the doctors. Of course, the cover gives much of the answer away, though there is a red herring or two thrown in as well.

If you’re looking for authentic medical stories, The Young Doctors is not for you. But if you enjoy surprisingly engaging medical dramas, albeit medically inaccurate ones, then take a look at this series.

Previous episodes of Flashback Week.

Tags: comics medicine the young doctors charltondr landon dr burke tom brent

Comics publisher EC took a substantial PR hit in the 1950s thanks in large part to psychiatrist Frederic Wertham’s book Seduction of the Innocent and anti-comic book congressional hearings. They gave up publishing their crime and horror comics, and instead switched to a “New Direction,” publishing comics designed to be more informative and inspirational. This concept never met with much success, and within a few years, the “New Direction” had failed and Mad Magazine was all that was left of a once successful comic book publisher.

M.D. was one of the “New Direction” comics. According to the preface of the first issue, M.D. was written to “contain stories of people…people who are helped by their Family Doctor and his associates in the Medical Profession. It will deal frankly and honestly with the diseases and misfortunes that beset people. It will deal graphically and candidly with the treatment they receive. At times, the stories will be poignant…at times they will be sad…at times they will be grim. But at all times, they will be true to life!”

Every issue of M.D. featured several realistic medical stories, each focused on a particular disease or condition. Issue #5 was the final issue of M.D. and frankly, it shows. The art is as intricate as always — if a little sensationalistic at times (particular when focusing on the grieving mother in the forefront of the panel, her fingers thrust worriedly at her lips) — but the stories are not nearly as compelling as in earlier issues, rather humdrum actually, which is unusual for any EC comic.

“Complete Cure” is the first story and tells of Philip Stuart, who had both of his legs amputated after an automobile accident. He takes the loss of his legs hard and decides to give up on his education and job, much to the concern of his wife and family doctor. In the end, Philip is introduced to another man who lost both of his legs (on the beaches of Normandy during D-Day, which pretty much trumps every other reason), but went on to become a successful surgeon. This inspires Philip who agrees to return to college.

The second story is “Child’s Play” and concerns Jimmy, a young child. He has gone deaf due to audiosclerosis (known as otosclerosis now) and needs an operation and a hearing aid to regain his hearing. His mother refuses, fearing that the other kids will make fun of Jimmy. Eventually, her husband steps in and sends Jimmy for the surgery. It’s a success and Jimmy’s hearing is returned. His mother still won’t let him play with his friends because she is convinced that they’ll reject him. One day she returns home from shopping and finds Jimmy missing. Fearfully, she runs down the street calling out his name, only to find him in the neighborhood clubhouse happily playing with the other kids, his hearing aid an object of interest, not scorn.

The third story, “Emergency” shows what happens in a hospital when a bad storm hits, knocking out both the power and emergency generators. By working tirelessly, the doctors are able to save everyone and even manage to perform an emergency surgery by flashlight. They end the story lamenting the fact that medicine has become so dependent on technology. Bear in mind that this was written over 50 years ago, and their medical technology consisted mostly of lights, x-ray machines, and iron lungs. The doctors of this story would be devastated to learn that modern medicine’s dependence on technology has increased a thousandfold since those halcyon days of not so long ago.

The fourth and final story deals with George Gordon. He is convinced that he has appendicitis, but his family doctor suspects otherwise. He believes that George has somatization disorder, and his depression is the root cause of George’s abdominal pain. George leaves in a huff and visits another doctor and hospital, but is told the same thing. Despondent, he threatens suicide but his family doctor is able to talk him down off the ledge and get him the help he needs. Based on my experience, somatization is never quite this easy to diagnose or treat, plus George seems to have as much a diagnosis of Munchausen’s Syndrome as somatization.

Previous posts on M.D.: Issue #1, Issue #2, Issue #3, and Issue #4.
Previous episodes of Flashback Week.

Tags: comics medicine m.d. amputation technology depression

The Fountain of Youth has long been a staple of stories and legends. It should come as no surprise then that the legend has made its way into comic books as well. Not always the fountain itself (though it does show up from time to time), but the concept of restoring youth to an older or aged character. In comic books, there are many ways this can occur, and regaining one’s lost youth is rarely a good thing.

Magic is the most common method of de-aging characters, at least when one considers the number of individuals affected For example, Klarion used his powers to de-age the entire JLA and JSA during the Sins of Youth storyline. Monster Girl of the Guardians of the Globe (as seen in Invincible) grows younger because of a curse whenever she uses her powers. Superman was turned into Superbaby by a mystic potion (labeled “Ye Youth Potion,” of course) in Superman’s Girl Friend Lois Lane #32.

Alien Super Technology is another common method of de-aging characters. It was used notably on Magneto and the Brotherhood of Evil Mutants by Alpha the Ultimate Mutant* in Defenders #16 and the Atom (Ray Palmer) during Zero Hour. Mojo used the superior technology of his Mojoverse to change the X-Men into the X-Babies in X-Men Annual #10.

Plain old American Mad Science can make characters more youthful as well. Lois Lane found this out when she decided to expose herself to Professor Lockhart’s Youth Rays in Superman’s Girl Friend Lois Lane #10 and ended up as a bawling baby.

Mutant powers can also lead to the de-aging of a character. This can be a mutant whose powers affect others (like Nanny, who regressed Storm in the Uncanny X-Men), or a character whose powers affect themselves (Sally Floyd’s daughter Minnie, as mentioned in Generation M).

Surprisingly, there is no mention of any de-aging medication (unless one counts Ye Youth Potion) in any comic book that I can find. (Slightly off topic, but as far as I’m concerned, the best scene with youth-restoring medication in literature of any sort occurs in Charlie and the Great Glass Elevator).

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You’ll notice that I’m only considering situations where a character actually becomes younger, not ones where lifespan and youth are preserved (like, Steve Rogers and Nick Fury) — that’s a post for another day.

I’m also not considering cases where the youthful characters are explained away as clones or denizens of an alternate universe (Batch SW6 in Legion of Super-Heroes, or the younger Tony Stark in Avengers: The Crossing)

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*This could also be considered de-aging due to mutant powers, but since Alpha was bio-engineered by Magneto using alien technology, I’m classifying it as “alien super tech.”

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Other Comic Book Diagnoses:
Frozen Solid
Brains! Brains!
Hypertrichosis
Xenografting

Tags: comics medicine youth jla jsa superman lois lane atom magneto x-babies

A helpful PSA comes by way of Adventure Comics #254, which teaches us how not to get lost in the woods. Well OK, it teaches us how to find north using the North Star — which isn’t quite the same thing as not being lost because it’s certainly possible to know where north is, yet still be lost –but at least it’s a step in the right direction (and a great deal more useful than most PSAs).

The PSA also mentions the star Vega, which ties into my post last week on Countdown #48 (All this talk about Vega reminds me of an old Star Trek pop-up book I had growing up: Star Trek – The Prisoner of Vega. It was years ago, but from what I recall, the story followed the old sci-fi trope of a planet ruled by women who held men as slaves. And there were Klingons involved somehow too. A quick Google search informs me that this is a “hard to find” Star Trek book, though there seem to be an awful lot for sale for such a hard to find book).

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

This PSA was written by prolific PSA scribe Jack Schiff with Lou Cameron doing the art. It comes courtesy of the ever helpful H over at the Comic Treadmill.

Tags: comics psa north star vega star trek

An uninspired episode with sloppy medicine. It’s a shame that this was the season finale of House. Hopefully they’ll rerun the first and second seasons during the summer instead of the third.

Esteban and Marina, a young couple from Cuba, travel to the United States in a rickety boat to get Marina treated by Dr. House. Their boat breaks down and they are picked up by the Coast Guard. Unfortunately, her medical records are lost in the sea. The couple is coming to America because Marina is “sick” and suffering from a variety of symptoms, many of them quite non-specific. She has been treated by medical experts in Cuba to no avail so her husband “got permission” (from whom?) to bring her to Dr. House for assessment. Her symptoms include fatigue, pain all over her body, cough, dry mouth, double vision, rash, fever, and an elevated bilirubin. The team’s initial diagnoses are rheumatic fever or some sort of infectious disease or parasite. House thinks the symptoms relate to her head, so he orders a brain MRI. He also has Chase evaluate the husband to see if shares any symptoms.

