Polite Dissent

What seems at first to be a rather dry “history lecture” public service ad is actually a subtly pointed affirmation of the Freedom of Religion — a lesson that could bear repeating today.

The PSA presents a fairly abridged version of the Flushing Remonstrance, but then it is only a five panel PSA intended for 8 to 12 year old boys.
Wikipedia has a nice summation of the Remonstrance.
The full text of the Flushing Remonstrance

Since this PSA was published just the one time, and because it is more political than most, I wonder what was going on in the country in 1957 that prompted Schiff to write it?

Remonstrance is a fun word to say; flushing is too.

This PSA can be found in DC comics from February, 1958. The script was by Jack Schiff, with the art by Bob Brown.

More PSAs

Tags: comics psa religion cbob brown jack schiff

Another episode with the team being mostly on their own while House and Wilson do their own thing. Not a bad episode, overall.

Dr. Treiber is the hospital’s outspoken pathologist. In the middle of an autopsy, he suddenly decides to cut his own scalp open with a scalpel and complains of being cold. He is admitted to House’s service — but House quickly runs off on a buddy trip with Wilson, so the team is left to solve the case on their own. Before he leaves, House suggests Treiber may be suffering from the Cotard delusion (a mental disorder where people believe they are dead — therefore House thinks Treiber was trying to perform an autopsy on himself), but the history doesn’t fit well. Other suggestions include liver failure due to hepatitis C, toxin exposure in the morgue (in particular, dimethyl sulfate), or blood clots. An ultrasound is obtained but shows no clots, and an examination of the lab turns up no toxins, but does reveal that Dr. Treiber is a big fan of energy drinks, the team now suspects he is suffering from stimulant psychosis, due to all the caffeine he consumes.

Treiber soon develops abdominal pain and distention, meaning that something else besides stimulant psychosis is going on. Adams still suspects the caffeine is behind most of his symptoms, except the abdominal ones, which she believes are caused by a bowel obstruction. Other thoughts are diabetes or ulcerative colitis (a type of inflammatory bowel disease). Chase finally suspects an intussusception (a collapsing of the bowel in on itself) due to cancer. They obtain an x-ray which is normal, but Treiber wants Chase to go ahead and check the small bowel surgically for the intussusception. Chase agrees to perform the surgery, but no abnormalities are found.

The team now decides that Treiber must have intermittent porphyria (an inherited metabolic disorder) and starts him on hemin (a treatment for acute intermittent porphyria). Despite the treatment, Treiber continues to decline and develops bilateral pleural effusions (fluid build up around the lungs). At this point, Treiber finally learns that House is nowhere to be found, and Foreman is brought on to the case. He immediately suspects a cardiac cause (not unreasonable, given the pleural effusions) and obtains a cardiac MRI which shows an enlarged left ventricle. Foreman takes this to mean that Treiber has an infiltrative disease of the heart (an accumulation of some substance in the heart muscle that is not supposed to be there), probably sarcoidosis, and wants a heart biopsy. Chase suspects a prion disease (a neurological disease spread by infected proteins) and wants a brain biopsy; he also wants to start him on amphotericin to treat the suspected prion disease. Unfortunately, only one biopsy can be performed and Foreman elects to go with the heart biopsy. Chase heads down to the morgue to find the source of his suspected prion disease The cardiac biopsy shows fibrosis, not infiltration, meaning Foreman was wrong about sarcoid, but Chase was also wrong about a prion cause (because no prion disease causes fibrosis in the heart). Foreman now suspects a viral infection (like a viral cardiomyopathy) and obtains cultures and starts antivirals, but Chase remains in the morgue, convinced the answer is down there. Overnight, Treiber falls into a coma, making Foreman and the rest of the team rethink their diagnosis. They come to the morgue to talk to Chase who has reluctantly decided that Treiber is too fastidious to have caught a disease in the morgue – but then he realizes it is that fastidiousness – or more specifically, the antibacterial soap he repeatedly uses – that is the source of the problem. The repeated exposure to Triclosan (an antibacterial in soap), plus a high dose of caffeine from the energy drinks, caused Treiber’s thyroid to shut down and Treiber ended up in a myxedema coma (a severe form of hypothyroidism).

