Polite Dissent

This year’s April Fool’s day post, including this new title graphic:

Today on Pullet Dissent, I’ll take a look at some notable entries from the recent San Diego Chicken-Con:

	Plucky Owner: M. Sterling An early season favorite from a long and distinguished line. Plumage looks good, though the beak is a little unimpressive. Grade: B+
	Kirk Owner: D. Wright Another strong contender from the California powerhouse. I expect multiple 4-H ribbons from the specimen, with a State Fair championship to top off the season. Grade: A
	Nitro Owner: K. Church Every since splitting off from the family fried chicken business, Church has been struggling to find the right competitor. This year, I think he’s finally done it, and his Nitro should give Kirk a run for his money. Grade: A-
	Funky Chicken Owner: D. Campbell A master of chickens from the 90s, Campbell has decided to have a go at current poultry as well. It’s a valiant effort, but ultimately I expect Funky to end up as soup. Grade: C
	Easter Dinner Owner: C. Sims Really, the less said the better. Grade: F

Tags: chickens competition 4-h state fair

Monday mornings often feel like a mutant zombie attack, so here’s a blast from the past (the 1980s, at least) to share that feeling: the ad for Yaquinto’s Attack of the Mutants game that used to run on the inside cover of most Marvel comics.

Personally, I like any ad copy which manages to use the phrase “brave little robot.” Plus, the fact that the scientists are advanced enough to build robots, but still use slide-rules really cracks me up for some reason.

Did anyone ever play this game?

Time to a second look at Marvel’s PSA campaign starring the X-Men from a few years ago. This second ad stars Nightcrawler.

Click on the image above for the full ad.

This one’s better than the Wolverine ad, and I can see the point they’re trying to make, but it still leaves me cold. For one thing, it appears that Nightcrawler is always stealing something or runnimg away. No exactly the activities I look for in a super-hero role model.

Second, is that kid with the basketball wearing a sweater over a collared shirt? It sure looks that way. No amount of reading comic books is going to make that pain go away.

Finally, there’s that tagline: “Verb — it’s what you do.” Yes, dodging, sliding, and dribbling are all verbs. But so are loafing, gorging, sleeping, whining, and slacking, (and maybe one day, even snarking). I’m glad this PSA campaign didn’t last long.

Tags: comics psa nightcrawler verb

Another episode of House where diagnosis after diagnosis is discovered, but the whole was ultimately less than the sum of its parts. Frankly, I found the medicine in this episode to be weak and confusing, and the melodrama too schmaltzy for my taste.

Emma is a 41 year-old photographer who happens to be 21 weeks pregnant. At a photo shoot, she suffers a stroke. Luckily, she recognizes the signs and has an ambulance called. She is admitted to the hospital under the care of her physician. Even though her doctor is ready to discharge Emma, Cuddy asks House to examine her. He notes a pronator drift (a sign of muscle weakness or upper motor neuron disease), weakness in some of the mouth muscles, as well as some microaneurysms in her retinas (generally a sign of diabetic retinopathy). He also notes a copious amount of blood in her urine. Her discharge is canceled and many tests are ordered.

A urinalysis reveals protein and blood in the urine. Blood studies show an elevated creatinine, suggesting that Emma has developed kidney failure. An ultrasound of the kidneys is normal. Her blood pressure is good and there are no signs of pre-eclampsia (Also known as “toxemia of pregnancy”. Classic signs are high blood pressure, water retention, and protein in the urine). An echocardiogram is also normal. Despite this, House is suspicious that the problem is her heart. Her medical records show evidence of past Strep throats, and he suspects she must have gone on to develop rheumatic heart disease, specifically mitral valve stenosis, as a consequence of the Strep infections. A heart MRI does reveal a slightly calcified mitral valve. This is opened up with a balloon, but her kidneys do not improve (and frankly, why should they? A slightly stenotic mitral valve has no effect on the kidneys, unless the valve threw a clot to the kidneys, in which case the damage has already been done).

