Polite Dissent

Iron Man #28 “Haunted”
Daniel and Charles Knauf, writers
Roberto de la Torre, penciler

I’ve picked on the Knaufs more than a few times during their run on Iron Man, but this time, they have it right — or at least mostly right

Tony Stark: Target pencil-laser to bisect calcaneus diagonally from tendo calcaneus to tibialis posterior tendon.

In order to remove the device around his ankle that’s stopping him from accessing his Extremis suit, Tony Stark has decided to cut off his heel.
The calcaneus is the large bone that makes up the heel.
The tendo calcaneus is an older term for the Calcaneal Tendon, better known as the Achilles Tendon.
The tibialis posterior tendon comes off the (wait for it) tibialis posterior muscle — one of the deep muscles of the lower leg. It wraps around the calcaneus on the inside of the ankle before inserting on the navicular bone (wih smaller insertions on some of the other foot bones).

Based on the art, it looks like Tony is cutting the calcaneus from the point where the Achilles Tendon first meets the calcaneus to the point where the posterior tibial tendon inserts on the navicular, which more or less matches what he is saying — though if I were cutting part of my anatomy with a laser I’d be very specific about where to cut so mistakes weren’t made.

It seems that the recent all-Spanish issue of Blue Beetle has proved so popular that DC Comics has decided to take the idea and run with it, expanding the comic into even more languages.

Here, as a Polite Dissent exclusive, is the latest version of Blue Beetle #26 — the all Pig Latin issue!

Click on the image above for the full preview page.

A double psychic nosebleed in Ultimate X-Men #93. Of course, most of the issue describes a fight between the two strongest mutant minds on the planet, so you knew that noses were going to bleed somewhere in this issue.

The image on the left is our first combatant, Apocalypse, while the image on the right is our second fighter, Charles Xavier.

Ultimate X-Men #92 is by Rober Kirkman and Salvador Larroca.

All previous Psychic Nosebleed Zen posts

A second episode of House in a row that felt shallow and superficial. There were two potentially great concepts in this episode: House kidnapping a soap opera star, and the hospital’s accreditation inspection, but both were essentially squandered in this disjointed episode.

House is convinced that Evan Greer, the star of his favorite soap opera, has brain cancer. House has noticed that Evan’s line readings are slower and he is pausing more which leads him to believe that Evan has bad peripheral vision from an occipital lobe brain tumor. So House does what any other self-respecting doctor would do: he kidnaps his patient by pretending to be a chauffeur.

Arriving at the hospital, House convinces Evan to let him run one test on him — a test of his visual fields to look for blind spots. House informs him that the test showed upper right quadrant blind spot and that he’ll need an MRI. Foreman picks this moment to show up and point out that House is lying and the test is normal. Frustrated, Greer leaves the room; House pauses a minute to grab something from Pyxis, then follows Greer onto the elevator. While having a conversation with Wilson, House reaches over and injects Greer with a sedative, knocking him out, so that the MRI can be performed. Surprisingly (to House at least), the MRI is normal and shows no tumor. Greer wakes up at the end of the test and is furious. He storms off to find Cuddy to complain when his right foot suddenly goes completely numb and he finds himself unable to walk. He is admitted to the hospital — officially, this time.

At this point the differential diagnosis consists of vitamin deficiency or a toxic exposure. Cameron suggests that Greer may have injured a nerve in his foot when he fell after House knocked him out and suggests an EMG. House order Kutner to pretend to perform the EMG (Electromyogram — a test that checks the conductivity of muscles and nerves), but Kutner decides to go ahead and runs the test for real. Meanwhile, House has the rest of the team watching old episodes of the soap opera for subtle diagnostic clues. Taub and Foreman think that there might be some slight neurological symptoms and suggest myxedema or demyelination. The EMG is negative, and Kutner adds atherosclerosis (hardening of the arteries) to the possible diagnoses.

