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

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

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 The instruments are then withdrawn and dressings applied to the incisions.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

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

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

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

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

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

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

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

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

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

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

The Story: Ben Stockton, a ten year old musical prodigy, is kidnapped by a mysterious woman after his father is put in a trance by red and green flashing lights. After Agent Dunham picks up the case, Broyles tells her that there have been four previous kidnappings, all experts in one field or another, all by the same mysterious woman, and all four of the victims ended up insane. Dr. Bishop recalls hearing of the red and green lights before, and eventually remembers that it was from another inmate at the asylum where he used to reside. It seems there was a fifth kidnapping that even the FBI was unaware of, and the victim ended up admitted to an asylum for the criminally insane. Walter recalls that the patient was fixated with an equation he couldn’t solve. Peter realizes that when that equation is expressed in musical notation, it is the same mysterious composition Ben had recently become obsessed with.

Agent Dunham figures the best approach is to interview the patient, but the director of the asylum won’t let the patient be interviewed by anyone except Walter Bishop. Reluctantly, Walter agrees to return to the asylum to conduct the interview, but while there he is sedated and held by the guards and director, who then informs Agent Dunham and Peter Bishop that he is retaining custody of Walter for his own safety. The next day, Dunham is able to procure a court order to release Walter, but it is clear the asylum director is up to something. Walter was unable to get much from the other patient except for some mumblings about a red castle. This is enough for Dunham to locate the villain’s lair and rescue Ben, but the mysterious woman is able to escape (though she ultimately meets her demise at the hands of a turncoat accomplice).

1. Nothing To See Here
The hypnotism scenes are pure science fiction, but I have no significant medical or scientific complaints other than that. A first for the show.
Does the red/green flashing cause a hypnogagic trance, or make the patient susceptible to suggestion? The show suggested both.
Agent Dunham should have stormed the castle with a team of red/green color blind agents. That would have caught Ostler unprepared.

2. Music
Walter Bishop transcribed the equation into “9 bars” of music, but it sure seemed like Peter played for longer than that.

3. Psychiatrists
This episode is another good example of Scott’s Third Law of Comic Book Physicians — when a character is introduced as “psychiatrist”, it is shorthand for “they are up to no good.”

Overall, Sable Hope remains in first with 30 points. JockM is second with 28 and Ash is third with 27. Chris jumps up to fourth with 24. and The Erskine holds relatively steady in fifth with 20 points.

Full scores are available here.

Sophia is a 16 year old emancipated minor working as a factory foreman. She sought emancipation after both of her parents were killed. While talking with a floor worker, she begins to have chest pain and shortness of breath, and then collapses, red frothy sputum flowing from her mouth.

She is admitted to the hospital for evaluation of her pulmonary edema. The initial differential diagnosis consists of parasite infection, gastrointestinal problem, pregnancy, or damage to the heart from drug use. House has Kutner perform an echocardiogram while Taub and Thirteen search Sophia’s apartment. The echo shows no structural heart disease, but the apartment search shows that she likes to build her own furniture, but it also turns up a bong. When confronted with this, Sophia claims that it is her ex’s bong, and it’s the reason that he’s an ex.

The team now considers that she may have intermittent tachycardia (occasional episodes of an abnormally fast heartbeat) due to drugs, though Kutner favors a diagnosis of vasculitis. He wants to giver Sophia steroids, but House turns him down, stating that a steroid could make an arrhythmia worse. House wants to start her on beta-blockers (a drug that lowers the heart rate) to control the suspected arrhythmia. Kutner decides to go ahead with his original plan and gives her steroids instead. A short time later, Sophia is violently yelling at the staff and having paranoid delusions. She is given Haldol (haloperidol — a potent antipsychotic) to control her outbursts. Kutner reports that labs show that her psychotic break is not due to any metabolic problem, and it was too soon to be related to the steroids.

Given the symptoms of lung problems and delirium, Foreman suggests Prinzmetal’s angina (heart pain caused by spasms of the coronary arteries) — only he suggests it involves arteries in her brain, not the heart. House thinks the idea shows promise, so has the team place her on ergonavine )a drug which can trigger blood vessel spasms) and check an fMRI (functional MRI – an MRI that looks at blood flow). Medically, this part makes little — if any — sense, but is really just used to set up the subsequent revelation. The fMRI shows no arterial spasms, but it suggests that she is lying when she talks about her dead parents. Kutner confronts Sophia and she admits that she lied about the death of her parents, and the truth is that she ran away from home because her father raped her.