Foreman announces that Marina must have multiple sclerosis (MS) and wants to start her on interferon. Esteban insists that Marina cannot have MS because she was tested for that in Cuba. While Foreman is examining her, he accidentally breaks her wrist by twisting it slightly. Now the question becomes are all her bones weak, or just the left wrist? The team considers osteoporosis and osteogenesis imperfecta (a genetic disease of collagen that leads to weak bones and frequent fractures), but discards them both as she is either too young or too old. Bone cancer is a likely cause of a pathological fracture, so a PET scan is ordered to look for a tumor. A hot spot is seen on the scan, but it is a blood clot and not a tumor. House now wants a cardiac catheterization because he feels that the ultimate cause of any clot is the heart. During the catheterization, Marina suffers ventricular tachycardia then slips into asystole (flatline). CPR is started. House refuses to stop the code or start her on a heart bypass machine until he can discover what caused her heart to stop. He polls a passing medical school class who suggest Marfan Syndrome or botulism from a bad Botox treatment. House discards both ideas. No closer than before to an answer, he reluctantly starts her on a heart bypass machine after she had been coded for three hours.

House tells Esteban that he must say goodbye to Marina because it is time to pull the plug. He shuts off the heart bypass machine, but miraculously Esteban detects a pulse. House switches on the monitors which show a normal heart rhythm. Marina wakes up and is fine, in fact all her pain has resolved and she feels entirely better. She attributes it all to an act of God. House suspects that there must be a congenital defect in one of her cardiac arteries, and inflammation from this has caused her symptoms. He wants to perform another cardiac catheterization, and this time finish the study, to find this abnormality. He talks Esteban into it. The catheterization shows normal arteries, but it also shows what House calls a “third ostium.” This hole between her left- and right -sides of the heart is the cause of all her symptoms, and Marina will be better after a surgery to repair the hole.

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The medical mystery wasn’t particularly interesting because the symptoms were so vague. The show could have used one of the dramatic character introductions it usually features or some of the fancy special effects. Instead it was all symptoms written on a dry erase board. The final solution didn’t seem all that exciting either, even though the writers tried to set it up as “House vs God” (a theme which has been handled better before, and really, couldn’t every episode be described as House vs God?).

The medicine itself seemed particularly sloppy. You’ll notice they never mentioned the MRI results — because that would have been normal, making MS much less likely, and the whole Foreman/interferon scene overkill. While the heart can frequently be the source of blood clots, these are best demonstrated on echocardiogram, not cardiac catheterization — but that echocardiogram would have easily shown the hole in her heart about thirty minutes too soon. Coding someone for three hours is simply ridiculous; CPR is not that effective for that long. Heart bypass machines are used for a few hours during heart surgery, not to keep someone alive who coded. Marina’s heart miraculously restarting on its own was just plain silly (and I don’t care what House thinks, this was never explained. And isn’t she still plumbed into the bypass machine, even if it isn’t on?) I’m not clear on the third ostium bit either. The ostium primum and ostium secundum are openings between the left and right heart that occur in the fetus prenatally. They can sometimes remain open after birth and may require a surgical repair (but do not show symptoms as dramatic as Marina’s). What then is this mysterious “third” ostium, and how would it be any different from the more common atrial septal defect or ventricular septal defect?

I’ve laid off complaining about the Young Guns performing tests they aren’t experienced in, but this episode pushed it over the edge. Since when are the Young Guns (or House) cardiologists and how did they get credentialed to perform cardiac catheterizations? And why is Wilson performing surgery?

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I give the medical mystery a D, because it was boring and uninteresting. The final solution I give another D- because it not only was uninteresting, but made no sense. The medicine was shoddy, sloppy, and often just plain wrong. A good example of the latter half of the season. I give it an F. The soap opera was the best part, but even then — other than the firing of Chase — was too telegraphed. I give it a B-.

The previous House review
A list of all prior House reviews

Tags: television medicine house season finale cardiac catheterization deptal defect

JSA Classified #24 “Nightfall, part 2”
J.T. Krul, writer
Alex Sanchez, penciler

In the previous issue, Dr. Mid-Nite fought the self-professed vampire Mircea and lost. As this issue begins, Mid-Nite retreats to his sanctum and considers the situation. He is positive that Mircea is not a real vampire. Instead, he is certain that there is a scientific explanation for Mircea’s appearance and abilities. He considers conditions such as Congenital Insensitivity to Pain (a genetic disease where the patient cannot feel pain, heat or cold. It was feature in a recent episode of House)and Familial Dysautonomia (an inherited condition marked by poor development of the autonomic nervous system as well as some sensory nerves), and severe anemia. Ultimately, he decides that the diagnosis that fits best is Xeroderma Pigmentosa

Xeroderma Pigmentosa (XP) is an inherited condition¹ where the skin is extremely sensitive to light. A person with XP suffers from many skin problems including a thin dry skin that ages prematurely. Their eyes are extremely sensitive to light and easily become bloodshot and irritated. An individual with XP lacks the normal mechanisms that repair DNA damage caused by UV radiation. Because of this, they develop frequent skin cancers.

Dr. Mid-Nite realizes that not only does Mircea suffer from XP, but he has been taking high doses of Steroid A39 to control the disease. It is the steroid that has been giving him the increased strength, as well as the pallid skin and eyes associated with vampires. Armed with this knowledge, Mid-Nite once again confronts Mircea and is able to use his own strength against him. While Mircea is down, Mid-Nite injects him with Rocuronium³, a paralyzing agent, and has him hauled off to an insane asylum.

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Notes:
¹Xeroderma Pigmentosa has an autosomal recessive inheritance pattern.

²This answers a question I had from the Dr. Mid-Nite mini-series. That story mentioned a condition called “Xenoderma Pigmentosa.” I was never certain if that was a typo for Xeroderma Pigmentosa, or if the writer (Matt Wagner) was inventing a new disease. Apparently it was a typo.

³Rocuronium is a good paralytic agent. It would paralyze Mircea’s skeletal muscles rendering him helpless. Unfortunately, there is a good chance it will also paralyze his diaphragm — an important breathing muscle — and he will suffocate if he doesn’t receive mechanical ventilation until the drug wears off (and its half-life is between 1 and 2 hours).

Tags: comics medicine dr mid-nite vampire xeroderma pigmentosa rocuronium

Tonight’s episode of House was primarily a character episode for Foreman, and other than some good House/Wilson (and sometimes Cuddy) moments, was a spectacularly lackluster show. Even the return of Charles Dutton as Foreman’s father couldn’t help. This week’s House medical review, chock full of spoilers, follows…

A 28 year-old inner city girl is playing a game of three-card monte when she suddenly suffers from abulia (a loss of will, shown as the inability to make a decision) and collapses. She is admitted to the hospital and Dr. Foreman explains that she has had a TIA (transient ischemic attack). He suspects the TIA was caused by drug use or toxin exposure, but the patient denies both and her drug screen comes back negative. Cameron suspects a clot from the heart and wants to do a bubble study (House told Cameron to do the bubble study, but it seems to have gotten lost in shuffle, which is a shame because it would have shown the correct diagnosis). Foreman still suspects drugs or contaminated drugs, and when he and Chase search her apartment they find a crack pipe. She insists the pipe was a boyfriend’s. The pipe shows evidence of arsenic, so her hair is tested but only shows a trace amount — not enough for arsenic poisoning.

While talking with Foreman, the patient develops a nasty cough which proceeds to a bloody cough. A CT scan of the lungs shows a large mass. The initial diagnosis is (wait for it…) autoimmune disease , including giant cell arteritis or lupus vasculitis. Foreman starts her on steroids. When he examines her eyes a short time later, he notes scleral icterus (the whites of the eyes are yellow), a sign of jaundice. He diagnoses her with liver failure (presumably he ran some other tests first). Foreman now suspects that her problem is not autoimmune, but instead a rare cancer: lymphomatoid granulomatosis. He recommends whole body radiation for treatment and manages to talk House into agreeing with him. In fact, House volunteers to get informed consent from the patient (because he wants to meet the patient who dislikes Foreman so much).

While House is obtaining informed consent, the patient has another episode of abulia then loses consciousness. House schedules her for the radiation anyway. When Foreman is examining her after the radiation therapy, he hears a new heart murmur. At the same time, the patient begins to scream in pain from the pressure from the blood pressure cuff. These two symptoms together tell the team that the patient has developed sepsis (an overwhelming bacterial infection of the body). At this point, the team decides that there is nothing that they can do for her. Foreman explains the situation to the patient and admits that his decision to give total body radiation wiped out her immune system and essentially killed her. She gets mad at him (understandably), but eventually they have a heart to heart and he sits by her side as she dies. In the end, House performs an autopsy and determines that she died of a Staph infection from a skin scratch caused by her bra clasp.

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Medically, this episode wasn’t horrible, but wasn’t great either. The medicine on the show always seems to suffer when they have a “special guest star” or a “character episode”, and this was no exception.