House checks out Greer’s dressing room and talks to his female costar. He learns that even though Greer’s character likes his gin and tonics, Greer himself does not drink — in fact, he’s kind of a health nut. Housee also learns enough to suspect that Greer may be suffering from erectile dysfunction. House suggests that Greer has B6 toxicity and the resultant autonomic dysregulation from eating too many sunflower seeds. The team decides to test whether the impotence is physical or psychological by testing heart rate, blood pressure, and tumescence after giving Greer some pornography. He is able to have an erection, but he also develops a dangerously rapid heart rate that requires defibrillation.

The differential now includes sepsis, paraneoplastic syndrome, and Graves Disease (an autoimmune disease which leads to too much thyroid hormone), with the latter being the most likely. House wants to “nuke” Greer’s thyroid to stop the Graves, but the rest of the team actually wants to test for Graves first by performing a radioactive iodine uptake test. The test shows that his thyroid is normal, but that he is starting to develop kidney failure. Autoimmune diseases are now added to the differential. A short time later, House is talking to Greer and he finds him repeating old lines from the show and discovers that he actually believes himself to be his soap opera character. He is also running an extremely high temperature and has slipped into delirium.

The team now suspects that Greer is septic, in other words he has an overwhelming infection. They are just not sure what infection it is. Pneumococcus, Tetanus, Lyme Disease are suggested, as are fungal infections. House also mentions rat bite fever and listeria. Greer is started on broad spectrum antibiotics, but is not improving.

While helping Wilson shop for a bed, House had an epiphany. Greer is not septic, instead he a rare type of allergic reaction known as allergic vasculitis and he is allergic to the chrysanthemums in his dressing room. House wants to start him on high dose steroids, but Foreman points out that high dose steroids would kill him if her were septic. Cuddy eventually steps in and allows House to start the steroids, but runs some confirmatory allergy tests. After these tests are complete she informs House of the results — negative: Greer has no floral allergies. They return to the patient’s room ready to restart the antibiotics only to find that Greer has greatly improved; the steroids worked. Later, House realized that Greer is allergic to quinine, the chemical in the tonic water his soap opera character drinks.

I can understand why House thought Greer had a brain tumor — that makes at least a little sense (though I think a frontal lobe tumor would fit the suspected symptoms better than an occipital lobe tumor). The rest of the medicine in tonight’s episode barely made sense, and the team basically haphazardly stumbled from one unsupported diagnosis to another to another. Here’s what caught my eye tonight:

The final solution of allergic vasculitis doesn’t really fit the case well. The symptoms Greer had are rarely, if ever, seen in allergic vasculitis and he was missing the common symptoms such as the distinctive rash. I would also like to point out that the team dismissed an autoimmune cause because he had a fever, but no one batted an eye at a fever being caused by allergic vasculitis — another type of overly aggressive immune response (in truth, both autoimmune diseases and allergic vasculitis can cause fever. Just give me a little consistency in logic, please). And why was House convinced that chrysanthemums were the cause — where did that come from? On a daily basis, people are exposed to hundreds if not thousands of allergens, it could have been any of them.

B6 toxicity doesn’t match his symptoms either. It can cause nerve toxicity, but not like Greer had. Sunflower seeds do contain a large amount of B6, but he would have to eat a hell of a lot of them to develop toxicity. An ounce of sunflower seeds contains 0.23mg B6. Toxic doses start around 500mg/day, or over 2000 ounces of seeds per day.

Giving someone porn and then watching them to see if they get an erection is not the way to differentiate physical from psychological causes. That situation is enough to cause psychological impotence in anyone.

Graves disease is an autoimmune disease. An ANA is not the definitive test for autoimmune — there really isn’t any one single test. ESR (”sed rate”) is probably one of the most common, but if the team had run that, they would have figured out the vasculitis much sooner.

100mg of IV methylprednisolone (”Solu-Medrol”) is not that uncommon a dose. When high doses are needed, it’s generally an emergency (acute asthma attack, for instance) and having to wait for Cuddy to sign off on it is a delay in treatment and a lawsuit waiting to happen. And you’d think the pharmacist would learn to lock his door by now.

Ampicillin is not an appropriate drug for sepsis, particularly sepsis of an unknown cause.