The differential diagnosis now includes pre-eclampsia, hypoperfusion (blood is going to the fetus preferentially instead of the mother), infection, HUS/TTP (hemolytic uremic syndrome/thrombotic thrombocytopenic purpura — diseases of the capillaries that can affect the kidneys), or a cholesterol embolus (a clump of cholesterol that breaks off the wall of a large vessel and proceeds to block off a small vessel), but tests for these are all normal. House believes that Emma has a rare condition known Maternal Mirror Syndrome (also called Ballantine Syndrome, or Maternal Hydrops). This is a maternal condition caused by an abnormality in the fetus (hence the term “mirror.”) House’s next step is to find the fetal abnormality. To get a good image of the fetus, House uses a paralytic agent to temporarily paralyze it while an MRI is obtained. The heart looks good, but the bladder is greatly enlarged, crushing the lungs. This bladder is enlarged because of a urinary obstruction. A stent is placed into the fetal bladder to relieve the obstruction. The surgery seems to go well, but now Emma is complaining of right upper quadrant pain (the location of the liver) and her sclera are icteric (the whites of her eyes are yellow), both signs of jaundice. Sure enough, lab tests show that she’s gone into liver failure.

House believes the only way to save Emma’s life is to terminate the pregnancy, but she refuses. Cuddy takes over the case. She slams Emma with high doses of steroids in an attempt to mature the fetal lungs. She suspects the liver failure may be unrelated to the Mirror Syndrome. This leaves a differential diagnoses of acute fatty liver of pregnancy, viral hepatitis, and HELPP (Hemolysis, Elevated Liver enzymes, Low Platelets) Syndrome. Cuddy wants a liver biopsy performed, but due to the risk of bleeding from low platelets, they’ll have to sample the liver from within the venous system itself.

The liver biopsy results are normal, but the procedure induced pre-term labor. Emma is given tocolytics to stop the contractions. Cuddy is now convinced that the Mirror Syndrome is the cause of everything and the problem must remain in the one area they haven’t been able to get a good look at: the fetus’s lungs — but because they are so underdeveloped, there’s no way to get a good look. Cuddy gives more steroids to Emma even though she is warned she could cause pulmonary edema — and (of course) she does. Emma is intubated and placed on a respirator and Cuddy keeps giving her steroids. Her plan works, the lungs open up enough that a scan shows that there is some sort of malformation there.

The only way to diagnose and treat for sure is to perform open surgery on the fetus. The surgery is rough, and Emma slips into ventricular fibrillation during the procedure. House wants to cut the umbilical cord (and kill the fetus) to save Emma, but Cuddy is able to shock her back into a normal rhythm and the surgery continues. The surgeon notes that the baby has CCAM (Congenital Cystic Adenomatoid Malformation) and he will be able to remove the lesions. With the baby’s lungs treated, Emma’s symptoms resolve and we learn in a closing scene that she delivered a healthy baby.

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Let me state up front that I am no expert in maternal/fetal medicine and high-risk obstetrics. That being said, I still had some significant problems with the medicine in this episode. To save time (and my typing fingers and your eyeballs), I’ll just mention what I thought were the four biggest problems (I’ll leave the rest, including the surgery scene, up to everyone else — though if you have specific questions, I’ll do my best to answer them):

1. Why didn’t the mitral valve problem show up on echocardiogram? And if the mitral valve did cause the stroke, it’s because there would have been a clot or vegetation growing on it, which would have shown up on the echocardiogram. And if there was a clot, the last thing you would want to do is force the valve open.

2. Speaking of stroke, I’m not clear on what caused the stroke that set off the whole chain of events. I can find no connection between strokes and Mirror Syndrome. There has been one recorded case of a seizure and Mirror Syndrome, but that’s the closest I could find. Nor can I find any connection between blood in the urine and Mirror Syndrome. Protein in the urine – yes. Blood – no. And what was with eye exam showing diabetic retinopathy?

3. Mirror Syndrome occurs when there is fetal hydrops (a serious condition of severe edema in the fetus — which this fetus did not have), and the mother develops pre-eclampsia like symptoms including edema, liver problems, high blood pressure and proteinuria. There are also other key findings including anemia and elevated uric acid that were never mentioned. Mirror Syndrome can be caused by all the fetal conditions mentioned in the episode, but there is significant debate over whether surgery is good treatment. One reference I read went so far as to state that Mirror Syndrome was a contraindication for surgery (that is, a reason not to do it) because removing the lesions in the fetal lung did not help the mother at all.
As far as this episode goes, Emma had some symptoms of Mirror Syndrome, but was missing common ones, and had other symptoms that didn’t match (blood in the urine, stroke). Her baby had CCAM, which has been known to cause Mirror Syndrome, but did not show the fetal or placental edema seen with the condition. Surgery may not have been the best choice.