As always, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

While triclosan has been implicated in thyroid problems in bullfrogs and mice, human studies haven’t shown this effect (admittedly it was a limited study looking at triclosan in toothpaste).
Similarly, there haven’t been any studies linking high caffeine intake and hypothyroidism in humans (there is a study showing caffeine can interfere with absorption of thyroid medication, but that’s a different situation).

No one thought to check thyroid studies for an unexplained coma?

Studies have suggested that amphotericin may play a role in treating certain prion dieases, but it’s never been tested in humans.

They can’t perform both biopsies because of the amphotericin Chase wants to use because it might theoretically limit the possible prion disease the patient might have. Problem easily solved. Hold the ampho (it’s never been tested in humans for this anyway) then you can perform both biopsies.

That was simply a horrible code, but then, I think it was supposed to be one because it was supposed to be a bad doctor. Just for starters: only two people involved (not counting the patient), and one is just idly looking at IV bags. Shocking a flatline. No airway.

A small amount DMSO applied to the knees got converted to a toxic amount of dimethyl sulfate via several brief shocks to the chest?

Did no one think to ask Treiber why he was cutting his own scalp? The answer would likely have been revealing.
Despite the hypothyroidism/myxedema coma worsening, his mental status was fine in his hospital stay, despite it being his presenting complaint.

Here’s what I could get off of Chase’s whiteboard (or whiteboards) — hopefully someone got a better screenshot. In no particular order: Neimann-Pick disease, Japanese encephalitis, Creutzfeldt-Jakob disease, Q fever, impetigo (really?), typhoid, schistosomiasis, leptospirosis, gastroenteritis, neurofibromatosis, fatal familial insomnia, Tay-Sachs disease, cronobacter, syphilis, kuru, lyme, aortic aneurysm, shigelloisis, malaria, HIV, Klinefelter syndrome, yellow fever, cryptosporidiosis, dengue, German-Straussler-Scheinker syndrome, hypoglycemia.

The medical mystery was interesting, if less so once the patient was admitted. I give it a B+. The final solution made a modest amount of sense, if you accept the fact that the condition has never been seen in humans — that’s a few point off, in my book. I give it a C-. The medicine overall was thorough — on Chase’s end, at least — but missed some obvious possibilities, with myxedema coma topping that list, and easily testable. I give it a weak B. I thought the soap opera was good. The House/Wilson last fling was somewhat cliché, but Chase’s dilemma was well done. I give it an A-.

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As usual, in a soap opera heavy House episode, the medicine suffers — though the writers tries to distract us by adding an unlikable character into the mix.

Emily is a six year girl with a variant form of AT (ataxia telangiectasia, an inherited neurodegenerative disease) who is admitted to House’s team after she develops a nosebleed and breathing difficulties while riding on a merry-go-round. Her mother Elizabeth, a geneticist and expert on AT, also joins the team, whether they like it or not. The initial diagnostic possibilities include a worsening of the AT or head trauma, but her mother rules them both out. Park suggests Wegener’s granulomatosis and Elizabeth agrees that is a possibility, so an MRI is arranged (AT patients have a decreased ability to repair broken DNA strands, so ionizing radiation such as x-rays are avoided whenever possible as they run the risk of damaging DNA). The study shows no signs of Wegener’s, but while undergoing the MRI, Emily develops cold and blue hands and feet. Emily’s circulation is restored and the new differential diagnosis includes primary Raynaud’s disease or Raynaud’s secondary to lupus. Emily’s mother doesn’t like any of these and instead blames heavy metal poisoning from her estranged husband’s new apartment. While she goes to search his apartment, Chase and Adams decide to search hers. They find evidence that Elizabeth has been giving Emily Lex-2, an experimental antibiotic thought to help patients with AT. Unfortunately, the antibiotic has also been tied to renal failure, and now there’s concern that may be what is ailing Emily.