Accreditation inspections involve a team of inspectors, not just one, and are not usually carried out on an annual basis unless there is a known problem.

I give the medical mystery a B+ because it was a clever idea: House deducing something is wrong just by watching an actor on television. Unfortunately, neither the final solution nor the medicine leading up to it were all that good; I give them both a C-. The soap opera was fairly average. There were a couple brief glimmers of cleverness, but nothing really memorable, so it deserves no more than a C.

The previous House review
A list of all prior House reviews

from The Brave and the Bold #59 (April/May 1965)

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

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

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

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

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

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

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

A classic style psychic nosebleed, courtesy of Atom Eve putting the whammy on two scientists/government agents. You know how hard it is to get bloodstains out of Kirby tech?

Invincible Presents Atom Eve #2 is by Benito Cereno and Nate Bellegarde.

All previous Psychic Nosebleed Zen posts

Continuing my look at Mike Carey’s and Scot Eaton’s X-Men - Legacy #209. (Part one can be found here.)

In this scene, Frenzy confronts Magneto and the recently revived Xavier. She plans on killing Xavier, but Magneto has other ideas — not to mention a conveniently near surgical laser.

Click here to read the full scene

Xavier: He’s thinking about your eyes
Frenzy: What?
Xavier: And — your optic nerve. Because for your eyes to see, the channel has to stay open all the way into your brain.

At first read, it sounds like Xavier is implying there is “channel” into the brain that is only open when a person is actively using their eyes, or maybe he’s suggesting that the optic nerve will transmit the laser like fiberoptic cables transmit light. Neither is correct.

However, after repeated reading, I think I know what Xavier’s trying to say in his own horribly wordy way. I suspect that he’s merely suggesting that Magneto will use the laser to essentially lobotomize Frantic by shooting the beam through the optic canal into the brain. The optic canal carries the optic nerve and ophthalmic artery from the eye socket to the brain pan. This will damage the optic nerve (rendering her blind — at least in one eye) and cause brain damage. But it sure is an awkward way to phrase it.

It would be a tricky shot too, as the optic canal is located off to the side of the eye socket and proceeds inward at an angle; it’s not the straight shot the art suggests. That’s also a pretty good range for a surgical laser (and note the significant change in the drawing of the laser between the panels. Initially, it’s hand held — like a thick pencil — but by the last panel it suddenly is drawn like a laser pistol).

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

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

Challenge scores from the past two weeks are in the post immediately beneath this one (or click here). This week’s scores will be posted later.

scene from Punisher: Force of Nature (By Swierczynski and Lacombe)

The “Coast Guard Cocktail” is a sea-sickness remedy of legendary fame. Like many legends, it’s not entirely clear how much is truth, and how much is myth. I’ve seen many references to the cocktail, but I’ve never met anyone who’s actually taken it. Was it actually dispensed, or at least condoned, by the Coast Guard, or is the name supposed to be a slur against them (as in “they need sea-sickness pills”)?

The medicine behind the cocktail is sound, if a bit excessive. Two separate pills make up the treatment. The first is promethazine, better known in the U.S. by the brand name Phenergan. It is an excellent medicine at quelling nausea and is indicated for prevention of motion sickness — unfortunately, it is also extremely sedating. The second pill in the cocktail, ephedrine, a stimulant, is taken to counteract the sedation caused by the Phenergan. It is the same medication that until recently was the active ingredient in many energy drinks and diet pills. It can cause nervousness and irritability, and at high doses there are concerns about elevated blood pressure and abnormal heart rhythms.

I’m always leery when a pill is prescribed to the combat side effects caused by another medication. That can easily lead to drug after drug prescribed, and before you know it, you’re on twelve pills for a simple problem. Plus, even with the ephedrine, I suspect the Phenergan is still going to be sedating. That may be all right for passengers who can sleep the day away, but I wouldn’t want any professional on it when they’re supposed to be on duty (or – like the Punisher — supposed to be shooting people).

