Polite Dissent

It was such a busy and hectic Friday at the clinic that I needed to take a sanity check, so I thought it would be the perfect time to stop and enjoy one of the best comedy routines of all time: Abbott and Costello’s Who’s On First.

Here are couple of more modern takes on the same skit. First, Johnny Carson as Ronald Reagan:

Second, Slappy and Skippy Squirrel at Woodstock, from Animaniacs (frankly, this is only Slappy sketch I could stand. I never really liked that character, nor the pigeon Goodfeathers)

You can watch the episode in its entirety here.

This week’s moment of psychic nosebleed zen was suggested by the inimitable PTOR.

All previous Psychic Nosebleed Zen posts

The season finale of season four of House. The medical aspect remained spotty, but this was primarily a character episode, so how much you liked it is probably determined a great deal by your personal tolerance for schmaltz.

House and Wilson find Amber across town, admitted at another hospital. She is in bad shape after the bus accident. She completely damaged both kidneys in the accident and needs dialysis. She also has an elevated heart rate. Despite this, House feels that she would be better served at Princeton Plainsboro Hospital and convinces Wilson to pretend he’s Amber’s husband so that he can get her transferred. On the ambulance ride, Amber slips into ventricular fibrillation. House prepares to defibrillate her, but Wilson stops him, feeling the chemicals released by the heart after the defibrillation will cause brain damage. Instead, he convinces House to put Amber on a heart-lung bypass machine in “protective hypothermia” to buy time so that he can figure out how to save Amber.

The initial differential diagnosis for Amber’s condition is an autoimmune disorder, a congenital heart defect, blood clotting disorder, and lead toxicity. House orders an angiogram, and orders Kutner and Thirteen to search Amber’s apartment. Taub decides to order a drug screen. House has a hallucination about Amber puring him some sherry (which Kutner interprets to mean Sherrie’s Bar); he also considers deep brain stimulation to recover his missing memory of the night in question. These ideas are dropped for now, but surface again later.

Both the angiogram and drug screen are negative. Searching Amber’s apartment, the team turned up some prescription diet pills. They conjecture that these might have injured Amber’s mitral valve, leading to her heart problem. Because her heart is stopped, they can’t check a CT scan, so instead House wants the team to crack open her chest and stick a finger in the pulmonary artery to check the valve.

As Chase is setting up the surgery, he notices that her eyes are icteric (jaundiced), a sign that she now has liver failure. Antitrypsin deficiency is suggested as a possible cause and a liver biopsy is ordered. Wilson feels that since the condition is progressing, Amber needs to be cooled further. Reluctantly, House agrees.

House and Wilson talk to the bartender at Sherrie’s and learn that Amber was sneezing. House considers a parasitic infection at first (it’s quite a stretch, but not as bad as the “cancer” diagnosis for an itchy nose last week), then decides the most likely cause of Amber’s symptoms is Hepatitis B. The liver biopsy seems to agree with this diagnosis and she is started on interferon. House heads home to try to catch up on sleep and has a dream about Amber and the small of her back. He returns to the hospital, and sure enough, she has a fine red rash on her lower back (so much for a good physical exam on admission). The possible causes of the rash the team considers are influenza, dermatomyositis, an allergic reaction, abscess, or Rocky Mountain Spotted Fever. This last one seems the most likely, so House and Foreman want to start her on doxycycline to treat the infection and then warm her up and restart her heart. Wilson wants to wait for confirmatory cultures first, but this will take much longer. House agrees with Foreman, but Wilson managed to guilt him into waiting for the cultures. Foreman goes to Cuddy, and she agrees that Amber needs her heart restarted sooner rather than later. Wilson walks in while they are rewarming her and freaks out. He notes that her brain waves show slowing so her condition must have spread to the brain and he blames Foreman and Cuddy.

With heart, lung, liver, and brain involvement, an autoimmune disease is the most likely cause. House plans to start Prednisone. Wilson reluctantly agrees, but wants House to undergo deep brain stimulation first, so that he can remember more of what happened the night of the bus crash. Undergoing the procedure, House recalls Amber sneezing several times and complaining about having the flu. He then notices her taking several pills. He determines that she has been taking Amantadine for the flu, and because her kidneys have been severely damaged, the drug has not been cleared and has built up to toxic levels, causing the other symptoms. Unfortunately, dialysis doesn’t work on Amantadine and the toxicity is irreversible — meaning that Amber is going to die. House passes on the sad news to Wilson just before he suffers a massive seizure from the brain stimulation. Wilson wants Amber to pass away without ever waking up, but Cuddy convinces him to wake her up so that they can spend a last few minutes together. He acquiesces.

Meanwhile, House is in a coma. The seizure reopened his skull fracture causing a bleed on his brain. He has a dream/hallucination featuring the now dead Amber, but then slowly returns to consciousness. As the season ends, House wonders if Wilson will ever forgive him for his part in Amber’s death.

The medicine was, like recent episodes, sloppy — but it didn’t seem as haphazard as the last few weeks, probably because they focused on just 3 or 4 diagnoses over the course of the episode.

The writers are correct in that Amantadine is poorly cleared by dialysis, and there have been deaths reported on the medication. The dose for the flu is 100MG twice a day. The only size pill Amantadine comes in is 100MG, so Amber taking two means that she was overdosing herself on it, so she bears some of the blame for this.

What happened to Amber ventricular fibrillation? Did she really remain in v-fib all the way to the hospital until she was cooled? That’s unlikely. Plus, the longer she remains in v-fib, the longer the nasty chemicals Wilson was worried about will build up. Defibrillating early is still the best shot.

Heart-lung bypass and “protective hypothermia” don’t work like that. They’re designed for short-term use, like surgeries. They are rarely used longer, for transplant patients for example, but you don’t keep cranking down the temperature.