The team now adds sexually transmitted disease (especially gonococcal endocarditis) and stress to her differential. House feels it is the latter and suggests that Sophia be put on diazepam (Valium) to help with the stress. As Thirteen is about to give her the medication, Foreman notes that she has reddish-brown urine which wouldn’t be caused by stress. A microscopic examination of the urine reveals “shredded red blood cells.” E.coli, Shigella, and Legionnaires Disease are all suspected, but House believes her symptoms are caused by arsenic poisoning from building furniture with treated lumber. The tests apparently support this and she is started on chelation therapy for the arsenic. After the therapy, when Sophia is ready to be discharged (which is always dangerous in House’s world), she suffers a seizure. A repeat MRI shows brain lesions that were not there just a few days before. Infection (syphilis in particular) and cancer are suggested, but shot down. Then Thirteen suggests acute promyelocytic leukemia (APL). A brain biopsy confirms the diagnosis. Arsenic is used to treat APL, so removing it from her system allowed the leukemia to spread. Giving her more arsenic may slow down the cancer, but according to House, bone marrow transplant is needed for the cure. A family donor would be best, but Sophia refuses to let them tell her parents. Disregarding her wishes, Thirteen visits Sophia’s family only to discover that Sophia has been lying and using a stolen identity. Told of this, House believes her responses are too rational and confronts her. She admits that she ran away from home because she killed her younger brother. House convinces her to contact her parents, and in the end we witness a tearful family reunion.

Meanwhile, Foreman is treating his own patient: Jonah, a four year old boy with several days of unexplained lethargy, diarrhea, and bloody vomiting. The standard tests are all normal, so Foreman proceeds with a capsule endoscopy (a swallowed wireless camera to transmit pictures of the inside of the gastrointestinal tract). As he swallows the camera, Jonah starts giggling uncontrollably with no provocation.

Foreman asks Cameron and Chase for help, and they consider meningitis, thyroid, stomach cancer, and porphyria, but all tests are negative. As they are wondering whether they should involve House, Jonah has a cardiac arrest, but is successfully revived.

Foreman does finally go to House and ask for help, but House turns him down. Commiserating with Cameron and Chase he has his own Eureka! moment when he realizes that Jonah is suffering from iron toxicity from all the extra vitamins his brother had been feeding him to make him stronger.

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

Once again, you do not shock a flatline.

I mentioned this above, but “Prinzmetal in the brain” to be diagnosed with ergonovine and fMRI is nonsense — and dangerous if it worked. If it did cause a spasm, then they just caused a stroke (or at least a TIA) in sixteen year old. How were they planning on correcting that?

fMRI has been studied as a lie-detector – Mythbusters featured it in one of their episodes. It doesn’t work quite as neatly as it did on the show. For one thing, small movements — like talking — will throw it off. Also, while the limbic region of the brain may house “imagination,” it is also important in emotions and long term memories — so it lighting up while talking about dead parents would be expected.

From my reading on APL, it is treated primarily with specialized chemotherapy (including arsenic trioxide) and has a very good response rate. Bone marrow transplant is not considered unless there is a recurrence.

Valium is overkill for an anxiety disorder. That class of drug (benzodiazepines) is not a bad choice for acute anxiety, but there are better choices than Valium, particularly in a sixteen year old.

I don’t know what procedure Wilson was going to perform, but it’s best to put on your surgical mask and eyewear before scrubbing.

Interesting how they immediately ruled out cancer as a cause of the brain lesions…and then ended up diagnosing APL, a type of cancer.

Neither medical mystery featured dramatic symptoms, but both were solid puzzles and earn a B+. The solutions were both logical and fit fairly well so deserve an A-. The medicine was better than the past several episodes but still had some large holes. Foreman’s case was handled better, but he was still stumbling around more than he should. Still, it was better than average (especially this season), so earns a strong B-. The soap opera aspects were minimal, though it was nice to see House interacting directly with the patient. I give this aspect another B-.

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Because she is in California dealing with an earthquake, Linda Danvers (a.k.a. Supergirl) has to cancel her date with movie aficionado Steve Gordon. Since Steve already bought the tickets, he decides to go with another girl — his younger sister. As they leave for the movie, his sister chides him to put on his seatbelt, but he declines, telling her that he “drives much better without it.” Those are dangerous words to speak when you’re in a PSA comic, and sure enough, Steve’s car is broadsided by a drunk driver. His little sister — who was wearing her seatbelt — only suffered minor injuries, but Steve took a bad blow to the head and has fallen into a coma.