Luckily, an ultrasound of the kidneys is fine, but then Emily develops chest pain and starts to cough up blood. Pneumonia is discussed, as is a pulmonary embolus (a blood clot that blocks part of the lungs(. An MRI of the lungs shows no evidence of any clot. However, Chase notices scleral icterus – yellow eyes – a sign of jaundice and deduces that Emily is now in liver failure. Further studies show she has a blocked hepatic vein (large veins in the liver). Diagnostic possibilities include polycythemia vera (the blood is thickened with too many red blood cells), a connective tissue disease (another name for an autoimmune disease), or advanced Lyme disease. The team decides that the Lyme is the most likely cause — it had been held in check by the experimental antibiotic Elizabeth was giving her, but flared up when the antibiotic was stopped. A lumbar puncture is obtained to confirm the diagnosis, but Emily suffers a stroke after the procedure. The differential diagnosis now includes a fungal infection or a hematological malignancy (cancer of the blood forming cells, like leukemia or lyphoma). Then Chase realizes Emily has an atrial myxoma, a tumor of the heart. Little pieces of this tumor are breaking off and have been causing all her symptoms (Raynauds, obstructed hepatic vein, stroke, pulmonary blockage). Surgery removes the tumor, and Emily is back to normal (her normal, that is).

As always, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

The chest MRI may not have shown a clot, but it should still have shown a blockage, or at least evidence of a recent blockage, especially given the severe symptoms Emily was having.

A normal renal ultrasound does not rule out renal failure. Blood tests and urine tests tell you a lot more about what’s going on in the kidneys.

I can see a shedding right atrial tumor causing blockages in the pulmonary circulation, but how is it going to get all its little clotty pieces into the systemic circulation when they have to travel through the lungs capillary beds first, which act as a filter. An ASD or VSD wouldn’t explain it, because that would cause a left-to-right shunt.

Emily doesn’t seem to be showing many signs of AT – which of course they explained away as “Atypical AT” but she wasn’t showing any signs of the condition at all.

I know it was a pathos thing, but I would be leery of an oncologist with as poor a grasp of statistics as Wilson. Trade a 25% chance of death for a 33% chance of death? Sure! Sign me up!

I like how Wilson’s blood counts miraculously improved overnight. (And how House doesn’t seem to believe in isolation or neutropenic precautions).

Foreman should never have allowed Emily’s mother onto the case. Her objectivity was compromised — demonstrably so with the discovery she was dosing her daughter with Lex-2 — and her alleged expertise added nothing; seriously, she said “no” a lot and never contributed anything constructive.

The medical mystery was fairly interesting, though the AT aspect only contributed slightly to the medical aspect of the show (the “no x-ray” part; the AT did contribute majorly to the pathos aspect of the show). I give it a B+. The final solution was modestly succesful; it explained most of her symptoms — though a murmur probably should have been found on a good physical exam. I give it a C+. The medicine overall was average and earns a C (which still makes it better than most soap opera heavy episodes). The soap opera was good and heartbreaking. Both the Wilson/House aspect and the knows-she’s-dying-before-her-time little girl aspect. I give it an A.

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Another episode of Fringe, more Cortexiphan Kids (haven’t they all died by now?) and another change to the universal status quo

The Plot: Just as the Fringe Teams from both universes are meeting to discuss Walter’s thoughts about David Robert Jones’ master plan, a series of twenty-seven earthquakes occur across the world – both worlds, actually – at precisely the same time. Walter determines that Jones has somehow set off these earthquakes to adjust the underlying frequencies of both universes to bring them together in an attempt to recreate the Big Bang. The team suspects that he’s using amphilicite, but they quickly discover he’s actually using some of the children dosed with Cortexiphan by Walter years ago. They capture one of the Cortexiphan Kids (this sounds like a Saturday morning cartoon about crime solving kids sponsored by a pharmaceutical company) and learn that Jones has told them they are fighting a war against the other universe. With only an hour left before the next, and cataclysmic, series of earthquakes, the teams decide their only option is to shut down The Machine and separate the universes. Everyone says their goodbye to their counterpart – Peter stays in our universe and Lincoln stays in theirs – and the machine is stopped and the bridge between the two universes disappears.

1. The Easy Way Out
Early in the episode, Olivia says the only option is to destroy the bridge. Certainly there are plenty of other options. Just off the top of my head: kill Jones, kill or otherwise stop the Cortexiphan Kids, or do something to increase the integrity of the universe. Shutting down The Machine is the easiest option, but hardly the only one.