The mitral valve is not in the pulmonary vein; it’s in between the left atrium and ventricle. Unless House is suggesting sticking a finger through the pulmonary vein, and then into the heart itself to reach the mitral valve. That’s a disaster waiting to happen. And how is sticking a finger in a major vein a good idea? How are you going to get the finger in there without cutting a big hole in it?

“Diet pills don’t cause jaundice,” that may be true, but blunt trauma does cause liver damage -– like from, I don’t know, a bus accident that destroyed both of her kidneys.

Even if deep brain stimulation could restore memory (and I see no indication in the medical literature that it can), there would be no way to target a specific memory. It’s also performed under general anesthesia (the patient is asleep) [UPDATE - Not necessarily; see the comments], and the results are not instantaneous.

That wasn’t a complex partial seizure House suffered, that was a gran mal (tonic clonic) seizure.

The medical mystery was good, and the ultimate solution clever (and mostly correct), if depressing, so both earn an A-. The actual medicine was — discounting the heart lung bypass/hypothermia — above average, but that bypass and hypothermia dragged it back down to an average C. The soap opera was powerful, if a little overwrought in the end for my taste, but still earns a strong A-.

The previous House review
A list of all prior House reviews

In the USA Network television series The 4400, a group of people who mysteriously disappeared over the past eight years, all return when a mysterious “comet” brings them to Earth. Most of these returnees (the “4400″ of the title) have developed strange powers.

One of the first to demonstrate his powers was Orson Bailey (played by Michael Moriarity), an insurance broker who disappeared in the 1970s. When upset, he exhibits destructive telekinetic powers that he is unable to control. The use of these powers is accompanied by a nosebleed (and later, ear and eye bleeding as well).

Also of note, the victims of his power also show bleeding from the eyes, ears, and nose — though in one scene, an x-ray of one of these victims demonstrates multiple skull fractures — so they at least show some anatomical justification of their bleeding.

These images are from the pilot episode (not-so-cleverly-named “Pilot“) of The 4400. The first image is from when Bailey is being interrogated by agents from the Department of Homeland Security about a mysterious death, and the second image is when these agents track him down and confront him after a public display of his powers at his wife’s nursing home.

All previous Psychic Nosebleed Zen posts

This week’s episode of House had a great set-up and a clever medical mystery. The medicine itself was only so-so, but the rest of the episode mostly made up for it.

The episode starts with House getting a lap dance at a strip club. He soon realizes that he has no recollection of how he got there. Seeing blood on his fingers, he has the stripper look at his head and she sees a scalp laceration. From this, he deduces that he has suffered a concussion with retrograde amnesia (unable to remember what happened before the concussion). Leaving the strip club, he comes across the remnants of a tremendous bus crash and realizes that he must have been on the bus and was injured in the crash. He also has a fleeting memory that he saw something important while on the bus. He remembers that he noticed a symptom in one of the other passengers signifying that he or she had a fatal disease. The trouble is, he can’t remember who it was or the symptom that he saw

He stalks around the emergency room, looking over the other patients, and spots some bruising on the bus driver’s shoulder. He declares it a sign of leukemia, but in reality it is only the bruise left from the seatbelt. Another patient complains of a stiff neck and House immediately announces that he has meningitis and no one is to leave the emergency room (he doesn’t really think the patient has meningitis, he’s just trying to keep all the crash victims where he can find them. 22 of the 30 victims are at Princeton Plainsboro, 8 are across town).

Kutner suggests that House undergo “medical hypnosis” to improve his focus and assist with memory retrieval. Chase just happens to be trained in hypnosis, so he puts House under. Remembering the bus ride, House recalls a punk rocker (or “emo Guitar Hero wannabe”) with a cough and a bad nose picking habit. House figures this must be nasal pruritis (an itchy nose), a sign of a tumor — but the exam is normal.

A short time later, the bus driver discovers that he cannot move his legs. The differential diagnosis of this sudden onset of paralysis includes subdural hematoma, stroke, and subarachnoid hemorrhage — but all were ruled out by CT scan. Guillain Barre is suggested, as is tranverse myelitis based on the patient’s increased white count. Foreman starts him on antibiotics for the tranverse myelitis.

House now begins smelling the clothes of the patients who were involved in the bus accident, reasoning that smell is powerful at evoking memories. He hallucinates that he is back on the bus, talking to the driver, but the driver seems more focused on House than himself. Wilson and the team break his hallucination and order him to undergo an MRI to evaluate his brain. Edema and swelling in the temporal lobe are noted, as well as a fracture of the temporal bone.

The bus driver is able to walk again, but now is now suffering from acute abdominal pain. A peptic ulcer is a possible cause, but House wonders if it might be Addison’s Disease (a condition where the adrenal glands do not make enough steroid hormones) caused by a tumor.

House places himself in a sensory deprivation tank to better remember what he saw on the bus. This time, Cuddy is there with him. They conjecture that he saw something in the bus driver that caught his attention, but it could only be something he saw from behind, possibly a bobbing head or wiggling ear lobes. The differential they concoct includes aortic insufficiency (a leaky aoritc valce in the heart), Marfan’s syndrome (an inherited disease of the connective tissues), syphilis, Ehlers Danlos Syndrome (another inherited connective tissue disease), and Cutis Laxa (still another inherited disease of the connective tissues). There are also suggestions of early Huntington’s or Parkinson’s Disease. House decides it is the latter. He comes out of the deprivation tank and immediately vomits and passes out. When he comes to, he is in his apartment with a nurse to look over him and a security guard to keep him from leaving.