• A TIA (sometime called a “mini-stroke”) is abnormal is a 28 year-old and they should have performed a more intensive work-up, at least a head CT, carotid doppler, and echocardiogram to look for treatable causes. Actually, they did perform the echocardiogram (as part of Cameron’s bubble study), but never saw fit to mention it again. This would have shown that something wrong with the heart valves from the beginning*.
• The jump from autoimmune to rare cancer was unintuitive, and I doubt that any radiation oncologist would give radiation treatments without a definitive diagnosis, or at the very least a signed informed consent form.
• My reading on lymphomatoid granulomatosis shows that there is no clear best treatment. Steroids can work (and the patient was already on steroids), and a recent strategy has been to use antiviral drugs. Radiation can be used for localized disease — which means that it would be very specifically aimed radiation, very different from the total body radiation the script described.
• The timing of the rest of the show was off. The radiation knocked out her immune system far faster than it should (I would expect several days), and then the infection flared up very quickly as well.
• An increased heart murmur can be a sign of infection (endocarditis), but linking the pain from the blood pressure cuff to sepsis was a stretch.
• More importantly, I don’t know why they wouldn’t at least start her on some antibiotics to treat the infection. Immune suppressed patients have survived infections — even sepsis — before and antibiotics played an important role. They throw antibiotics at patients at the drop of a hat, and now when they have an actual infection, they don’t?

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The medical mystery was started out good (abulia), but went downhill with each revelation and earns a C+. The solution was something that should have been caught in the first place, by a test they ran! This gets a C-. The medicine was haphazard and — more than usual — clearly just served to get the plot from point A to point B. It wasn’t horrible, just maddeningly average, which is not what I expect from House. It earns a meagerC. The soap opera was enjoyable, particularly the House/Wilson and Wilson/Cuddy scenes. The Foreman scenes felt like they were trying too hard. Still, the soap opera earns a B+.

The previous House review
A list of all prior House reviews

Tags: television medicine house lymphomatoid granulomatosis tia sepsis

That was an expensive mini-series, and pretty much a complete waste of time, money, and paper. For those of you who haven’t read World War III, it basically retells and expands the events of 52 #50. The series also briefly explains how most of the non-”Big Three” heroes achieved their one-year-later status. Some of the revelations were interesting (Aquaman, Manhunter), most were not (Hawkgirl’s “Oh by the way, Dr. Mid-Nite shrunk me back to normal size” and Donna’s off-panel decision to dress as Wonder Woman).

Speaking of 52 #50, it struck me as a little silly that Black Adam was subdued with a gag from Futurama (and it probably wasn’t original there, either). Sure, it’s clever, but now whenever I see Black Adam I’ll be thinking of Bender.

On a personal note, it was nice to Hawk and Dove in action again, even if the colorist can’t decide if Hawk is a blond or brunette. I wonder how they regained their powers, since the last time we saw them (in the Infinite Crisis: Day of Vengeance Special), they had lost their powers after the Spectre destroyed the Lord of Order and Lord of Chaos who granted them their power (though as I noted then, they had already died once before).

To save you money, here’s the key points from each issue of World War III so you can decide whether it’s worth owning:

World War III #1
Black Adam is pissed. Martian Manhunter is hurt.

World War III #2
Black Adam is pissed. Martian Manhunter is moping. Supergirl returns. Batgirl revelation. Aquaman revelation.

World War III #3
Black Adam is pissed. Martian Manhunter whines. The Teen Titans appear (are any of them teens anymore?) and do quite poorly. Manhunter (Kate Spencer) revelation.

World War III #4
Black Adam is pissed, then defeated. Martian Manhunter revelation.

A nice brisk episode of House with two good medical mysteries. One involves a woman hospitalized with neurological symptoms, and the second involved House and Cuddy stranded on a plane with a possible meningitis epidemic. Spoilers follow, so make sure you watch the episode first…

The first story concerns a 58 year-old woman who presents to the clinic after suffering blurry vision and a fainting spell. Her medical history is negative, except for a recent trip to Caracas where she went a little wild and indulged in drugs, sex, and — one presumes — rock and roll. Wilson finds a scopolamine patch (used to treat motion sickness) behind her ear, and blames the symptoms on this. He removes the patch and sends her on her way, but she has a seizure as she leaves the clinic. She is admitted to the hospital and the team’s initial thoughts are that she either has a neurological problem of some sort, or an allergy. Wilson orders a drug screen, a head CT, a chemistry panel, a blood count, and a screen for STDs (sexually transmitted diseases). He also has Cameron and Chase search her house for toxins or allergens.

The search of the house turns up nothing, the head CT is negative, and the blood tests are also negative. Wilson deduces that she must be have paraneoplastic syndrome (a rare condition where the body’s immune system over-reacts when a cancer is present) from an undiagnosed breast cancer. He orders mammograms, but as Fran is suffering through them, she develops a sudden blindness in her right eye. This makes the cause more likely to be neurological than cancer. An EEG with evoked potentials is obtained, and as the test is proceeding, Fran falls into a sudden coma. Foreman believes she has increased intracranial pressure from a bleed and that is the cause of her symptoms. He wants to drill a burr hole in the skull to relieve the pressure. Cameron is skeptical of a bleed (and rightly so) since it didn’t show up on the CT scan. She wants to perform an LP (lumbar puncture, also known as a spinal tap) to look for signs of bleeding or other causes before they drill into Fran’s skull. The spinal fluid apparently supports Foreman’s bleed theory (yet it looked clear to me), and the team proceeds to surgery (and since when is Foreman a neurosurgeon?). Meanwhile, Chase remembers that Fran’s cat seemed to have lost its appetite, and Fran didn’t each much in the hospital either, and thinks these might be clues. He re-examines Fran’s house, and finds an old pipe that leads from her house to a neighbor’s house — a house which had just been fumigated with methyl bromide. The surgery is stopped in time, and with supportive care, she recovers.

The second story occurs on a plane — a plane that House and Cuddy just happen to be flying on back from Indonesia. Mr. Peng, the passenger next to House becomes violently ill with a fever and vomiting. Upon examining him, Cuddy notes abdominal pain and a splotchy red rash on his lower back and believes that he has bacterial meningitis (a very contagious and frequently fatal disease).

Another passenger, a young woman this time, becomes sick with the same symptoms. Enlisting three passengers as stand-ins for the Young Guns, House lists other possible causes, including organophosphate poisoning, jet lag, a Dramamine overdose, a DVT (deep venous thrombosis — a blood clot in the leg) and food poisoning. He suspects that it is ciguatera poisoning from the sea bass served for dinner, but Cuddy still maintains it is meningitis.

They re-examine Mr. Peng, and House notices that one leg shows a history of a fracture and wonders if maybe the patient has radiation sickness from too many x-rays. With little warning, Cuddy herself becomes sick with vomiting, rash, abdominal pain, fever, and photophobia (eyes that are sensitive to light). In addition, 3 other passengers become sick. House collects all the medications he can from the remaining passengers and finds only a few useful antibiotics (though he does diagnose a herpes infection along the way).

Cuddy continues to insist that the cause must be meningitis, but House is still not convinced. He decides to improvise and perform a lumbar puncture using available equipment on Mr. Peng. He collects his sample, and immediately enters the main cabin, grabs the intercom, and announces to the passengers that there is a meningitis outbreak aboard the plane. He advises them all to look out for symptoms including abdominal pain, nausea, and left hand tremor. This is a ruse on his part — the spinal fluid was clear (infected spinal fluid would be cloudy) so there was no meningitis. His ruse was to show that people on the plane were panicked and easily suggestible, and everybody who had symptoms (except Mr. Peng) was suffering from conversion disorder (in other words, they thought they must be sick, so they subconsciously became sick. They never had any physical disease.)

House now turns his attention back to the only truly ill patient, Mr. Pengm. His differential diagnosis includes head trauma, cerebral infarction (stroke), and cerebral hemorrhage (bleeding in the brain). Cuddy suggests syphilis. This causes House to think of condoms, and he now believes that Mr. Peng must be a drug mule — a person who smuggles drugs stored in swallowed condoms. He thinks one of the condoms must have burst open and Mr. Peng is suffering from acute cocaine poisoning. He is ready to operate when he notices that applying pressure to Mr. Peng’s joints relieves the pain. He now realizes that Mr. Peng is suffering from the decompression sickness, better known as “the bends“. He had gone SCUBA diving on vacation and had ascended to rapidly. The low pressure in the airplane exacerbated his symptoms. House has the pilot fly at a lower altitude and places Mr. Peng on oxygen. This will help until he can get to a hospital equipped with a decompression chamber.