4. Mature lungs produce a chemical known as surfactant. Surfactant helps with the surface tension within the lung and keeps it from collapsing. Premature babies who are born without the ability to make surfactant can develop severe lung problems including respiratory distress syndrome. A dose or two of corticosteroids given 1-7 days before delivery will help the lungs create surfactant. Steroids do not otherwise help the lungs mature. Giving repeated doses of corticosteroids to a woman who is only 21 weeks pregnant (a long way from needing surfactant) will accomplish nothing useful.

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I give this episode a B for the mystery, because it was intriguing; and another B for the solution, because it did ultimately fit. Unfortunately all the medicine in between was sub-par and earns a weak D. The soap opera had some good moments, but seemed to waste a lot of potential, so it also earns a B.

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

Tags: television medicine house kidney failure liver failure pregnancy

• I’ve long said that doctors’ offices and dentists’ offices would be a great place to get a younger audience exposed to comic books. It seems that someone finally listened to me. One of the doctors in the clinic received a subscription package from DC Comics that included a subscription form as well as a sample of Teen Titans Go! I think this is a great idea, even if it wasn’t sent to me (an oversight, I’m sure). It would have been better had it included a different subscription form instead of the standard one — for instance, highlighting which books are truly all ages. An institutional discount would be nice too, and would encourage larger orders. Still, it’s definitely a step in the right direction.
  Personally, I would be happy to stock any Johnny DC or Marvel Adventures comics in my exam rooms and waiting room. I have also had good success with several Oni Press titles, especially Alison Dare and The Magic Pickle.
• The Comic Treadmill shows some Micronauts love in their latest edition of the Scaled-Down Smack Down. Now if H would just hurry up and get to The Brave and the Bold #181 in his review of the title so I can see his thoughts on Hawk and Dove’s co-starring role.
• This came up in the comments the other day. Here is an online copy of the comic book that came with the old Atari game Yars’ Revenge (Yars’ Revenge: The Qotile Ultimatum!)

Batwoman (Kate Kane) is bound to an altar to be sacrificed by Bruno Mannheim, the leader of Intergang. Renee Montoya, Kate’s lover and the new Question, rushes in to rescue her.

With Kate bound on the altar, Mannheim drives the sacrificial blade into her heart. This is quite an impressive feat. The blade appears to be a fairly wide blade, yet he drives it vertically into her chest. Remember that the heart is protected by a little something known as the rib cage. Mannheim would have to drive the blade through a rib or two to reach her heart — and maybe even the breastbone — no easy task.

Kate tells Renee not to remove the blade. On one hand, this is good advice. The blade is plugging the hole it made and removing it will let blood pour out of the heart. On the other hand, blood loss is only part of Kate’s problem. The blade is large enough that it would have severely lacerated the heart muscle. The heart is a very efficient pump and contracts concentrically to push the blood through the arterial system. A large laceration will disrupt this contraction and compromise the heart’s ability to pump blood. Additionally, the knife probably severed one or more of the coronary arteries — the arteries that supply the heart muscle itself with blood. A severed coronary artery deprives the muscle beyond it of blood causing a heart attack. The knife wound would also disrupt the electrical conduction of the heart, further compromising its ability to function. Finally, the trachea, lungs, and esophagus may have been injured as well — and seeing the blood oozing from Kate’s mouth — probably were. In real life, without immediate resuscitation and surgery, this would be a mortal wound.

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Fatal wound or not, Kate is able to sit up, wrench the blade from her heart (and rib cage) and throw it at Mannheim.

Even accepting the comic book truism that all thrown weapons land blade-first, this is still an impressive throw. Despite being weak from her injury, she is able to bury the blade hilt deep in Mannheim’s back — remember that little thing called the rib cage? Kate manages to cut through it with a thrown knife. Her throw looks like it landed a little right of center, so she would have missed his heart. However, given the amount of blood shown in a later image, she probably cut through one of the major blood vessels such as the subclavian artery or vena cava, which would also be a mortal wound. I think it’s safe to say that severe lung damage would have occurred as well.