The bus driver is not doing well. He has developed liver failure, jaundice, and has a low albumin. The team suggests Wilson’s Disease (a disease of copper metabolism affecting the liver), hepatitis, hepatic fibrosis, and Thyrotoxic Periodic Paralysis. To rule out the latter, they carbohydrate-load the patient and put him on a treadmill. This should induce the paralysis, but since it doesn’t, the team concludes that the patient does not have the condition. He does become acutely short of breath and hypoxic, however. The team believes the patient has suffered a pulmonary embolus (a clot blocking one of the blood vessels of the lungs), but House deduces that the bus driver developed an air embolism from some recent dental work and as this air bubble has moved throughout his body, it has caused all his symptoms. He positions the patient in such a way that the air is trapped in the heart and has Dr. Thirteen remove it with a syringe. The patient immediately improves.

At home that night, House has a dream featuring a striking woman with a red scarf. The dream convinces him that the bus driver was not the patient he remembered. He reenacts the bus ride, with co-workers playing the role of passengers. He also downs a handful of phisostygmine to help him remember. He flashes back to riding on the bus, and realizes that it was Amber who was on the bus with him, and she is the patient in question. She was critically injured in the crash and hauled off to another hospital as “Jane Doe.” (And we’ll have to wait until next week for the conclusion of the story.)

The medicine was more haphazard than usual tonight, and it’s been very haphazard recently. Of course, part of that could be blamed on House’s own haphazard state tonight.

Hypnosis, even “medical hypnosis” simply doesn’t work like that. If it were that miraculous, it would be used by every police department in the country.

Stroke, subarachnoid hemorrhage, and subdural hematoma aren’t going to cause bilateral leg paralysis and shouldn’t have been so high on the list of possible diagnoses.

Tranverse myelitis is not a bacterial infection, and is not treated with antibiotics. It can be caused by certain viral infections or systemic conditions, but is most often caused by an overactive immune system attacking the spinal cord. Steroids are the treatment of choice.

While physostigmine has been used in cases of Alzheimer’s and other dementias, it has shown at best only minimal improvement. Several decades ago it was tested as a memory aid, but with lackluster results. It is also not available commercially in the U.S. as an oral formulation, unless House has access to a researcher’s stash.

For someone with an open fracture of the skull — indicated by House’s bleeding ear — submerging in a tub full of water is a great way to get an infection straight to the brain.

Nasal pruritis can suggest many things. Seasonal allergies would be at the top of my list. A tumor is a possibility, but a very very remote one. If the concern is that high for a tumor, a quick look up the nose is not going to be enough.

The air embolism from a dental procedure would have been tiny — too tiny to cause all the patient’s symptoms. Once an air embolus gets into the blood vessels, it either rises (going to the brain, since it started in the mouth) or is pushed along the circulation until it reaches the heart and then the lungs (where small ones are absorbed; large ones cause a pulmonary embolus). The air embolus wouldn’t travel elsewhere in the body unless the patient had a severe heart defect with a left-to-right right-to-left shunt.

The medical mystery was very good — one of the best ones yet and easily earns an A. The medicine was very haphazrd, but even so, it was better than it has been the last two weeks so deserves a B-. The final solution (bus driver) didn’t really fit the patient (or the anatomy or the scenario), so is knocked back down to a C. The final solution (Amber), will have to wait until next week, but come on — “resin?” House would have figured it out then and there. The soap opera was minimal, but intriguing, especially the hallucinatory and remembered parts. I give it a B.

The previous House review
A list of all prior House reviews

I’ve finally gotten around to totaling the scores from the last 2 weeks. Both were low scoring weeks, for the most part, though a few players each week were able to predict the final diagnosis.

As of Episode 14, Georgie has the lead with 68 points. Close behind and tied for second are proudfoot and Justin with 66 points. Tim is in fourth with 59 points, and Chi has fifth with 58 points.

Full standings and scores can be found here

Tonight features the first of four new House episodes. It was a decently mediocre episode — not bad, but not particularly outstanding, either. Kind of “House Lite.” An episode recap, medical discussion, and spoilers follow!

Jeff, a carpet cleaner by trade, is spending his lunch hour with his wife, a nurse on the picket line in front of the hospital. While there, he starts to have nystagmus (twitching eyes) and then collapses. He is admitted to the hospital Emergency Room for evaluation, but — thanks to the chaos from the nursing strike — is given a low priority and basically sits there waiting for several hours. House, who is in the Emergency Room avoiding Cuddy, is perplexed by Jeff’s constant cheerfulness and niceness. He decides that something must wrong with him and admits him to his service for evaluation.

Jeff’s initial complaints are syncope (fainting), dysgeusia (altered sense of taste), and “niceness.” The altered taste (everything tastes like lemon meringue pie) and happiness have been present for eleven years. House suggests that Jeff may have a metabolic disorder, toxic exposure, carcinoma of the tongue which has spread to the brain, epilepsy, or multiple sclerosis. Taub suggests he just has the flu. House disagrees and orders Foreman and Kutner to search Jeff’s house for toxins, and tells Thirteen and Taub to check an MRI and EEG. The tests are normal, but the team searching the house finds carpet cleaning chemicals including hydrofluoric acid, which is known to affect calcium. From this, House deduces that Jeff has Williams Syndrome. Taub disagrees, pointing out that Jeff is missing some of the necessary symptoms to make the diagnosis including the characteristic facial appearance, lower than normal intelligence, and musical ability. While the team is arguing, Jeff suffers a stroke.

Thirteen suspects that Jeff has a heart defect (a patent foramen ovale) and this is what is causing his symptoms, but never gets the chance to run the test because the patient’s VDRL — a test for syphilis — has come back positive. The team now suspects that Jeff has neurosyphilis. He is started on penicillin to treat the syphilis, and a short time later he begins to vomit blood (”hematemesis”). According to the team, this could be from the syphilis, or it could be due to a reaction to the penicillin, carpet cleaners, or even alcohol. More tests are run and the patient is determined to have “hepatitis” — not viral hepatitis, but some other non-specified kind. House orders a test for sarcoid, and starts Jeff on steroids to treat the hepatitis.