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I felt the medicine was decent this time, particularly the airplane scenes. I do have a few concerns about Fran’s care. First, why did the ambulance take her to the clinic? Shouldn’t she have gone to the ER (unless it’s an acute care clinic that’s part of the ER)? Wilson and the Young Guns seemed to lose their focus after the initial tests came back negative and lurched from diagnosis to diagnosis, but we’ve seen that before. Cameron was right, and any bleed substantial enough to raise intracranial pressure enough to cause a coma would show up on a CT scan — and even if it didn’t show up on the first CT scan, it would be reasonable to repeat the scan after her condition worsened. When Chase performed the LP, since the team was concerned about intracranial pressure, he should have checked for opening pressure. Speaking of the LP, the fluid sure looked clear to me. Presumably, Chase and Cameron saw blood and felt that this meant Foreman was right. Of course, blood in the fluid could have come from the tap itself, and not the brain. Maybe he saw xanthochromia (a yellowish discoloration of the spinal fluid from broken down blood cells), which can suggest a cranial bleed has occurred, but it usually doesn’t appear until about twelve hours after a bleed. Finally, I wonder if Fran really would have survived. There is no treatment for methyl bromide other than supportive care, and the fact that she got worse even after being removed from the source makes me suspicious the damage had already been done.

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Both of tonight’s medical mystery were good and deserve an A. The solutions fit the cases and earn another A. The medicine was a mixed bag, a B- for the hospital plot, and an A for airplane plot, so I’ll give it a B+ overall. The soap opera aspect was decent — not terribly exciting, but not bad either — and earns a B.

The previous House review
A list of all prior House reviews

Tags: television medicine house methyl bromide meningitis decompression sickness

JSA #17 “Injustice Be Done, part 2: Cold Comfort”
David Goyer and Geoff Johns, writers
Stephen Sadowski, pencils

The JSA has been attacked by the Injustice Society and Sentinel takes a severe blow to the chest. Mr. Terrific drags him into a side room and prepares for surgery:

Mr. Terrific: The big gun of the JSA, Sentinel, just got his chest ripped apart. He’s gone into shock and he’s lost a lot of blood. We’re lucky he’s not already dead.
It’s my job to get his oxygen-starved pumper up and running again. Dr. Mid-Nite’s book on TMR is my only option other than cardiac bypass surgery.

Hold on a minute there, Mr. Terrific (a.k.a. “the World’s third-smartest-man”). Both TMR (transmyocardial revascularization) and CABG (coronary artery bypass grafting) are used to treat patients with severe coronary artery disease — people who are not getting enough blood flow to the heart because of narrowed or blocked arteries. That’s not Sentinel’s problem. He had a huge branch shoved through his chest — that’s the problem. He doesn’t need TMR or CABG, he needs the damage caused by that branch repaired. If he has an oxygen-starved heart, it’s only because he’s lost a tremendous amount of blood from the injury. He needs fluids (which, to be honest, Mr. Terrific is providing) and surgical repair of the trauma ASAP, not revascularization surgery.

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Meanwhile, Dr. Mid-Nite and Black Canary enjoying a dinner date when they are ambushed by Count Vertigo. True to his name, he causes everyone in the restaurant to become dizzy and nauseated. To counteract the count’s attack, Dr. Mid-Nite injects Black Canary with meclizine and diazepam.

That’s the right idea, but probably a little overkill. Meclizine (brand names: Antivert, Bonine) is a drug similar to Dramamine that is good for treating motion sickness and dizziness. It is usually the first-line agent for treating vertigo. If the meclizine doesn’t work, then diazepam (brand name: Valium) is prescribed. Drowsiness is a significant side-effect of both of these drugs, and I suspect it would be hard to avoid with both medications taken at the same time.

Also, Diazepam is a Schedule IV Controlled Substance — which means that this is yet another example of Dr. Mid-Nite giving out controlled substances illegally without a prescription (and without a medical license, state controlled substance registration, or DEA number). “But your honor, I was just giving the Valium to my date.” Yep. That’ll go over real well.

Tags: comics medicine jsa dr. mid-nite black canary

A request has been made for me to review New Excalibur #17 which details Talia’s recovery from her stroke. First, however, I’d like to take a look at New Excalibur #16, which features the stroke itself.

New Excalibur #16 “Fallen Friend, part 1”
Chris Claremont, writer
Scot Eaton, penciler

In Excalibur #16, Talia (Nocturne) suddenly suffers an apparent stroke. Visiting Dazzler in the hospital, she suffers a sudden loss of coordination, headache, numbness of both arms and legs, and then unconsciousness.

Generally speaking, there are two types of strokes. The most common (80%) is an ischemic stroke, where blood flow to one of the blood vessels in the brain is blocked by a clot. This prevents blood from getting to part of the brain, and this part will almost immediately stop functioning, and will die if blood flow is not restored quickly. The leading treatment for ischemic strokes are clot-busting drugs (also known as thrombolytics), but they have to be given within 3 hours of the onset of symptoms. Blood thinners may be used to prevent a subsequent stroke,

The second type of stroke is a hemorrhagic stroke, where one of the blood vessels in the brain starts to leak or bleed. This causes damage in several ways. First, the brain tissue beyond the bleed is denied its blood supply and can die, just like in an ischemic stroke. Second, blood is irritating to the brain tissue which causes swelling and inflammation. Third, if enough bleeding occurs, it can raise the intracranial pressure which can restrict blood flow to the entire brain. The treatment of a hemorrhagic stroke should come as no surprise: stop the bleeding. This may require surgery. Additionally, if a large amount of blood has collected, it may need to be surgically drained. Since the treatment for an ischemic stroke, clot-busters and blood thinners, will make a hemorrhagic stroke worse, you need to be sure what type of stroke has occurred before treatment is started.

So far, it’s not clear which type of stroke Talia suffered. Given her headache and loss of consciousness, a hemorrhagic stroke seems more likely as these are symptoms of increased intracranial pressure. However, no mention has been made of any surgery or neurosurgical evaluation. On the other hand, no mention has been made of thrombolytics or blood thinners either, though when Sage explains what a stroke is to Pete Wisdom, she only mentions ischemic strokes. Frankly, I’d be surprised if we ever find out for sure what type of stroke she had.

Doctor: Set up a fell series of x-rays — chest and skull. MRI’s as well — someone find out if we have to worry about her super-powers? And check with her teammates, she’s got different hand and feet structures, blue skin and weird eyes — are there any internal differences we need to know about?

I’m not certain why the x-rays were ordered. Talia was showing neurological symptoms and then she lost consciousness. The differential diagnosis would include stroke, seizure, hemorrhage, drugs, infection, or metabolic disorders — none of which show up on x-ray*. There is only a limited time window to treat a stroke, particularly an ischemic stroke, so there is no need to waste time getting unnecessary x-rays. An MRI makes sense because it has a good study for showing a stoke, either ischemic or hemorrhagic.

It’s nice to see a doctor taking super-powers into account , one would presume both for his sake as well as the patient’s. It’s what I would expect to see in a comic book hospital. Of course, in a comic book universe, we should probably add “telepathic disorder” to the differential — but then again, she doesn’t have a nosebleed, so maybe not.

Tomorrow: The requested review of New Excalibur #17 (plus I believe #18 is available in stores UPDATE: Oops. Not yet)

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*to be fair, “trauma” would also be on the differential – and that would seem a likely possibility in a superhero who had recently been in a fight — and while trauma should show up on x-ray, it would show up on the MRI as well, so there’s no reason to waste time getting an x-ray. (Plus the x-ray wouldn’t give a good view of the brain itself, just the skull. ) Just go straight to the MRI (or CT).

Tags: comics medicine excalibur chris claremont stroke

Of all the comic book writers of the Silver Age (and even later), I don’t think anyone has ever written better technobabble than Bob Haney. His descriptions sounded impressive and were concise, yet made no sense when you actually tried to think through what was said, let alone applied conventional medical knowledge or physics.

Good technobabble is a lost art, and Haney was the best:

Tags: comics medicine technobabble bob haney

Oops. I accidentally published this as “private” instead of “public.” If there is any significant problem with the Wordpress blogging software, it’s the ease of making this mistake. I corrected my error, so now everyone can enjoy the brilliance of Bob Haney.

One of the better issues of the series, and not just because it accomplishes the nearly impossible: it manages to fit the horribly out of continuity Brave and the Bold #181 logically into the main Hawk and Dove storyline. For those of you who don’t remember, that issue of The Brave and the Bold featured a middle-aged Hank and Don Hall being stripped of their powers because they didn’t fulfill their destiny and they fought with each other too much. It did have nice art by Jim Aparo, though.