Phenergan is available by prescription only (at least in the U.S.), and the legality of ephedrine varies by locale. The “over-the–counter stuff” the Punisher refers to is likely either Dramamine (dimenhydrinate) or Bonine (meclizine). Both are good at motion-sickness, though not quite as good as Phenergan. Both are also sedating, but again, not as sedating as Phenergan (particularly meclizine, which is less sedating than Dramamine).

Extra credit to writer Duane Swierczynski for having himself listed as the doctor on the Punisher’s prescription bottles.

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

In this scene from the long-gone-and-best-forgotten Titans series (issue #41 to be precise), Lilith uses her psychic abilities to peer into the mind of an “autistic” child and exorcise the psychic entity that has taken root there. I use the word “autistic” in quotes because while the child was labeled autistic in the comics, she never met any of the criteria for autism; it was just a convenient and inappropriately used label. Titans #41 was by Jay Faerber and Peter Grau. A new Titans series has started, but so far is no better than the last. Lilith remains deceased. All previous Psychic Nosebleed Zen posts Tags: comics medicine nosebleed lilith titans

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

I’ve discussed commotio cordis a couple of times, most recently in relation to Batman #672-674.

Commotio cordis is a rare and frequently fatal condition. It occurs when an individual receives a direct blow (blunt trauma) to the chest at precisely the right time in the cardiac cycle to stop the heart and cause a cardiac arrest. Children are more susceptible to the condition than adults.

Sports injuries are a common cause of commotio cordis, particularly thrown baseballs and softballs. Other causes include physical blows to the chest during a fight, steering wheel impact in motor vehicle accidents, and even the blunt force of bullets stopped by body armor.

The best, and really only, treatment for commotio cordis is immediate cardiopulmonay resuscitation, usually requiring defibrillation and cardiac medications.

Wikipedia has a good write up on commotio cordis

Commotio cordis has been in the news recently because of a lawsuit filed by a New Jersey family against several groups: a maker of aluminum baseball bats, the Sports Authority*, and Little League Baseball**. It’s an unfortunate story on many levels: Twelve year-old Steven was pitching in a baseball game when a line drive hit by the batter caught him square in the chest, causing his heart to stop beating. He was eventually revived, but remained in a coma for several weeks, and now has severe brain damage.

It’s a sad story and an unfortunate case, but personally I think it’s a stretch to treat it as cause for a lawsuit. I know that we Americans always like to blame someone when something goes wrong, but there are times that it’s not appropriate. This is one of those times.
There is no hard evidence that aluminum bats are any more dangerous than wooden ones, particularly in cases of commutio cordis (remember, it’s an issue of timing, not an issue of force).
There is an inherent risk of injury in playing any sport. Proper safety precautions will minimize this, but never eliminate it entirely. I am well aware of this whenever I go for a bike ride on the back country roads near me. Who knows what drunk-driving redneck may be out there weaving across the center line?***
And suing Little League because they endorsed the bat? Give me a break.

*The store where the bat was purchased
**Not because it was a Little League game — it was not — but because they “endorsed” the bat as safe.
***It would be like me, after getting hit by a reckless driver, suing Ford because the person was driving a Mustang and those can go faster than other cars. It may be true (arguably), but it really has nothing to do with the accident and injury.

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

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

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

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

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

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

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

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

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

Tags: comics nascar nascar heroes daytona

Batman dukes it out with Pete “Nails” Logan, a mobster wanted for murder.

scene from Batman #9 (February/March 1942)

I’m impressed that the doctor was able to deduce that Nails had been shot without seeing a bullet wound. And with just a stethoscope. I guess medicine was more advanced in 1942 than I thought.

(Make your own Tony Stark/shrapnel analogy here.)

Booster Gold #9 by Geoff Johns, Jeff Katz, and Dan Jurgens.
Frequent contender Maxwell Lord is back in this scene from Booster Gold #9 and telepathically dueling with J’onn J’onzz, the Martian Manhunter. Both have had their share of psychic nosebleeds, so there’s no way this duel wasn’t going to end up a two hanky battle.