Jeff’s wife returns to visit him, and he is uncharacteristically mean and angry. He then suffers a heart attack (which actually seems more like a cardiac arrest). The team considers the situation: is the rage due to the steroids (too soon; not as common on glucocorticoids as anabolic steroids), a penicillin allergy, a heart defect, or maybe his real personality finally re-emerging? In the middle of an echocardiogram to look for a heart defect, Kutner has an epiphany. The patient doesn’t have syphilis — he has another condition which gives a false positive VDRL result. Jeff has Chagas Disease, a rare parasitic condition (rare in the U.S., at least) which he picked up while in the Peace Corps. He has had a low-level encephalitis since then, and the immune suppression from the steroids caused it to flare up and his symptoms — the anger — worsen. He is started on the appropriate treatment and House assures him that he will be cured in a month — but what personality is the real personality?

I don’t have too much to comment about this one, medically. In this episode, the medicine was clearly secondary to the personality issues (What is Jeff’s real personality? and House vs. Amber). House and the team skipped over a bunch of more common causes of Jeff’s symptoms, going straight for the obscure. They then focused on these obscure causes, when some simple — and frankly standard of care — follow-up tests would have shown them their error from the beginning.

Syphilis antibody tests such as the VDRL are notorious for their false positives. That’s why you always run a confirmatory test such as the FTA-ABS, which was never done. For neurosyphilis, you should test the spinal fluid and not just the blood. Many different things can cause a false positive VDRL, not just Chagas Disease. The list includes HIV, Lupus and other autoimmune diseases, Lyme disease, mycoplasma, hepatitis, mononucleosis, and certain drugs.

Despite what House implies, cure rates for chronic Chagas Disease are dismally low. Treatment is not recommended for those who have been infected for over 10 years due to the low success rates (less than 25%). By this late in the disease, the damage to the heart and other organs has been done — this damage cannot be reversed, but can be fixed with appropriate medications, and in some cases, surgery.

I give the medical mystery a B+ because it brought up some interesting points — is being too happy a bad sign? And if so, is being too curmudgeonly equally bad? The final solution was moderately clever, but even more an out-of-the-blue answer than usual, earning a C. The medicine was weak and sloppy throughout and could have been handled better by a second year medical student; it deserves only a measly D. The House/Amber/Wilson/Cuddy soap opera was good, the House-has-syphilis not as good. Still, I give the soap opera aspect a generous A-.

(And as an aside, why would House and Amber submit to Cuddy’s punishment? When has House ever done anything Cuddy has said, and what power does she have over Amber?)

The previous House review
A list of all prior House reviews

Continuing a look at psychic nosebleed in other media besides comic books. Today’s example comes from the science fiction television show Kyle XY.

Kyle XY is an original series on the ABC Family network featuring a pair of genetically altered teenagers: the eponymous Kyle, and his female counterpart Jessi. They both seem to be developing a wide variety of powers, both mental and physical in nature. However, whenever they push their powers, they end up suffering a nice little nosebleed.

Jessi

Kyle

The first scene takes place after Jessi uses her telekinetic powers to cheat at pool, and the second takes place after Kyle uses his powers to heal another character of cancer. Both scene come from Episode 19, Season 2: “The First Cut is the Deepest.”

All previous Psychic Nosebleed Zen posts

Time to pick — briefly — on New Amsterdam again. This appears to have been the third episode, so they must have shown a second episode that I missed last week.

The first topic is Civil War medicine.
Good: Morphine was available and used as a painkiller (though many Civil War veterans ended up addicted to it)
Good: Ether was used as an anesthetic (in roughly 30% of surgeries. Chloroform was the most common, but also more dangerous than Ether)
Bad: The term “Phantom Limb” was not coined until well after the Civil War, in 1872.

In terms of the more modern medicine:
Bad: Intramuscular shots aren’t given in the antecubital fossa (the inside of the elbow). IV medication is given, well, through IVs.
Bad: The doctors have an exaggerated sense of how effective antipsychotic medications are. Patients don’t miraculously become lucid, even after a few hours.
Good: I saw nothing wrong with the doctor’s physical exam technique.
Bad: There have been some studies suggesting beta-blockers will help victims of post-traumatic stress disorder, but they need to be given shortly after the traumatic event, not years later. That being said, beta-blockers still have some important other uses that may apply here: they are good for high blood pressure, certain social anxieties (public speaking, for instance), tremors, and a racing heartbeat. Overall, I find the studies suggesting beta-blockers for PTSD not particularly compelling or convincing.

So far it’s an interesting show about an immortal New York detective and I’d say it has definitely has the potential to be a good show

I did have a couple of medical nitpicks, though. The first one I’ve mentioned multiple times.

You don’t shock asystole (a flatline) — not only does it not work, but it’s actually counterproductive. Giving epinephrine or atropine is fine. CPR is good. Transvenous pacing is better. Defibrillation — not a good idea.

If Amsterdam has such a rare blood type that everyone who has it died out, why are they testing for it?

Finally, on a non-medical note, in the last flashback it was rather disconcerting to see the New York area tribes of Native Americans living in tipis — which were used by the tribes of the Great Plains, not the northeast.

The Set-Up: Derek Reese, John Connor’s uncle, has been shot and severely wounded. He needs a transfusion, but since he’s a wanted man Sarah doesn’t want to take him to the hospital and instead elects to perform a transfusion in the kitchen. She offers her blood, but since she is O- and Derek is AB- her ex-fiancé (an EMT) tells her it won’t work; Derek needs an exact match. John offers his blood and it must be a match because we see him a short time later transfusing his blood into Derek.