Hearing the news, Linda rushes to the hospital and is dismayed when she realizes how badly Steve has been hurt. Doing what any normal person would do when she finds a loved one injured, she runs off to Superman’s Fortress of Solitude and uses some of the alien machinery there to access Steve’s mind in an attempt to bring him out of the coma.

First she finds herself in a scene that best described as a cross between the Road Warrior and the Iditarod. Steve is dreaming that he is a post-apocalyptic word and must drive his souped-up ski-car across the frozen tundra to get fuel for his town. Along the way, he needs to steer clear of the evil marauders who want to steal the fuel. Once again, he neglects to put on his seatbelt and is injured when the marauders slam a (futuristic) bulldozer into his car. In the real world, Steve’s coma worsens.

Now Steve imagines himself in an Indiana Jones scenario, but when his jeep is crushed by a Nazi truck — and he is once again not wearing his seatbelt — his medical condition takes another turn for the worse. His next dream is a classic noir setting, with Steve playing the part of a Sam Spade-like private eye. This time, he remembers to buckle his seatbelt, so is barely injured when the bald villain rams his car. Having learned his lesson, Steve wakes from his coma, none the worse for wear.

In the recent episode “Bloodlines”, Chloe uses her Braniac-ish abilities to access the Kryptonian crystal in an attempt to bring Clark back from the phantom zone. Messy Kleenex is the result.

And no, I can’t explain the all-white eyes that follow the nosebleed. That’s more than I can understand, let alone attempt to explain away.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine tv nosebleed smallville chloe phantom zone

It succeeds, but not only does Sue develop a psychic nosebleed, but she also falls into a coma (and the bloody nose miraculously disappears and reappears randomly over the next several panels).

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Tags: comics medicine nosebleed sue storm ultimatum

1. The Heart of the Matter
The emergency department doctors defibrillate Mr. Loeb when he is in asystole. Asystole is the medical term for flatline, and as we all know, you don’t shock a flatline.
Later, when Loeb is in ventricular fibrillation, one shock is tried (along with a dose of epinephrine a few minutes before). When that doesn’t work, the doctor decides to crack Loeb’s chest open and perform open heart massage. That procedure, though dramatic — and it did reveal the parasite — is rarely called for, and certainly not this early in the resuscitation (and not for ventricular fibrillation). The doctor took his own sweet time opening the chest too; it would have been nice if someone had done some chest compressions in the meantime.

2. There’s an Intestinal Parasite in His Chest?
It’s a huge jump from a simple parasite like Giardia to a giant-centipede-looking-plant-like parasite wrapped around the heart, but I guess that’s just Dr. Bishop’s way of thinking.

3. Relax, part 1
When the parasite starts squeezing harder, Peter injects Loeb with some cyclobenzaprine. Cyclobenzaprine is better known as Flexeril and is a skeletal muscle relaxant used for muscle spasms such as whiplash injuries. It doesn’t have an effect on the heart, so I’m assuming Peter was giving it to Loeb assuming it would be absorbed by the parasite and cause it to relax its grip on the heart. That’s quite a jump in logic: that a moderately strong (at best) mammalian muscle relaxant would affect a giant-centipede-looking-plant-like parasite.

4. Relax, Part 2
If I were Peter, I would definitely want a sedative. He recovered remarkably quickly, though.

5. Needle in the Heart
Sticking a syringe full of adrenalin blindly into the heart is a very bad idea because of the risk of injuring a cardiac artery, but I guess that’s just Dr. Bishop’s way of thinking. Or maybe he watched Pulp Fiction too many times at the asylum.

6. The Treatment
Mebendazole — known in the U.S. as Vermox — is an antiparasitic used to treat a variety of worm infestations. A hydrolase is an enzyme catalyst involved in the hydrolysis of a chemical bond. A thermophilic hydrolase is one that is active at high temperatures (such as those found in hot springs). Which seems to have no bearing on this case.

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

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

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

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

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

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

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

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

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

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

Why did Stewart need a jugular line?

Surgery is not first line for partial small bowel obstruction.

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

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

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

Last week’s House review
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That was enough to jump Sable Hope into first with a total of 27 points. Ash is bumped down to second, which he shares with JockM, with 26 points. Tied for fourth with 19 points are Dogma-Central, Estella, and The Erskine with 19 points.

Full scores are available here.