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I’m generally a big fan of Darrick Robertson’s art (way back from his time on the New Warriors) and his last go on 52 was some of the best pencils of the series. The art this time is not nearly as good — far too dark and scratchy - and looks like it was rushed. It costs the fight scene much of its excitement. There’s also the matter of the magically shrinking altar. When the scene starts, the altar ends a good foot above Kate’s head; her arms are resting on top of it. At the end of the scene, the altar now ends at the top of Kate’s head with her hair and arms dangling off the edge. Personally, I blame Darkseid.

Tags: comics medicine batwoman renee montoya the question 52

Which of these are real drugs, and which are comic book drugs?

• Venox
• Gardasil
• Denyitol
• Timelozar
• Exubera
• UFOpium
• Valtrex
• Scapalamine
• Rocuronium
• DMN

This example of the psychic nosebleed comes from Factor X #4, one of the comic book “re-imaginings” that took place during the Age of Apocalypse back in 1995. (For those of you who don’t know or don’t remember, the Age of Apocalypse was a glimpse at what the Marvel Universe would have looked like if Charles Xavier had died before he could start the X-Men. For four months in the summer of 1995, all the X-books were renamed and together told the story of this alternate world. On a recent rereading, the stories held up surprisingly well, but the art — with all its ’90s excesses of shoulder pads, pouches, and facial tattoos — did not.)

Anyway, here is the Age of Apocalypse’s Jean Grey giving it everything she’s got. There’s a nose bleed, an eye bleed, and what appears to be a forehead bleed. I have no idea where that last one comes from — she didn’t have it in the previous panels and suffered no head trauma in the meantime. Maybe it’s just miscolored sweat.

Scenes from Factor X #4. Words by John Francis Moore, pencils by Steve Epting

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed jean grey apocalypse

Last year it was the Avengers, the year before it was the Justice League. This year…

Happy Easter from the Legion of Super-Peeps

Tags: comics peeps legion of super-heroes

On today’s Monday PSA, we have a mystery: who swiped the kids’ money?

• Was it Jim? What secrets lurk within that sweater vest?
• Is it the kid in the striped shirt? Will he grow up to be the Goon?
• Is it the Jughead wannabe? Did anyone really wear those hats?
• Will it be one of the other two members of the club? Are they the Andrew Ridgeley and Art Garfunkel of this PSA?
• Maybe it was Buzzy? Why is he hanging around the clubhouse if he’s not a member? And what’s with the bow tie?
• How about the mysterious “Uncle Ned”? Did he really just give Jim $5?

Click on the image above for the full ad.

These mysteries and many more will be answered* if you dare read “Buzzy says ‘Be Sure of Your Facts!’”

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*More or less. Some things will always remain a mystery, like sweater vests and Jughead hats. Personally, I think Jim was a little too forgiving. He should have at least kept the popcorn for himself.

This PSA graciously provided by H of the Comic Treadmill
Tags: comics psa buzzy

Make sure to check out today’s installment of Penny Arcade. I think we are witnessing history here: the first webcomic appearance of the psychic nosebleed.

All previous Psychic Nosebleed Zen posts

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

from this week’s 52 #49

I’m a bit puzzled by this Associated Press article on the new treatment recommendations for Gonorrhea.

I’m not surprised that drug-resistant Gonorrhea is on the rise, nor that the CDC now recommends cephalosporins as a first-line treatment agent — pretty much everyone knew this was coming.

What I am puzzled about is the second-half of this statement from the article:

The newly recommended class of antibiotics includes the generic drug ceftriaxone, also known under the brand name Rocephin, which must be injected and “works very well” although the drug is not commonly stocked in doctor’s offices, Douglas said.

[Emphasis mine. The Douglas the article refers to is Dr. John Douglas Jr., director of the CDC’s division of STD prevention.]

I’d be interested to know on what Dr. Douglas bases his statement (if it was indeed correctly attributed to him). It runs contrary to my experience and to the experiences of my colleagues.

While I don’t know for certain, I suspect the vast majority of STD patients are seen by their primary care physician, the ER, an urgent care clinic, or their OB/GYN. I have never known a primary care physicians office, emergency room, or urgent care that did not stock ceftriaxone; it is that common a medication. (I’m not entirely sure about OB/GYN offices, but a quick informal poll tells me that the local offices all carry ceftriaxone.)