Though Sarah Connor is blood type O- (known as the “universal donor”) she cannot donate blood to Derek because this is a whole blood transfusion. In a normal transfusion, just the red blood cells are transfused, but in a whole blood transfusion both the blood cells and blood plasma (i.e. the “whole blood”) are used. The blood cells carry the proteins that determine a person’s blood type, but the plasma carries antibodies that react against other blood types. Because a whole blood transfusion deals with both blood cells and plasma (and proteins and antibodies), the donor and recipient blood types need to match exactly or there will be a nasty transfusion reaction.

AB- is the rarest blood type. In the general population of the United States, about 1 person in 167 (roughly 0.7%) are AB-, though blood type distribution can vary greatly by race.

The most important aspect of the transfusion seems to have been entirely missed by the writers: since Sarah has blood type O-, that means that she cannot be John’s mother. John gave Derek a transfusion so he must be AB-. That means that he inherited an A gene from one parent and a B gene from the other (A + B =AB). Sarah is blood type O which means that she has neither an A nor a B gene to pass on to John. Blood type O parents can only have A, B, or O children, depending on the blood type of the other parent. They can never have AB children*.

Miscellaneous nit-picks:
That sure was a tiny IV to transfuse 3 units of blood through. It would have taken the better part of a day.
What sort of EMT strolls around carrying a sedative in their bag (and given the small dose needed to work, it must be a controlled substance, such as Ativan or Valium) or has blood typing serum?
A “manual aspirator to drain the lung” — what the heck does that mean? Did he mean a chest tube?

*I guess John could be a spontaneous mutation, or maybe a liver-transplant recipient, but those are both quite a stretch.

Quite likely the final episode of House in this strike-shortened season. Overall, it was a good episode even if it was another exploring the House-versus-religion theme. While the medical mystery was just moderately interesting (at least initially), the solution was clever, and the medicine mostly correct. Good soap opera too.

Roz is a Hasidic Jew, recently converted, and even more recently married. At her wedding ceremony, she loses control of her bladder, and a large stain of bloody urine appears. She collapses and falls, breaking her leg. She is admitted to House’s team for the evaluation of her condition. Dr. Thirteen reports that Roz’s urine culture was negative (meaning no urinary tract infection) and there is no history of trauma or sexually transmitted diseases. A CT scan was negative for cancer and kidney stones. She reports that Roz’s sodium was low, however, and suggests that Roz may have endometriosis of the bladder. Taub counters that the low sodium may be related to Roz fasting before the wedding, while House posits that Roz may have been exposed to a toxin, carboxylic acid in particular. House agrees to let Thirteen start Roz on treatment for the possible endometriosis (with AIs, i.e. Aromatase Inhibitors) and get a cystoscopy . Meanwhile, he sends Taub and Foreman to search Roz’s apartment where they find no carboxylic acid, but discover that prior to her conversion, she had been a heavy metal record producer. She admits to a history of heroin use, but not for some time. A hair sample is obtained, but the tests are negative. Additionally, the treatment for endometriosis has been unsuccessful and the cystoscopy clean.

Taub suggests Roz may have cryoglubulinemia (abnormal proteins in the blood that thicken with cold temperatures), but House feels she has porphyria (problems in the synthesis of hemoglobin), and her sudden conversion to Judaism suggests the mental problems commonly seen in certain types of porphyria. Roz’s husband considers this an insult, and requests a new doctor. Cuddy agrees with the cryoglobulinemia diagnosis and wants to start her on Indomethacin (a potent non-steroidal anti-inflammatory drug, the same class as Motrin). Meanwhile, Roz has become hypoxic with her oxygen saturation dropping to 85%. This argues against both cryoglobulinemia and porphyria. She is kept on oxygen and her saturation improves. Foreman mentions Wegener’s Granulomatosis, but House now believes it to be Lupus with a hidden heart problem. He orders a stress test. Roz makes it through the test well and has no evidence of heart problems. After the test, she develops sudden leg pain and the team believes that she might have a blood clot. An MRI is obtained, which shows no clot, and an fMRI (functional MRI, which works by detecting increases in blood flow within the brain, and these are believed to represent area of brain activity) is ordered as well, ostensibly to look for subtle signs of a stroke. The fMRI shows activity in her limbic system (one of the emotion centers of the brain) when Foreman is placing an IV (a painful situation) which House believes shows that Roz has masochistic tendencies, but Thirteen discovers she was praying during the IV placement, so that might explain the limbic activity.

As Roz stands up after the test, her blood pressure and heart rate come crashing down. When she sits or lies down, she is fine — she only has a problem when standing (orthostatic hypotension — low blood pressure when standing). She is started on fludrocortisone and ephedrine (two drugs that can be used to treat extreme cases of orthostasis). The differential now includes pheochromocytoma (a tumor that releases high levels of adrenalin and similar compounds), systemic sclerosis (better known as scleroderma, an autoimmune disease), and a heart arrhythmia. An EP study (”electrophysiology study”, which looks for abnormal rhythms in the heart) is ordered, but the results are normal. The suspicion now turns to an autonomic nerve disorder such as Riley Day Syndrome. A thermoregulatory sweat test is ordered, but instead of becoming overheated, Roz becomes hypothermic (an abnormally low temperature) and has a seizure.