This week’s moment of psychic nosebleed zen was first pointed out by Mike Sterling, lord of the Progressive Ruin.

All previous Psychic Nosebleed Zen posts

The Brave and the Bold #48 (June/July 1963)

One of my favorite days of the year: The Indianapolis 500 in the afternoon, and then the Coca-Cola 600 in the evening (plus barbecue, lots and lots of barbecue). I hope everyone enjoys their holiday weekend,

Flash #240 “Fast Money, part three: Broken News”
Tom Peyer, writer
Freddie Williams II, penciler

In the recent Flash #240, Flash rushes across town to battle the villainous gorilla Grodd (and for those of you not up on your Flash lore, Grodd is an super-intelligent gorilla with mind control powers).

Flash (monologue): Please Please Please. Let me see Grodd first — because if his force of mind kicked in — well, I’m faster than light but a helluva lot slower than thought. If he saw me first, I’m dead.

Just like the Mirror Master, Flash seems very confused by the difference between the speed of thought and the speed of light.

The speed of light is roughly 670 million miles per hour. Thought is a process involving neurons in the brain, and is thus subject to the speed at which impulses can travel along nerves. Depending on which nerves are involved, transmission speed can vary; regardless, nerve conduction tops out at around 250 miles per hour — six orders of magnitude slower than the speed of light (plus Flash is faster than the speed of light).

Even if you want to get metaphysical and claim that the “speed of thought” refers to something abstract which does not obey the rules of physics, remember that Flash is concerned that Grodd may see him first. Eyesight relies on light reaching the eyes and is thus dependent on the speed of light. Since Flash is moving faster than the speed of light, he should reach Grodd well before he can be seen.

Topic suggested by Andy D.

When last we saw Batman (in this blog, at least), he was smacking around a criminal lowlife who just happened to have a retained bullet that was too near his heart, and Batman inadvertently killed him with a punch.

Now the tables have turned and Batman’s in the same situation.

As The Brave and the Bold #100 opens, Batman is shot by a sniper. He survives, but the bullet has lodged inside his chest, right next to the heart. It’s one of those Tony Stark wounds that exist only in comic books: the bullet will kill him in less than a week, but it is too dangerous for any ordinary surgeon to remove. There is one doctor in the entire world who can save him, but that doctor is in Zurich and it will take him several days to get to Gotham City. In the meantime, Batman is bandaged up, placed in a wheelchair, and told not to move because even the slightest movement could dislodge the bullet and kill him!

A near fatal injury and confinement in a wheelchair might stop an ordinary super-hero, but not Batman. He is determined to capture the drug lord who had him shot. Using Green Arrow, Green Lantern, and Black Canary as his street operatives, Batman is able to foil the all of the drug lord’s schemes to import heroin into the country. Until the final confrontation that is, which takes place in the operating room with the Batman under anesthesia and the drug lord masquerading as the surgeon. You’ll have to figure out for yourself how that one ended (but as a hint, The Brave and the Bold continues for another 100 issues).

Notes:
For all you ballistics experts, the bullet is identified as a .30-06.
The doctor is saying that the bullet penetrated the pericardium — a fibrous membrane that surrounds the heart — and stopped just before it hit the left auricle, which is part of the left ventricle atrium.
Interesting x-ray machine that shows a perfect image of the heart and diaphragm, but no other organs (like the lungs or bones), and only the silhouette of the bullet.
Batman’s bandages are placed over his costume.
Much like the young Tony Stark, every four of five panels Batman makes a point to mention how much his chest his hurting.
Black Canary doesn’t come off very well in this issue. In one particularly memorable scene, she is unable to hear the Batman’s comm signal because she is in a beauty shop getting her hair done after it got ruined in the rain (which is ridiculous because her blond hair is a wig). Come to think of it, Canary didn’t come off too well in any of her appearances in The Brave and the Bold.
The Brave and the Bold #100 is by Bob Haney and Jim Aparo.

A quick Reminder that Alan David Doane is having a Spring Cleaning Comic Sale over at his blog. There are quite a few good deals available.