I’m just wondering who is out of touch here, me or the CDC’s Director of the Division of STD Prevention? (Personally, I’m suspicious that it’s the third option: clumsy reporting from the AP. Wouldn’t be the first time. I e-mailed the CDC and asked for a clarification — we’ll see if I ever hear back).

The Amazing Spider-Man #529 “Back in Black, part 1 of 5”
J. Michael Straczynski, writer
Ron Garney, penciler

Aunt May has been shot by a sniper in the left side of her abdomen. Let’s speculate for a moment about what injuries she might have suffered. The spleen is on the left side of the abdomen and an injury there can lead to a great deal of blood loss. There is also a kidney on the left and an injured kidney can lead to all kinds of problems. There is lots of bowel as well, and a perforated bowel is high risk of infection and a surgical emergency. If the shot were angled a little toward the center then other key structures would be vulnerable including the spine, aorta, and pancreas. The matter of ballistics is also important. Did the bullet go clean through? Did it fragment inside of Aunt May, or maybe bounce around in the abdomen her causing even more damage?

Peter Parker is unwilling to wait for the ambulance, reasoning that it will take too long to arrive and he can get her to the hospital faster. That’s probably true — to a point. While the ambulance may indeed be slower than Spider-Man, it has other key assets. For one thing, it has a trained medical crew that can stabilize Aunt May and at the very least start her on IV fluids and apply direct pressure to her wound. Additionally, the crew is going to make sure she isn’t injured further. Remember our discussion about anatomy? She could very well have a spinal injury. Swinging her across the rooftops — no matter how fast it may be — is not a good idea for an injured patient. The ambulance crew will also be in contact with the hospital so May will get quick and appropriate care when she arrives.

Speaking of arriving at the hospital, what does Peter do? He crashes through a second-floor window and places May on an empty bed, then leaves. This really isn’t a good idea. I’m sure the nurses and staff of the second floor are good, but an elderly woman with a gunshot wound is not something they are equipped or trained to handle. There’s probably not even a doctor on the floor. The hospital has a department that is specially trained, staffed, and equipped to handle emergencies, and it’s called — you guessed it — the emergency room. Any time that Peter might have saved getting May to the hospital has been wasted as the second floor staff scrambles to find someone who knows how to treat gunshot wounds. In all likelihood, they’ll just wheel May down to the ER, where she should have gone in the first place.

And stop with the plasma! I know I’ve covered this again and again. Plasma is not transfused except in very specific circumstances, and this is not one of them. Aunt May needs type O blood now while she is typed and crossed and prepped for emergency surgery.

A little while later, Mary Jane shows up at the hospital looking for May. The doctor who treated May just happens to overhear the conversation and comes over to talk to Mary Jane. This would never happen in real life. First, the receptionist is not allowed to give out any admission information at all; it’s illegal thanks to a little federal law known as HIPAA (and wasn’t likely to happen before HIPAA either). Similarly, the doctor’s not going to tell Mary Jane anything. He has no way of knowing whether or not she’s truly related to May — for all he knows she could be one of the gang that shot her in the first place and is now looking for her to finish her off.. There’s no way that he’s going to divulge sensitive medical information in this situation. If anything, he’ll delay her until the police arrive and ask her what she knows about how an elderly lady got shot and then dumped at the hospital.

Finally, let’s take a look at poor Aunt May in her ICU bed. Overall, it’s a well drawn scene, but two mistakes immediately jump out at me. First, patients who are on ventilators are intubated (they have a breathing tube inserted); they don’t use a mask. It’s a matter of resistance: the ventilator needs to force air into the patient’s lungs so they can breathe. A short wide tube offers the least resistance. A mask offers far too much. I’m willing to give the artist a pass on this mistake, since it’s not commonly understood, but not the second mistake: why is her bandage over her gown?