Infection is now considered as a possible diagnosis, as is Addison’s Disease (a condition where the adrenal glands do not make enough steroid hormones). Roz is started on Cortisol to test for Addison’s and she starts to feel better (cortisol is a steroid hormone). As Thirteen examine her though, she notices a swollen abdomen and Roz reports that she is starting to feel dizzy. Thirteen quickly realizes that Roz has internal bleeding. Chase (apparently the only surgeon in the hospital this season) wants to perform an exploratory surgery to locate the source of bleeding, but Roz decides to delay the surgery until after she has had a chance to celebrate Shabbat with her new husband, even though it might cost her her life. The differential diagnosis now includes DIC (disseminated intravascular coagulation), hydatid cyst (a tapeworm cyst), volvulus of the small intestine (a twisting of an intestinal loop), polycythemia vera (too many red blood cells in the blood), thrombocytopenia (low platelet count) and even Parkinson’s Disease. During the brainstorming session with the team, House has a sudden revelation and realizes that Roz has a nephroptosis, also known as a floating kidney. Instead of being firmly secured to the underlying tissue, her right kidney is hanging loosely, just supported by a few blood vessels. This explains the blood in the urine, the internal bleeding, and the orthostatic hypotension. The strain this is putting on the right adrenal gland (located on top of the kidney) likely explains most of her other symptoms. The floating kidney was not noticed on the scans because they were all performed with her laying down and it only shows up when she is standing up. Surgery should be able to fix her problem and stop the bleeding.

I really don’t have too many medical complaints this episode, other than my usual litany of untrained people doing potentially dangerous tests and results comic back to quickly. Now, you’ll notice I didn’t say I had no complaints, just not as many as usual:

Roz didn’t just have a slight bit of blood in her urine, that was gross hematuria. In my mind, that should have necessitated a full bladder and kidney work-up from the very beginning that should have caught the nephroptosis.

Was it just me, or did they seem to keep forgetting about her broken leg? It never seemed to be splinted or cast. She did get to do the arm stress test, instead of the treadmill one, but that seemed to be the only acknowledgment of the broken leg.

I’m not clear on what caused her shortness of breath (that improved overnight) or her sudden leg pain (other than, you know, that fracture thing). Maybe blood loss and anemia led to her shortness of breath, but that much anemia should have been easily noticed on her labs.

They sure like to jump to the big guns early, don’t they? Aromatase Inhibitors. Fludrocortisone. Ephedrine. I’m not saying these drugs don’t have their places, just not first thing.

From what I read, there is some debate in the medical community over how significant a “floating kidney” actually is. All of Roz’s autonomic symptoms (hypotension, low sodium, low temperature, etc) are quite a stretch, especially when you remember that she was lying down when many of them happened.

The medical mystery was moderately interesting, frankly not something that would I would expect to pique House’s curiositu — I give it a weak B. The medicine was better than it has been recently, though still not without mistakes or unexplained symptoms — another B. I thought the solution was clever and elegant, though the severity of her autonomic symptoms were straining credibility. Still, I give the solution an A-. The soap opera was good and almost — almost – had me liking Amber. It was nice to see Cuddy back to her normal acerbic self, especially when she was talking to Wilson. I also give this aspect an A-.

All in all, not a bad quasi-Season Finale. Not a grand slam, but at least a solid triple.

The previous House review
A list of all prior House reviews

Lots of players earned points this week, but there weren’t any dramatically high scores.

Three people topped the scoring this week with a total of 6 (count ‘em: 6) points: me (finally!), Georgie, and Andrew K.

This propelled Georgie to the top for a last minute upset victory for the season, with a total of 56 points. proudfoot was right behind with 55 points, and Chi was just two point behind in third.

Full standings and scores for the Season can be found here

This was probably the last episode of the season, but if they manage to produce and air any new shows, the challenge will pick up where we left off.

House lands the prime post-Super Bowl slot, and it was a strong episode overall. The medical mystery was intriguing, as were the logistical difficulties involved in solving it. There were some strong character moments, and a surprise reveal at the end that I did not see coming.

The medicine? Eh, it was OK. The rest of the show was good though.

Cate is a psychiatrist working at the South Pole on a psychological research project, as well as serving as the physician for the team stationed there. Just after treating another staffer with an injured femoral artery, she develops sudden intense right-sided flank pain, vomiting, and begins gasping for breath. No other physicians are available at the South Pole and evacuation is not an option. Since Cate is an adjunct faculty member at Princeton-Plainsboro Hospital, the Psychiatry Department asks House to treat her. Given her location, all the diagnosis and treatment must be done over webcam, and the medical supplies and tests available at the South Pole are minimal.

The initial differential diagnosis includes appendicitis, gallstone, or kidney stone. House in particular feels she has a struvite kidney stone due to recurrent urinary tract infections (large and jagged kidney stones that form due to urinary infections). She denies any history of urinary tract infections. Her Chem 7 (also known as a Basic Metabolic Panel, or BMP) shows declining kidney function, which House believes proves the existence of a kidney stone. He wants her to take a dose of intravenous Cefuroxime (a broad spectrum antibiotic) to cover any infection. She declines, telling House that there are other people who may need their limited supply more. Her kidney function continues to decline. House continues to believe this is a kidney stone, but she believes it is because of dehydration from the vomiting (and dehydration can certainly alter kidney function tests, though it usually has a very specific pattern); she wants to repeat the test after she’s rehydrated. In the middle of the conversation, she becomes tachypneic (rapid breathing) and develops chest pain. House notices that her trachea is deviated to the left which means that she has a tension pneumothorax, a life threatening emergency. Under his direction, she is able to relieve the tension by performing a needle thoracostomy (basically inserting a needle into her chest to relieve the pressure and allow the lung to re-inflate).

The differential now includes tuberculosis — but her PPD was negative, as was everyone else’s at the South Pole — and cancer in the kidney or lungs. An x-ray of her body shows an enlarged mediastinal node which could be a sign of lymphoma. Unfortunately, it is too deep for anything but a surgical biopsy, and that’s not an option. No other lymph nodes show up on x-ray (but then, x-rays aren’t very good at showing lymph nodes), so House has her perform a detailed physical exam on herself to look for other nodes, closer to the surface. She finds an enlarged node just above the belly button. Under Wilson’s direction, Cate plunges a syringe into it and withdraws about 2cc of a straw-colored fluid. No cancer cells show up in the fluid, but there are signs of inflammation. Unfortunately, Cate now begins having severe left flank pain, identical to what she had earlier on the right.