Hawk & Dove #25starts just as the story from The Brave and the Bold is ending: Batman is swinging away and Hank and Don are discussing the loss of their powers. Hank returns home to his estranged wife Linda, who welcomes him with open arms…

…but then before his eyes she morphs into Ren. Not quite the same Ren we know and love, but a hippie version of her, including bell bottoms, tie-dyes, and psychedelic posters on the walls. Confused, Hank stumbles outside…

…and finds himself back on the Georgetown campus. There’s a crime in progress, but Hawk and Dove are already there. Only it’s his late brother Don, the original Dove, and a female Hawk. They capture the criminals, make snide remarks about the SCU, and then change back into their civilian identities. Hank confronts the two of them, protesting that he is supposed to be Hawk. You get the feeling this is an old argument between the brothers. Don sadly reminds Hank that while he was saving the children’s lives during the Crisis he was crippled, and subsequently stripped of his powers and a new Hawk chosen. Hank keeps protesting, “I’m Hawk,” over and over again…

…and he wakes up in bed, apparently a victim of nothing more than a bad dream. Then his wife appears, and it’s Dawn. He panics, but Dawn reminds him that they lost their powers on Druspa Tau. They returned home and subsequently married. She pushes Hank into the shower…

…and he finds himself back in the real world as Hawk, punctured by spear growing from a giant blue gem (just like on the cover). Hawk thinks back: he remembers entering the Smithsonian, changing to Hawk, and stealing the sapphire his brother needs to return to life. He remembers dodging the Smithsonian security and heading to roof to hide. He also remembers being puzzled when he didn’t immediately change back to Hank — but then he realized the gem had started glowing. The gem suddenly exploded in size, piercing him with several of its blue crystal arms.

Now that he’s awake, Hawk realizes that the gem is magic and somehow related to Order (the opposite of the Chaos that gives him his powers). It is purposefully warping his mind and memories. He is able to summon the willpower required to break the gem’s hold on him. Then he smiles because the gem has transformed into a giant blue crystal golem, and he realizes that he has something to hit.

Meanwhile, Ren is at the hospital visiting the still recuperating Rodger. She is concerned that she hasn’t been able to get in touch with Hank for a few days, and even more worried that it might have something to do with Dawn and Dove. Rodger does his best to reassure her.

Speaking of Dawn, she is on a date with Captain Arsala. They are sitting in his car, watching the sunset and eating burgers when his pager goes off. Hawk is robbing the Smithsonian and Arsala and the SCU are needed there. He offers to drop Dawn off at home on the way, but she declines and tells him she’ll get a ride home once they get to the Smithsonian.

The SCU team arrives at the museum grounds to find Hawk battling a blue crystal monster. He defeats it, and it reverts back to the sapphire he stole from the Smithsonian. Arsala orders him to surrender. Dove appears and asks Hawk what happened. He is surprised to see her, and tells her that he can’t explain, but asks for her just to trust him. He runs off, gem in hand. Arsala demands that Dove fly after him, but she refuses, saying that Hawk must have had a good reason for his actions.

The issue ends with Hawk alone in an abandoned warehouse, staring at the gem he stole, and wondering out loud if it was worth it.

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The writing was very good this issue, and the Kesels manage to weave action and soap opera together seamlessly. The opening alternate histories of Hawk and Dove are extremely well done, and each story has a distinctive voice — but then I’ve always been a sucker for alternate history stories. Each of the different versions has art by a different team, with the regular Guler/Hannah team handling the art on the main story.

It was clever of the Kesels to reconcile the Brave and the Bold story by explaining it away as one of the alternate histories shown by the gem. I’m not sure who provided the art on this section (the comic only all the artists involved, not who did each section), but they did a good job replicating the Aparo art from the original story. The second alternate history basically serves as a segue from the counter-culture late ’60s, when Hawk and Dove debuted, to their reappearance in the ‘90s. It sets up the most powerful of the alternate histories, the third one, where Hank has lost his powers. In this version of events, Hank went back to save the kids during Crisis on Infinite Earths instead of Don. Since Don didn’t die, he’s still Dove. Unfortunately, Hawk was crippled saving the children and a new Hawk appointed. Trivia buffs should note that this is the first appearance of a female Hawk, though I doubt she is anyway related to the current female Hawk as she goes by Kath and not Holly. The art is very somber The final alternate history presents Hank and Dawn as a married couple. In this reality, they lost their powers after the death of T’Charr and Terataya, but returned home from Druspa Tau to fall in love and get married. I did recognize the art on this section — it’s by Kevin Maguire, who also drew Hawk & Dove #20. I like the little touches like the wedding pictures on the wall with Hank in a blue tux.

Sadly, this is the last really good issue of Hawk & Dove. There are great moments in the remaining three issues (and one annual), but no single issue stands out.

All Previous Hawk and Dove Reviews

Tags: comics hawk dove jim aparo kevin maguire

Image taken from the Museum of Questionable Medical Devices

Tapeworms as a diet aid? Legend has it that early in the twentieth century, tapeworms were sold as a diet aid. This story surfaced again in the 1950s when noted opera singer Maria Callas lost close to 80 pounds over the period of a year. It was widely claimed that she lost weight by intentionally ingesting a tapeworm. Another story has it that her weight loss was due to tapeworms, but ones acquired unintentionally through her love of steak tartare and other raw meat dishes. The singer herself claimed her weight loss was due to a sensible diet and regular exercise.
Snopes considers the tapeworm diet legend of “undetermined” veracity.

The concept of the tapeworm diet continues today, with at least one website* recommending tapeworms not just as a diet aid, but as a treatment for allergies and asthma. The weight loss ascribed to the tapeworms in the FAQ on the site is the same weight loss one would obtain from a healthy diet and exercise. Guess which one is better for you in the long term?

Medically, intentional ingestion of tapeworms strikes me as a very stupid idea — so I don’t want anyone to think I’m endorsing this. I’m not. I just find it fascinating that people would intentionally infect themselves with a parasite. Tapeworms are unpleasant and frequently cause abdominal pain and other gastrointestinal symptoms. They don’t just steal calories, but also vital nutrients. I think this quote from an article from the Arizona Republic sums up some of the other concerns well:

Do you know what ascites are? A big pool of fluid in your tummy caused by an immune response to something in your guts. Something like a tapeworm. It gives you a big potbelly, which runs kind of counter to the look you might be wishing for.

And a tapeworm might not necessarily just set up camp in your innards. It can also cause cysts in your muscles, liver and eyes. Your eyes!

So don’t you think it might be easier instead to just eat a bit less and exercise a bit more?

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*I’m not going to provide linkage to the site due to its potentially dangerous “medical” advice, but if one were to Google for “tapeworm diet” I bet they could find it.

Tags: medicine tapeworm diet weight loss

This is the fourth in a series of Spider-Man public service comics¹ that take place in Canada and were originally given away free². The first two books dealt with drugs and featured Peter Parker visiting a Canadian science fair³. Next, Peter went to Toronto to catch a ball game and teamed up with Ghost Rider to stop a drunk hit-and-run driver. This final comic is the most forgettable of the bunch. The theme this time appears to be bicycle safety, although it only mentioned in two panels of the entire comic. While the comic does feature a super-hero team cameo, that team happens to be the Rangers. Once again American super-villains are an integral part of the plot⁴ and Peter just happens to be in the right place in the right time (and luckily criminals only victimize one city at a time in Canada).

As the comic starts, Peter is at the Calgary Stampede taking pictures for the Daily Bugle. Alongside him are Nobel Prize winning physicist Dr. Cargill and his wheelchair bound daughter Joline⁵. Performing at the Stampede are the Rangers, some of Marvel’s cheesiest heroes: there’s sharp-shooter Shooting Star, mysterious vigilante Phantom Rider, and the Texas Twister, half man-half cyclone. Appearing with the Rangers are the Right Riders, the safe-riding bicycle team from the previous issue. A watered-down version of the Frightful Four choose this moment to attack the crowd and kidnap Dr. Cargill.⁶

Peter rushes Joline to her father’s RV where she’ll be safe. He then changes into Spider-Man and rushes back to rescue the doctor. Meanwhile, the Rangers have taken on the Frightful Four and lost in record time. Back at the RV, Joline switches to a souped-up hovering wheelchair and becomes Turbine, Canada’s newest super-hero. She joins up with the Right Riders and together they rescue the Rangers and help Spidey capture the Frightful Four and rescue Dr. Cargill.

Yep, that’s all there is; that’s the story. No great morals or lessons learned, just American heroes and villains (and Turbine — Canada’s newst super hero!) duking it out in Calgary. Oh, and remember to wear your helmet kids!