Tags: comics medicine spider-man aunt may straczynski

Nate Grey is the Nathan Summers (a.k.a. Cable) of the Age of Apocalypse. Only, he’s supposed to be more powerful than Cable because he doesn’t have to squander some of his power keeping a techno-organic virus in check. (Though Nate always seemed to get the short end of the stick whenever he encountered Cable, so maybe he’s really not more powerful after all — or maybe just less experienced.) In this scene from X-Man #2 (words by Jeph Loeb, art by Steve Skroce), Nate has just used his power of telekinesis to fly for first time. All previous Psychic Nosebleed Zen posts Tags: comics medicine nosebleed nate grey apocalypse

Nate Grey was one of the few who survived the Age of Apocalypse and somehow ended up in the regular Marvel Universe (the others being Sugarman, the “Dark” Beast, and sometimes — via the Exiles — Blink)

In this scene, he is thinking back over the events that led to the collapse of the Age of Apocalypse and he ends up losing control of his powers and destroying a tanker truck. (The line down the middle is from the page seam; this is two-page spread. Now that I’m looking though it, you really didn’t get your money’s worth out of this comic. In a mere 22-pages, there are three two-page spreads and two full-page panels. And it’s not like the other pages had much either, most just had 3 or panels. Some quick math tells me that X-Man #5 delivered an average of just 2.7 panels per page.)

Scene from X-Man #5. Words by Jeph Loeb, pencils by Steve Skroce

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed nate grey

I thought it was time for a another visit with Dr. Dazzler*. This story comes courtesy of Ben Casey #3 (Dell, December 1962).

Click on any of the images for the full story

Discussion questions:
1. Why does Dan Dazzler not want any time off? Is he that lonely?
2. Were all the good gang names already taken?
3. If it’s a puncture wound, how is it large enough that he can tie off the bleeders?
4. Why do the walls keep changing colors? Is everyone on drugs?
5. Is it a ever good idea to leave your wallet and coat lying around in a room surrounded by juvenile delinquents? Explain in a haiku.

*Dr. Dan Dazzler was the four-page back-up comic that ran in Dell’s Ben Casey comic book. Further adventures and information on Dr. Dazzler can be found here.

Tags: comics dell ben casey dazzler

Another Monday and that means another PSA — and this week’s ad once again contains words of wisdom from our teenage pal Buzzy. Not only that, but it features the return of Buzzy’s macrocephalic friend Wolfie.

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

This PSA appeared in a handful of DC comics from September 1954 including Adventure Comics #204, Batman #86, Detective Comics #211, Superboy #35, World’s Finest #72 and the debut issue of Superman’s Pal, Jimmy Olsen. Like most Buzzy PSAs, the script was by Jack Schiff with Win Mortimer on the art.

Tags: comics psa buzzy jack schiff win mortimer

Frankly not a good episode tonight — in fact, I gave it a failing grade. There were too many missteps and some appallingly misunderstood medicine. See if you agree — or can show what I’m missing…

Jasper, a very rambunctious eight year-old boy, has just been a fight and received a bloody nose and his father has been called to day care. While his father is stopping the nosebleed, his six year-old sister Lucy collapses and is struggling for breath. She is admitted to the hospital and found to have a restrictive pericarditis (the sac around the heart becomes too tight to allow the heart to correctly fill with blood) and elevated blood pressure. She undergoes surgery to remove the pericardial sac. Differential diagnosis includes bacterial infection, viral infection, amyloidosis, sarcoidosis, hemochromatosis, and tuberculosis. Blood tests are negative, but the perciardial sac shows granulomas which are thought to represent a fungal infection. House wants a lymph node biopsy to determine which fungus (but why not just test the granulomas themselves?), but the test is negative suggesting that there is no fungal infection. As the biopsy is being performed, Lucy develops double vision which is ultimately diagnosed as uveitis.

The differential now includes autoimmune disease such as Lupus, Kawasaki’s Disease, and JRA (Juvenile Rheumatoid Arthritis). Lucy is started on steroids to treat the presumptive JRA. While Foreman is talking to the father, she develops a left-sided facial droop and is diagnosed with a middle cerebral artery stroke. She is started on tPA (a “clot busting” drug used to break up the clot that caused an acute stroke or heart attack. Not approved for use in children, but I’m not sure what else one could try). She is noted to be polycythemic (her blood is too thick because there are too many red blood cells), and is started on hydroxyurea (a drug used to treat polycythemia vera — one particular type of polycythemia that the team doesn’t even know whether Lucy has) as well as therapeutic phlebotomy (blood letting).