House suspects an autoimmune disease such as SLE (lupus) or vasculitis. He wants to start her on Prednisone, but she doesn’t want to use the medication unless she knows for sure that it’s an autoimmune condition. Foreman states that the normal test, an ANA, is not available, nor is an older test looking at C3. They can perform an improvised LE Prep (Lupus Erythematosus Cell Preparation). The test result is negative, arguing against an autoimmune condition, but House is still suspicious. Reluctantly, he agrees to Foreman’s plan to have Cate go outside, on the theory that the extreme cold will reduce the inflammation of the autoimmune disease and reduce her symptoms. She is about to comply when she passes out and then slips into a coma.

House, Foreman, and Wilson are now dealing with the station mechanic, as Cate is in a coma. They have him taste her urine to see whether it is concentrated (suggesting a kidney problem) or dilute (suggesting a brain problem). The urine is watery, so the cause of Cate’s coma is likely in her brain, they suspect an elevated intracranial pressure (ICP) or a hypothalamic problem. Under the team’s instructions, the mechanic drills a burr hole into Cate’s skull. This is to relieve any increased ICP. Sure enough, she comes out of her coma shortly after the hole is drilled.

House’s team now considers what condition could cause kidney problems, lung problems, and increased intracranial pressure. The differential includes tumor (already ruled out), bacterial endocarditis, deep vein clots, atherosclerotic emboli or fat emboli. House is intrigued by this last suggestion. Cate was cold during the exam and had left her socks on. When they are removed a broken toe is revealed. This broken bone has been throwing off clots of fat to the kidney, lungs, and heart, causing her problems. The bone is reset and splinted and she should be fine.

Fat emboli can definitely cause lung problems in the form of pulmonary embolism (clots to the lungs), but I don’t see any way it cause a tension pneumothorax. In terms of the treatment of Cate’s tension pneumothorax, the needle thoracostomy relieves the tension aspect of the pneumothorax, but a simple pneumothorax still remains. Cate needs a chest tube (or if it’s small enough, 100% oxygen — all the time, not just an occasional breath).

That’s not how a percutaneous needle biopsy is performed, and that’s an incredible amount of fluid to get back — it’s a solid tissue structure they’re biopsying, not a cyst. PLus, I find it hard to believe the medical kit wouldn’t contain a local anesthetic such as Lidocaine.

Sending someone with an autoimmune disease or vasculitis out in the cold is not a clever idea. It may reduce their symptoms, possibly, if the moon is right. Or it could cause a bad case of Raynaud’s Disease (a cold-induced spasm of the blood vessels in the fingers and toes. It is common in people with autoimmune diseases and vasculitis).

I can see how a fat embolism in the brain could cause a coma (from causing a stroke), but I don’t know that it would increase the intracranial pressure and cause a coma that way.

How did fat embolism lead to enlarged lymph nodes?

It’s fractures of the long bones (femur, most commonly) that lead to fat emboli. I don’t think there’s enough fat in a toe bone to cause a fat embolism.

I give the medical mystery an A because it was the best mystery they’ve had in a while. The limitations imposed by the patient being at the South Pole were well done. The final solution fit the big picture (lung, kidney, and brain damage), but missed the specifics (how did clots do all that? And from the toe?) so gets a merely mediocre C-. The medicine was for the most part appropriate, especially given the limitations already mentioned. The final answer is where the medicine fell apart. Still, I’ll give it a B- overall. The Three Musketeers didn’t add much this week, but Wilson and special guest patient Cate more than made up for them. That Wilson-is-dating-who? ending is worth some points as well. A for the soap opera.

The previous House review
A list of all prior House reviews

A low scoring week despite the presence of fan (and writer) favorite lupus.

High scores for this week go to Ledasmomand Chimmie, who both earned 6 points. JockM and Lucy tied for third highest with 4 points, then there were a bunch of 3 pointers, thanks to Lupus.

Overall, after Episode 11 there is no change in the top standings: proudfoot retains the lead yet again and Chi remains in second. Georgie and Justin stay tied for third overall.

Full standings and scores can be found here

A fairly high scoring episode this week, but then having such common answers as lupus, sarcoidosis, and multiple sclerosis always helps. Correct final answers were given to people who answered either breast cancer or paraneoplastic syndrome.

High scores for this week go to Georgie and Justin, who both earned 19 points, and Chi, who earned 16.

Overall, after Episode 10, proudfoot retains the lead for another week. Chi moves up to second, and thanks to this week’s scores, Georgie and Justin tie for third overall.

Full standings and scores can be found here

Normally I can just ignore the bizarre science and questionable medicine on Doctor Who and Torchwood, but it was so bad this time I can’t keep quiet.

Well, that was a lame and stupid science-saves-the-day ending.

A futuristic bomb has zeroed in on the genetic profile of John Hart and embedded itself in his skin. Not wanting to go down alone, he chains Gwen to him with “hypersteel” (like regular steel — only more so!) handcuffs.

Frantically, Owen and Jack take the tubes of blood they have of every Torchwood member (convenient, that). They spin it down in a centrifuge and then take the remaining blood cells and combine them into a single syringe. Arriving just in the nick of time, Jack plunges the syringe into John’s heart. This small amount of blood is enough to confuse the bomb so that it lets go of John, giving Jack enough time to hurl it through the rift*.

First of all, I’m a little creeped out by the fact that they’re got tubes of the team’s blood stored in the fridge at Torchwood — not surprised, really, just creeped out. Of course, blood has a short shelf life, so they’d have to keep drawing new blood every few weeks to keep it on hand “just in case.”