Notes:
¹In all fairness, I should point out that this comic was not written by Dwayne McDuffie, the writer of the previous issues, but instead by Scott Lobdell. Mr. Lobdell wrote many fine comics during his tenure at Marvel. This is not one of them.
²Though we Americans had to pay for our copies
³We never did find out what Beth’s super-secret project was that all the villains wanted was.
⁴New motto: Canada — Where all the Super Villains are imported!
⁵Not Jolene, that’s entirely different.
⁶Why is the Wizard even considered a genius? This is one of the stupidest plans ever: Instead of surreptitiously breaking into Dr. Cargill’s house and kidnapping him, we’ll do it in broad daylight, in front of thousands of spectators and hundreds of police and at least one super-hero team. And then get beaten by kids on bikes.

Previous Issues:
The Amazing Spider-Man: Skating on Thin Ice!
The Amazing Spider-Man: Double Trouble
The Amazing Spider-Man: Hit and Run!

Tags: comics psa spider-man canada

Continuing my catalogue of nosebleeds resulting from the use of psychic powers. This weekend, I’m taking a look at Maxwell Lord, back from when he was involved with the Justice League International. In addition to yesterday’s look at Max, he was also featured in one of my original posts on “telepathic” nosebleeds from little over a year ago.

Lost at sea, Max has just used his powers to keep the Huntress from killing him.
from Justice League #35 (Giffen, DeMatteis, Hughes)

Tags: comics medicine nosebleed max lord

Once again it’s time for my favorite holiday of the year: Talk Like A Pirate Day!
Being the good buccaneer that I am, I looted last year’s post (which was itself plundered from the year before that), and I’m reposting and updating it — and new additions are always welcome!

Comic-book pirates (and pirate comic books) off the top of me head (to be updated as I think of more):

• Crossbones
• The Psycho Pirate
• Occulus from Fantastic Four
• And in the Fantastic Four’s first encounter with Dr. Doom (FF #5), The Thing ended up becoming Blackbeard.
• Pirate Club
• The evil pirates from My Monkey’s Name is Jennifer
• The Starjammers
• The hilarious Scurvy Dogs (”The cow says moo…”)
• The abandoned Barbarossa and the Lost Corsairs
• El Cazador
• Street Angel #2
• Long John Silver and the Pirates (Charlton comic from the 1950s)
• Belit (and Conan, for a time) from the Conan comics (older Marvel volumes)
• The Black Pirate appeared in some of the 1940s issues of Action Comics
• There was the pirate comic-within-a-comic in Watchmen (Tales of Black Freighter)
• Buccaneers from the 1950s
• The similarly named Buccaneer, also from the 1950s
• The Golden Medallion, a pirate comic book put out by LEGO
• The Pirates of Dark Water A kids comic put out by Marvel based on the Hanna-Barbera cartoon.
• Terry and the Pirates. Sure it was a comic strip, but it’s been reprinted in comic book form several times
• Then of course there’s Colonia (pointed out to me last year by Laura, the “Scourge of the Seattle Seas”)
• Pirate Corp$
• Even Mickey Mouse is getting in on the act: Air Pirates Funnies
• Metrokitty (the “Feline Felon”) reminded me that there was a pirate as a suporting character in the Starman series (and in one of the Talking with David issues).
• Speaking of Disney, we can’t forget air pirate Don Carnage from Talespin
• Pirates appeares in at least one Spirit story
• EC’s Piracy
• Indiana Jones and the Sargasso Pirates
• Some pirates appeared (briefly, before being slaughtered) in Grendel: War Child #4
• Polly and the Pirates
• The Aquaman villains Cutlas Charlie, Captain Squid, and Captain Blackjack
• The subway pirates from Seven Soldiers: Manhattan Guardian

Tags: comics pirates talk like a pirate day

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.

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* 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

Civil War: Frontline #1 “The Accused”
Paul Jenkins, writer
Steve Lieber, artist

I want to take a brief look at Civil War: Front Line #1. Not the boring main story, but the first of the backup stories — the one that deals with Robbie Baldwin, a.k.a. Speedball.

Speedball was caught in the explosion that kicked off the “Civil War” and was blown 500 miles away. He was found unconscious in a field and is now being cared for in some sort of highly secure government facility. It is unclear how much time has passed since the explosion and what precise injuries he suffered.

When we see Speedball, he is lying unconscious in a hospital bed and bruises can be seen on his chest, mouth, and eyes. His head has been shaved. There are electrodes attached to the left and right sides of his chest and abdomen. There is an IV running into the back of his left hand (most of the time) and there is a pulse oximetry monitor on his left index finger (which reads the amount of oxygen in his blood). He has a nasogastric tube in his right nostril, and there is tape over the bridge his nose.

Medically, the main concern for Speedball would be the damage he sustained from the explosion as well as from the force of his landing. His powers seemed to have protected him from most of the damage, but seem to have been burnt out in the process. If I were his physician, my main concern would be why he is unconscious and not whether or not he has lost his powers. I think it’s safe to assume that they’ve taken the necessary precautions and ruled out any spinal trauma or cerebral hemorrhages.

Speedball is in an intensive care setting, so the heart monitor and pulse oximetry make sense (though I’d recommend placing the electrodes where the heart actually is, on the left side of the chest, not evenly spaced over the entire torso). It’s always a good idea in critical care situations to have intravenous access, though Speedball seems to have a magic IV — sometimes it’s on the back of his hand, sometimes it’s in the crook of his elbow. Nasogastric tubes are generally used either to deliver food, fluids, or medicine to the stomach — or to suck out gastric contents. In this case, I suspect they’ve been feeding him through the NG tube, but it doesn’t seem to be hooked up to anything. It’s not clear why his head has been shaved — maybe surgery — or why he has tape on his nose — maybe it’s broken?

There are all sorts of other equipment around the room including surgical lights, monitors, and what appears to be an unused dialysis machine. They may have used these when he first arrived, or may have them around just in case they need them later. I have no problem with this. The middle of an emergency is the wrong time to go scrounging for the piece of equipment you need. Still, I bet if we look hard enough, I’m sure we can find the machine that goes “ping.”

Doctor #1: John! We’ve got a spike!
Doctor #2 (presumably John): What? What kind?
Doctor #1: EEG!* He’s coming to!**

I have a couple of problems with this. First, this is not how EEGs work. They can’t magically and instantaneously tell the difference between unconsciousness and alertness. They show differences in voltages across the brains as a series of waveforms, and many of these waveforms can be the same for alert, asleep, and unconscious patients depending on the circumstances. Anyway, “spikes” on EEGs do not represent waking up, but instead signify epileptiform behaviour — in other words, seizures.

Finally, I’d have a lot more faith in this doctor’s interpretation of EEG reading if Speedball actually had any EEG electrodes on…

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*I could be reading this wrong. The doctor in question might not be saying “E.E.G.,” but may instead have made the exclamation “Eeg!” – just as others might say “Arrgh!” “Jeepers!” or “Hoboken!” The lettering is not clear.

**Boy, that’s some of the most awkward dialogue I’ve seen in a while. Try reading it out loud, emphasizing the words the way the author did.

Tags: comics medicine civil war front line speedball eeg paul jenkins steve leiber

“Dallan and Sepsis Preserve Us!”

Those of you who read the Marvel Comics series Micronauts during the ’80s no doubt recognize that sentence, while those of you with less comics knowledge but more medical background are understandably puzzled. It was a common oath muttered (or screamed) by the denizens of Homeworld whenever danger threatened.

A little background: A thousand years ago, King Dallan Rann and Queen Sepsis Rann were the rulers of Homeworld, the lead “planet” in the Microverse. They sent their only son Arcturus Rann out to the far reached of the universe on a thousand-year quest for knowledge¹. Shortly after he left, Dallan and Sepsis were killed by their son’s tutor, Baron Karza², who went on the conquer Homeworld and the rest of the Microverse and set himself up as dictator. Upon returning from his voyage and discovering what had happened in the Micorverse while he had been gone, Arcturus Rann took the name Space Glider and joined the Resistance trying to drive Karza from power. With the other core members of the Resistance (Marionette, Bug, Acroyear, Microtron and Biotron), Rann formed the Micronauts³.

Personally, I think it’s a clever bit of storytelling to have the modern denizens of the Microverse revere Dallan and Sepsis Rann as saints or demi-gods. It ties together the past and present of the Microverse (but for Space Glider, it’s got to be a bit creepy having your girlfriend pray to your dead parents).

Dallan is a good name. According to Wikipedia, in the Christian context it means “blind,” named after the blind Irish poet Saint Dallan Forgaill. It’s also an Arabic word meaning “lost” which can be used in several contexts including a loss of the true religion. It’s not an uncommon name for boys.