When Cameron and Chase are searching the house looking for carbon monoxide (a cause of polycythemia), they come across a bloody t-shirt hidden in a vent in Lucy’s room. They are concerned Lucy might be the victim of child abuse. A vaginal exam reveals shallow cuts around the vagina, but no evidence of penetration. Ultimately the team discovers that the blood is menstrual blood, and Lucy had started her menstrual cycle…at age six (the shallow cuts are from her attempt to shave her pubic hair off with Dad’s razor). The team now considers a tumor a likely cause, especially a pituitary adenoma (a type of hormone secreting brain tumor) or an ovarian tumor. Cameron suspects that Lucy has been exposed to excess estrogen from the environment.

An MRI shows no tumors in the brain, but it does show what appears to be a tumor on her ovary — however it ends up just being a cyst. While the cyst is being biopsied, Lucy slips into ventricular tachycardia, but is successfully revived (just once on House, I’d like to see an episode where a patient does not have v-tach during surgery. I promise you, codes during surgery are very very rare. At least Foreman used correct pediatric setting for the defibrillators.)

Meanwhile, her eight-year old brother Jasper had been hitting on Cameron. When he goes so far as to attack Chase in jealousy, House realizes that Jasper is also going through precocious puberty. His testosterone is measured and is sky high.

Lucy now complains of abdominal pain. Scanning shows new cysts in her pancreas, kidneys, and lungs. Cameron is now convinced that the others were right and that it is a pituitary tumor (just one that won’t show up on an MRI). She wants to remove Lucy’s pituitary and even talks the dad into agreeing to the procedure. House is not convinced about the tumor; he now agrees with Cameron’s original assertion that there has been an environmental hormone exposure. He goes to the daycare center the kids attends and talks to their teacher. He discovers that she has been having a relationship with their father. She has also had a recent lip wax to remove excess facial hair. House puts all the clues together and deduces that the father has been using a non-prescription testosterone cream. Even though he has been careful about applying it only at the gym, the excess hormone has seeped through his pores, exposing his children to high levels of testosterone (and the day care teacher too), causing their symptoms.

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Medically, this episode was very scatter shot, with symptoms not matching up with the diagnoses. I’ll agree that excess testosterone can cause polycythemia, which can lead to a stroke. However, I can find no connection between testosterone and restrictive pericarditis, or testosterone and uveitis. Nor do I understand why high testosterone would cause randomly appearing cysts. More importantly, I cannot understand why testosterone, a hormone that leads to male sexual characteristics (e.g. the teacher’s hairy lips) would cause early menstruation. If anything, high levels of exogenous sex hormones would shut down Lucy’s pituitary/ovary axis by feedback inhibition. Frankly, I’m also skeptical of the excreted-though-the-pores scenario, but I can’t find any good studies. Testosterone is a complex chemical and not excreted in any meaningful amounts through pores (my sources indicate excretion is 90% urine, 10% feces).

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The medical mystery was fair — and I liked the red herring of the mother’s brain cancer — so I’ll give it a B. The ultimate solution, while clever, simply did not fit the majority of Lucy’s symptoms. I’ll give it partial credit, but only a D+. The medicine had too may unexplained symptoms and the confusion over male/female hormones dropped the score to a F (if anyone can show why I’m wrong, I’ll certainly re-evaluate). The soap opera aspect was better than last week’s (thanks to the Cuddy/Wilson play angle) and earns a B+.

The previous House review
A list of all prior House reviews

Tags: television medicine house precocious puberty restrictive pericariditis stroke uveitis

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.

Do you need instant relief from the traumas of modern day society? How about the chance to get down to the real knitty gritty with a psychedelic experience? Take the Teeny Quiz and find out! Click on the image at the right for the full-size quiz As the story goes, back in 1967, DC Comics got the bright idea to publish a comic-book-sized pop music magazine titled Teen Beat. For the second issue, the name was changed to Teen Beam (allegedly due to the threat of a lawsuit from the publishers of Tiger Beat). This house ad from Superman’s Girl Friend Lois Lane #80 (and found in other DC comics from January 1968) advertises Teen Beam #2, the only issue of that “12¢ now mag in full groovy color” ever released. Tags: comics music teen beam lois lane

Instead of the normal writing team of Karl and Barbara Kesel, this issue credits just Barbara as the writer, but there is no discernible change is style. The art is handled by the reliable team of Greg Guler and Al Vey. It’s a fairly dark storyline this issue with the forces behind Don’s “resurrection” finally revealed¹.