Blood doesn’t have a lot of DNA. Red blood cells don’t have a nucleus and thus are missing almost all their genetic material. There are other blood cells that do have a full complement of DNA but they are not as numerous as the red blood cells. (Yes, I know that forensic shows and even actual forensic scientists are able to get a DNA profile from a minuscule amount of blood, but that’s because they’re using a special technique known as PCR to amplify what little DNA there is.)

It would be hard to hit the heart with that small a needle (and aiming that high on the chest). And why specifically did he feel the need to target the heart?

Mostly, I just find it very hard to believe that a super-sophisticated future tech bomb is going to be fooled by that tiny amount of non-John DNA. Assuming Jack plunged a full 5cc syringe of foreign blood into John’s circulation, that still means that 99.9% of the blood in his body is his own. And that’s only counting the blood — all the other cells of the body have DNA too. In the end, that syringe of blood probably means that only 99.99999% of the DNA in his body is his own, and 0.00001% is foreign.

It’s likely it did set him up for a nice transfusion reaction though, as the antibodies in his blood target the foreign blood cells (unless the blood types are compatible or he’s type AB+).

*Watching the show, my wife and I had the same thought: Just cut off John’s arm (the one chained to Gwen with “hypersteel”) and hurl the rest of him into the rift, bomb still attached. No great loss. Seriously, did the character have a single redeeming quality?

Episode Title: In Which Dell Finds his Fight

A mediocre episode of Private Practice. The writers were clearly trying to tug the heartstrings with Dell’s grandfather but weren’t able to pull it off. Frankly, they didn’t even reach maudlin.

Dr Addison Montgomery and Dr. Naomi Bennett
Cathleen and Geoffrey, the couple who were having difficulties with vaginismus is a previous episode, are back to talk with Addison. They are concerned about fertility, and even though they’ve only been trying to conceive for 2 months, Addison agrees to go ahead and run some fertility tests. Cathleen’s tests are fine, and in fact show her to be ovulating. Geoffery’s sperm count, on the other hand, is zero. Addison and Naomi suggest adoption or using a sperm donor (though it might have been a good idea to work up why Geoffrey was sterile; it might have been something correctable). Geoffrey declines adoption because he knows that Cathleen wants to experience pregnancy. They look though the “Catalog” but can’t decide on a sperm donor. Geoffrey has the bright idea to use his brother Mark as a donor since that way the baby will have genetics close to his. Just as Cathleen is ready to go through the procedure, she and Geoffrey simultaneously tell Naomi to stop — as they both realize that they don’t want to use Mark’s sperm after all (because he’s a jerk, and they seem to believe that jerkiness in an inheritable trait).

Addison suggests a surgical procedure to look though Geoffrey’s testes to find some viable sperm and then use that to fertilize one of Cathleen’s eggs. As luck and prime time television would have it, Addison is able to find a single sperm and when they implant it into one of Cathleen’s harvested eggs, they fuse and the egg miraculously and instantly divides. The egg is implanted back into Cathleen and she leaves the office already feeling pregnant.
Since when is Addison a Urologist? She shouldn’t be poking around down there with sharp instruments without the right training.
The fertility treatments scenes were wrong on so many levels, it makes my head hurt just to think about it. Suffice it to say, real world fertility treatments bear little — if any — resemblance to what the episode showed. It is never a waltz in, waltz out sort of treatment.
Success rates with a single implanted egg aren’t particularly high, and in fact the odds are against Cathleen having a successful pregnancy. But then again, in an earlier episode, Naomi guaranteed she could get a couple pregnant and no real world fertility specialist would ever say that.

Dr. Sam Bennett
Dell comes to Sam because he is concerned about his grandfather Wendell. Dell has noticed that his grandfather often has bruises he is reluctant to explain and suspects that he might be a victim of elder abuse in his nursing home. Sam interviews and exams Wendell and his friend Nate. He does find a few scattered bruises but his patients assure him that they are not being abused. Sam is inclined to believe them, but Dell is convinced something is wrong. Naomi tells Sam to trust Dell, so Sam checks out the medical records of Nate and Wendell and finds a suspicious number of minor injuries over the past several months.

Sam and Dell go to the nursing home (after hours, of course) to check things out, but discover that none of the residents are in their rooms. They manage to track them to the back of a storage room where the residents are holding a boxing match featuring Wendell and Nate. Dell and Sam intervene, but it’s too late. Wendell hits Sam with a strong blow and he goes down — and stays down. Sam checks him out and realizes something is wrong with Nate’s heart and calls for an ambulance.

It turns out that Nate has suffered a heart attack. He does not fare well at the hospital and eventually dies. Sam reports to Wendell and Dell that Nate had a long history of heart problems and was “living on borrowed time”; he tells Wendell that he shouldn’t blame himself for Nate’’s death (whereas I think Wendell should bear much of the blame — it was his punch that finished Nate off after all). Wendell gives an (allegedly) impassioned speech about growing older that boils down to “carpe diem.”

Dr. Cooper Freedman and Dr. Peter Finch
In order to proved to Charlotte that he can be “bad,” Cooper — with help from Pete — runs a parenting workshop for new fathers. Not only is Cooper’s seminar in direct competition with Charlotte’s, but he steals her list of participants. They are not the best teachers in the world, but that works out all right, because they don’t have the best students either.
Naomi, Miss “I-can-guarantee-you-a-baby”, lectures Cooper about the cost of insuring a parenting class. A parenting class? I guarantee they are much more likely to get sued for unrealistic promises and infertility than anything taught in a parenting class.
I can’t be the only that finds it hard to believe that Charlotte would just shrug off a loss of $27,000 and a blow to her esteem in the hospital just for sex with Cooper.

Tonight’s House is a repeat of an episode from last season (Season 3, Episode 18 to be exact), “Airborne.” It features Wilson leading House’s team while House and Cuddy are on a flight back from a medical conference. Medical chaos, of course, ensues.

The medical review of “Airborne” can be found here. Comments are open.

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 biop