Sepsis, on the other hand, is an unfortunate choice for a name. Sepsis is the medical term for an overwhelming infection of the entire body, though the term is also used to refer to the body’s response to this overwhelming infection. Regardless, sepsis is frequently fatal and always represents a tough battle to survive. Not the best name for a beautiful Queen, though I doubt writer Bill Mantlo was aware of the actual meaning of Sepsis when he chose the name⁴. Still, it’s hard not to chuckle whenever I see a character praying to “Sepsis.”

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NOTES:
¹Not the really best plan to insure the continuance of your dynasty.
²If I were undisputed ruler of the Microverse, I would have chosen something better than Baron. King, or Emporer maybe.
³Though I notice the team was now called the Microns when they appeared in Peter David’s Captain Marvel. I suspect it has to due with the rights to name Micronauts.
⁴Though Mantlo also named another beautiful female character Slug, so maybe he used the term on purpose.

Previous fond memories of the Micronauts:Micronauts #26-28 (The Micronauts and S.H.I.E.L.D. fight Karza) Micronauts #29-35 (The quest for the origin of the Microverse).

Tags: comics medicine micronauts sepsis

It’s that time once again to see what searches have brought people across the web to Polite Dissent. Capitalization has been added to make the searches more readable, but the grammar and spelling are untouched otherwise. As usual, my snarky comments are added in green.

Comic Related Searches

• Is Superman’s girlfriend pretty? All that matters is that Superman thinks so.
• Batman parents disappointed Death and the Maidens I think we all were disappointed with that comic.
• Clark Kent’s 8 pack abs Two better than six-pack abs.
• Green Arrow Longbow rape I’m sure we all can guess what this search was in reference to. For the record, I always though she had been.
• Zatanna naked The return of a classic search term.
• Wonder Woman groin I have no idea what they were searching for here, but I hope I answered their question.
• Lana Lang underwear ditto.
• Does Carter Hawkman Hall have a doctorate? Good question.
• John Byrne Vision Scarlet Witch genitalia I blame Chris Arndt for this one.

Medically Related Searches

• Do drug testes screen for Ritalin? I’m going to assume you mean “tests” and not “testes”, but the answer is yes — I suspect someone takingRitalin would test positive for amphetamines.
• Differance between cyst and mass A mass is solid, a cyst is hollow.
• Why is clostridium perfringens likely to grow in gangrenous wounds? You have it backwards, it is the infection with Clostridium that is causing the gangrene.
• Rh negative celebrities I have no idea. I’m A-, do I count?
• Cleaning a wound bleach Please don’t. While it’s true the bleach would probably kill any nasty germs, it would also kill many of your own cells, severely impeding the healing process.
• Rash where butt hits toilet seat Probably because somebody smeared something on the toilet seat.
• Medical term when scrotal organ burst out Painful
• Will the pregnancy test aome out positive when using the IUD? If you’re pregnant it will.

Homework

• Macbeth soliloquy she should have died hereafter. OK, here you go. From Macbeth, Act V, scene v, spoken by Macbeth:

  She should have died hereafter;
  There would have been a time for such a word.
  To-morrow, and to-morrow, and to-morrow,
  Creeps in this petty pace from day to day
  To the last syllable of recorded time,
  And all our yesterdays have lighted fools
  The way to dusty death. Out, out, brief candle!
  Life’s but a walking shadow, a poor player
  That struts and frets his hour upon the stage
  And then is heard no more: it is a tale
  Told by an idiot, full of sound and fury,
  Signifying nothing.

To Each Their Own (presented without comment)

• Kim Possible and Ron Stoppable having sex
• funny sex comics with the Teen Titans and Kim Possible
• Peter Parker adult fanfiction Norman Osborne

Miscellaneous

• Comics of nose Huh?
• Intravenous pumpkins Double huh?
• Obsessive compulsive personality disorder getting married Hope for neat spouse, or failing that, a patient one.
• Homemade defibrillator These two words should not go together.

Watching, or rather listening to, the music of Superman Returns reminded me of how much I loved the soundtrack of the original Superman movie. I’m not just talking about an exciting title theme (like the Raiders of the Lost Ark theme), but a soundtrack where the entire album is a good listen.

In reverse order, here are my top three favorite movie soundtracks:

3. The Princess Bride
Great music, especially the title theme.

2. Superman
The title theme and Planet of Krypton theme remain two of the best movie themes ever, but the whole album is good. Heck, I even used the Planet of Krypton theme as part of my wedding music.

1. The Last of the Mohicans
The perfect movie soundtrack, from start to finish. It’s easy to picture the scenes in the movie just listening to the music, and the entire album is a good listen.

Tags: movies soundtracks princess bride superman last of the mohicans ponderables

As this mini-series starts, Lois is feeling low. She has recently bungled a major interview, and her reputation at the Daily Planet has never been worse. In the midst of a dinner date, she notices police cars tearing down the road and she ditches her date (and “borrows” his car) to follow them. She ends up at a crime scene where the body of a murdered little girl is pulled from the harbor. At that moment Lois Lane, prize winning journalist, has an ONISGS (Oh No, I Suddenly Got Stupid) moment and suddenly realizes that there are missing and exploited children out there, and all too often they turn up murdered.

She spends the rest of this comic and the subsequent issue, both double-sized issues mind you, trying to come to terms with the fact that children go missing and are murdered. She antagonizes Clark Kent, Lana Lang, Jimmy Olsen, Perry White and even her sister Lucy. She harasses the police and assorted businessmen. She meets with parents of missing and murdered children and attends their support groups. In the end, nothing changes, except that now Lois — and we, the reader — know of the dangers that children face.

To be fair, it is not the worst story I’ve ever read, nor even the worst PSA comic. The writer mentions that she was inspired to write this comic after watching the TV movie Adam. Missing and exploied children are an important topic, and the comic does present the information fully, both in the storyline and in the accompanying text pages, but it’s just so heavy handed it’s no fun. If anything, the comic tries too hard and takes itself too seriously. To begin with, it’s hardly the most pleasant idea for a story, and then when you add a depressed and obsessive Lois on top of that, it becomes virtually unreadable.
When you forget the First Rule of PSA Comics (”Keep It Brief”), the message just gets lost.

The art by Gray Morrow is very moody and fits the story well. However, considering that one of this comic’s themes is the exploitation of women and children, it’s amazing how often Lois ends up in her lingerie, just her bra, or in the all together.

The big shocker of the book comes near the end of the story, at a police press conference that Lois and Lana are attending. As the police are discussing a dead body that has been found, Lana gets nauseous and bolts from the room. Lois follows her. In the conversation that follows, we learn a little secret: While Lana was in Europe, she got married and had a son. This child was kidnapped by an Italian terrorist group who sent Lana a little memento — her son’s ear — before ultimately killing him. To this day, Lana keeps her son’s ear in her safe deposit box. So not only did Lana have a marriage and child in her past — a family that has never been mentioned before or since — but she keeps her dead son’s ear (which she describes as “a dried piece of skin that looks like an apricot”) at her bank.

Did I mention what an enjoyable comic this was?

Tags: comics psa lois lane lana lang

I recently won a set of auctions for several hundred comics of the ’80s and ’90s. At what amounted to 20¢ an issue (with shipping), I was able to acquire a bunch of comic series and specials that I had thought about owning, but never had the time to seriously track down, or never wanted to spend that much money on. I’m about halfway through the stack now, and here are my thoughts so far:

Air Boy
Loosely based on the Goldenn Age Airboy (the new Airboy was his son). The supporting cast was great (Iron Ace, Valkyrie, Sky Wolf, the Heap), but I found most of the stories to be rather lackluster, particularly the later ones. I think the main problem was that the title character was so dull and bland. Writer Chuck Dixon didn’t seem to know which direction to go with the character and what sort of stories to tell, a fact admitted in the final issue.

American Flagg (both volumes)
The prototypical Chaykin-man: square jawed, follows his own set of ethics, likes the ladies. The Chaykin penned and drawn stories were great. When other writers tackled the character, it wasn’t nearly as enjoyable. While some of the non-Chaykin stories are quite good, nobody else seemed to have as much of a handle on the character. As far as I know, this is the first series to feature a main character (or at least major supporting character) with diabetes.

The Atlantis Chronicles
A history of DC Comic’s Atlantis, as told by Peter David and Esteban Maroto. The idea of having the official Atlantean chronicler as the narrator is a clever idea and bridges the issues well. The story starts out good, but seems rushed at the end. I think too much time was spent in the founding of the underwater cities, and the later stories suffered for it. The art is spectacular.

Hammerlocke
A nine-issue science fiction mini-series by DC Comics. I would love to see this reprinted on some high quality paper as the Chris Sprouse art is wonderful, but gets lost and muddy on the cheaper paper. It’s well done, but not quite what I was expecting. The story is fascinating and there are some good characters, but it could have used about three more issues or tighter storytelling.