Hawk returns to his apartment to find another message from his deceased brother Don. Hank is informed that there will soon be a fatal car crash at a particular corner. He is to crush the sapphire he stole from the Smithsonian and sprinkle it over the victim of the car crash. This will bring Don back to life. Hank is concerned about the morality of the plan, but Don reminds him that the victim will already be dead, so no harm done. Reluctantly, Hawk agrees.

Sure enough, just like Don said, there is a bad car crash. Hank sprints up to the car to discover that it was no ordinary car, but a senator’s limousine. He wrenches open the back door and finds that the victim was Senator Tim O’Neil, a popular and powerful politician. Hank grabs the body and changes to Hawk, sprinting off down the street. He runs to an abandoned warehouse, and once inside, he sprinkles the crushed gem over the dead body. As predicted, the Senator’s body returns to life, only it’s not Don, but someone else – someone malevolent. Just as Hawk has realized that he’s been played for a sucker, the police break down the warehouse door and charge in. The Senator points at Hawk and accuses him of attempted murder.

Unbeknownst to Hawk (but beknownst² to the reader), there’s a lot more going than he realizes. Behind the scenes, Barter has been playing a major role in the conspiracy against Hawk. Remember Barter? He’s the dealer of “everything” who swore revenge against Hawk back in issue #14 after he reneged on a deal³. Barter has been arranging the plan with an as-yet-unnamed partner. He caused the car crash providing the “body” for the plan. He also had one of his agents among the onlookers at the car crash inciting the crowd against Hawk. He has them believing that it was Hawk who caused the accident. By the time the police arrive, the crowd is convinced that Hawk caused the crash and then kidnapped the Senator. When the “Senator” himself confirms this, Hawk has suddenly become Public Enemy #1. He escape through the wall of the warehouse with the police and Dove close behind.

Everything comes to a head in Hawk & Dove #28, the final issue of the series. The identity of the second conspirator is revealed, and the Hank-Dawn-Ren-Sal triangle (quadrangle?) is finally solved for good⁴. And the Titans Hunt and War of the Gods crossovers are thrown in for good measure.

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Notes:
^1. Mostly. The remainder is revealed next issue
^2. Is that even a word? If not, it should be.
^3. Sure, Hawk also beat him senseless and tied him up, but it was breaking the deal that really hurt.
^4. At least until Armageddon 2001, when it all goes to Hell, and JSA, when it gets even more confusing.

All Previous Hawk and Dove Reviews

Tags: comics hawk dove barter

Apparently Nate’s nose bleeds so much that he is completely nonchalant about it when talking with Rahne (Wolfsbane of X-Factor). I also haven’t ruled out the possibility that’s it’s not a psychic headache, as much as a reaction to Rhane’s outlandish brogue. Anyway, that’s some strangely viscous blood. This scene is from X-Man #12 (words by John Ostrander, art by Steve Skroce), when Nate has just been feeling quite Old Testament and parted the sea so that he and Rahne can get a good look at an old shipwreck. All previous Psychic Nosebleed Zen posts Tags: comics medicine nosebleed nate grey john ostrander

Another look at Maxwell Lord, this time from his penultimate scene in Wonder Woman #219. He may be gloating now, but karma will catch up with him soon. Very soon. Like in about 20 pages.

Wonder Woman #219 was one of the key books leading up to Infinite Crisis. Script is by Greg Rucks and I believe the art is by Ron Randall on this page.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed maxwell lord wonder woman

Don’t think of this as a day late — think of it as 17 years and a day late!
In case you missed it, yesterday was Earth Day, so here’s an Earth Day PSA from Flash #39.

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

This is rather lame for a full page PSA. You think that DC could at least tell the reader a little about what Earth Day means, or how Earth Day should be celebrated, or at least give a little information. Instead, they give a picture of the Earth and Superman (and it looks like John Byrne art) and give you an address to write for more information. This was pre-internet, so you’d have to use dead trees to write off for more information, and get dead trees in return — which kind of defeats the whole purpose, doesn’t it?

Tags: comics psa earth day

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