Lois Lane
A very heavy-handed not-very-enjoyable morality tale. And did I mention it’s a two-double-sized-issues heavy-handed not-very-enjoyable morality tale. Has one of the most shocking and bizarre forgotten bits of continuity since Peter Parker’s childhood abuse was mentioned and then abandones in the Spider-Man/Power Pack special. Look for it in a PSA Monday post soon.

Metropolis S.C.U.
An enjoyable four issue mini-series starring (among others) Maggie Sawyer and everyone’s favoritebisected villain Terra-Man. Contains one of the most naturally written gay relationship storylines I have seen in a mainstream comic. Still I wonder about the name: If it’s Metropolis S.C.U., what are they doing jaunting all around the country and the world solving crimes?

Rocket Racoon
Classic Bill Mantlo and Mike Mignola craziness. Four issues was probably one issue too long, though.

Deadshot (first series)
Very well done, but then what would you expect from John Ostrander, Kim Yale, and Luke McDonnell? They set up a good mystery and keep you guessing until the end, though once you know who the mastermind is, the parts all fall into place.

Captain Atom
Extremely enjoyable. Probably the most readable and consistent translation of the prior Charlton characters. The first fifty issues in particular, written by Cary Bates, are well worth tracking down.

Impulse: Bart Saves the Universe
Fun, but I was expecting a little more craziness. Writer Christopher Priest has the speed power down well (but not as well as Waid did in the destined-to-be-a-classic Impulse #3, but misses the best part of Impulse…the impulsivity, the lack of post hoc ergo proctor hoc that makes bart so Bart (or did until Geoff Johns sadly adultified him in Teen Titans).

Fury/Black Widow: Death Duty
Prestige format blah!

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

Every once in a while I sit back and realize that comic books need to feature more talking animals. I don’t mean Disney books or any “funny animals” comics, but standard comics that feature talking animals. Look at the list below and tell me those characters weren’t one the best parts of their respectiver series:

Raul American Flagg Detective Chimp Day of Vengence, Shadowpact, et. al. Matthew the Raven, Barnabus Sandman Grodd Flash, JLA, et. al. the talking cat (name?) Book of Lost Souls the astronaut monkey (name?) Book of Lost Souls

Somebody please explain the recent Warlord mini-series to me. I can’t be the only one who thinks it’s a complete mess and a disservice to a character with a respected pedigree.

The original Warlord by Mike Grell was great. It was a fun pastiche of Burroughs, Howard, Kane, and Stoker (but mostly Burroughs) that never failed to enterain, particularly the issues drawn and written by Grell himself. Travis Morgan is the epitome of Grell’s über-masculine characters, later seen in his runs on Green Arrow (still my favorite take on the character) and Jon Sable, Freelance. Morgan’s shown up once or twice since the demise of his series, first in Green Arrow (in a classic storyline where everyone tries to kill him because they think he’s Ollie), a second time in a six issue 1992 mini-series, and then more recently in a storyline in Aquaman (Dan Jurgens’ run towards the end of the 1994 series). (And how could I forget Justice League Unlimited?)

The new Warlord, by Bruce Jones and Bart Sears, is wrong on so many levels. The story is paper thin and even that has already been stretched out for too many issues. Characters who were once complex and interesting are now two-dimensional caricatures (oh how I miss thee, fur-clad Tara). Morgan no longer feels lost in this strange new world, but is smugly confident that he can conquer it from his first appearance. To top it off there’s the addition of that cheapest of fantasy plot devices: the prophecy — and one that Morgan just happens to fulfill. It’s like Strange all over again, only without the nice Brandon Peterson art (I normally like Sears’s unique take on human anatomy, but this series just isn’t working for him. The action is messy and hard to understand, and the art is entirely too sketchy. He needs a bold inker; add him to the list of pencilers who should not ink themselves).

I would welcome Jones and Sears working on a Warlord series that builds upon Grell’s, but why start over when the new version offers no improvement upon the original?

Tags: comics warlord travis morgan mike grell bruce jones bart sears

A very somber (but sadly, not sober) episode this week. As usual, there are significant spoilers for this week’s episode of House ahead, so don’t come crying to me claiming nobody warned you.

A husband returns home to find his wife Kara have a seizure in the bathtub and their four-week old son Mikey drowning. By the time they reach the hospital, Mikey has resumed breathing and Kara has stopped seizing. Mikey is taken to the neonatal intensive care unit (NICU), where Chase happens to be working. Kara’s case is tackled by House, Cameron, and Foreman. Her calcium is elevated, and the initial concerns are hyperparathyroidism, cancer, and a “calcium-mediated neurotoxicity” — but apparently all those were ruled out in the ER. The next diagnoses considered include polyarteritis nodosa (a rare inflammation of blood vessels), Whipple’s disease (a rare type of bowel infection), a Strep infection, and vasoconstriction (a sudden narrowing of important arteries). The Strep test is negative, and when she is undergoing angiography, Kara suffers some sort of massive muscle contraction/seizure.

Meanwhile, Mikey’s oxygen levels suddenly drop. Chase listens to his lungs and diagnoses a collapsed lung (pneumothorax). He performs a needle thoracostomy and then acquires x-rays. He thinks the x-rays show a chemical pneumonitis (an inflammation of the lungs caused by an inhaled — or swallowed — irritant), but House disagrees and thinks the x-rays look like a bacterial pneumonia. He suggests placing Mikey on antibiotics and ECMO. Chase decides that House must be correct and starts the antibiotics and ECMO (extracorporeal membrane oxygenation — a big machine that oxygenates the blood and removes carbon dioxide).

In terms of Kara, the doctors are now considering a lithium toxicity and a myelogenous meningitis (a rare complication of leukemia where the cancer cells invade the lining of the brain). An MRI shows no brain tumor, but it does show a subarachnoid hemorrhage. It turns out that Kara has a bleeding disorder and her blood is not clotting as well as it should. Foreman’s search of Kara’s apartment turned up no lithium, but it did show a hidden bottle of vodka. When the team discovers that Kara is a former alcoholic, House suspects that she started drinking again and is now suffering from delirium tremens (a dangerous form of alcohol withdrawal). The liver damage from the alcohol would cause her bleeding problem (though they never seemed to run any liver tests). Foreman thinks it may be a conversion disorder, basically her body is having seizures to cope with the severe stress in her life. House overrules him and they place Kara in a phenobarbital coma to essentially sleep off her delirium tremens.

Kara’s feeling better when she awakens from her coma, and she is delighted to see her son (who appears fully recovered) and her husband. A short time later, House discovers her trying to suffocate Mikey. Chase resuscitates the baby and rushes him back to NICU. The team is now concerned that Kara has postpartum psychosis, especially after she admits that she hears voices telling her to kill her son. To ensure there is not some other neurological condition going on as well, they attempt to cause a seizure in her with sleep deprivation and strobe lights. Ultimately they succeed in setting off an atypical seizure that causes them to think that Kara is suffering from some sort of progressivedelirium. The possible diagnoses at this time includes Wernicke’s Encephalopathy (neurological disease caused by a severe thiamine deficiency – common in alcoholics), lithium toxicity, Whipple’s Disease, and pellagra (neurological disease caused by a severe niacin deficiency). Pellagra is the best fit, so they start her on niacin supplementation.

In the NICU, Mikey is not doing well. The lack of oxygen has severely damaged his kidneys and he has developed hyperkalemia (high potassium). Chase tries medication to bring the potassium level back to normal but it doesn’t work, and Mikey suffers a fatal arrhythmia (an abnormal heart rhythm — ventricular fibrillation in this case).

Kara is not improving despite the niacin, and complains of stomach pain shortly before vomiting blood. House has an idea but needs an intestinal biopsy. Because he suspects a disease that has a genetic component (and because Mikey has been breastfeeding and essentially eating the same food as mom), he can test the baby. A post-mortem examination of Mikey’s intestine reveals celiac disease, an autoimmune disease tied to eating food with gluten (wheat protein). This has caused malabsorption of vitamins (niacin, leading to pellagra and vitamin K, leading to a clotting disorder) as well as led to the development of a stomach cancer.

As the episode ends, both Kara and her husband are trying to come to terms with their son’s death — and having a hard time of it. Foreman is struggling to regain the skills he lost, and did I mention that Cuddy is looking for a sperm donor?

Kara’s medical care wasn’t that bad, but the pediatric medicine was sub-par. First, Chase is an adult intensivist, not a neonatologist, and the two are not interchangeable. Second, why did Mikey develop a pneumothorax? Infection (or pneumonitis) are not causes of a collapsed lung. T