2. Needs A Band-Aid
Why, once the bridge is destroyed, would the other universe no longer be in danger from the Fringe events they suffered since Walter’s original breach? (Other than the writers trying to soften the blow of all but abandoning them.)

3. Geocentrism For The Win
Apparently Ptolemy was right, and the Earth is the center of the universe(s).

4. Common Sense
With all the issues with the Cortexiphan kids in the past, you’d think they’d be kept under surveillance. Especially since we’ve learned Jones has been playing with the stuff..

5. No Bridge, But Other Fords Remain
It’s not like Jones has ever needed the bridge to cross over (though it may have helped the Cortexiphan Kids in their part).

6. A Surefire Money Maker
If ever end up in the world of Fringe, I’m going to invest in empty warehouses.

7. Alternotes
No rainbows.

The re-separation of the Universes was well done, but the rest of the episode was just OK. The Fringe Doomsday Clock remains at 11:54.

This week’s Fringe cipher was: ALIVE.
A list of all previous Fringe reviews is available here.
Karl, as always, has more to add.

There’s so much wrong in this scene from Blackhawks #7, let’s just hit the highlights:

Problem #1: Electrical shocks don’t cause a heart attack, though they can can cause a cardiac arrest, which is a different thing entirely.

A heart attack is caused when one of the tiny blood vessels that supply the heart muscle with blood gets blocked and some of the heart dies. It’s what I call a “plumbing problem.” On the other hand, a cardiac arrest occurs when the heart stops beating because there is a problem with the heart rhythm. I refer to this as an “electrical problem.” Strong electrical shocks can override or damage the heart’s intrinsic rhythm, leading to a cardiac arrest. So a shock can affect the electrical system. Makes sense. It also makes sense that electrical shocks would not affect the plumbing.

Problem #2: You can’t shock a flatline back into rhythm, which is just what Lincoln is suggesting here. Despite what you see in such cinematic masterpieces as Flatliners, you can’t just turn the heart on and off like flipping a light switch. Once the electrical system is off, it’s completely off — and you need CPR and medication (and a tremendous amount of skill and luck) to get it started again, not another shock.

Just for the sake of argument, let’s say the bullets just shocked people into and out of ventricular fibrillate or another nasty heart rhythm instead of actually stopping the heart, would that work better? Not really. Once again, despite what you see on TV and in the movies, getting people out of v-fib (or other fatal arrythmias) and back into a normal rhythm is a dicey situation at best. It’s not guaranteed to work, and more often than not, it fails. Overall survivability for a cardiac arrest, even with treatment, is less than 7%. Not quite how I’d define “non-lethal.”

A nice hopefully-we’ll-never-see-this-again scene from an old time Little Angel comic.

House continues the decline started last episode.

Lue, an eight year old Hmong boy dreams of being choked and wakes up unable to breathe. He is taken to the ER in acute respiratory distress (but apparently gets better) and ends up admitted to House’s service for evaluation. House tells the team that SUNDS (sudden nocturnal unexpected death syndrome) is more commonly seen in Hmong immigrants, but cautions the team that SUNDS is the easy way out — he wants a real diagnosis. Initial thoughts include ventricular fibrillation due to catecholamine (chemicals like adrenalin) release from a nightmare, obstructive sleep apnea, lung damage from inhaled toxins, or an upper respiratory infection (URI). House starts Lue on antibiotics for pneumonia and has the team search his house for toxins. The search turns up no toxins, but they do find a ritually slaughtered pig in Lue’s bedroom – a Hmong exorcism rite carried out by his grandfather who believes that Lue is possessed by a demon.

About this time, Lue slips into ventricular tachycardia (v-tach, a potentially fatal arrhythmia), but is brought back to a normal heart rhythm by defibrillation and medication. Bearing in mind the new cardiac symptoms — plus the team has learned Lue’s father is in prison for murder — the differential diagnosis now includes PTSD (post traumatic stress disorder), a malignant arrhythmia (a term for a potentially fatal arrhythmia), or acute pericarditis (inflammation of the membranous sac surrounding the heart). House favors the latter and has the team check an echocardiogram, which is normal. Lue starts to complain of abdominal pain, so the team quickly ultrasounds his belly and finds no evidence of obstruction, but does find constipation. Chase now suspects Hashimoto’s thyroiditis so wants a thyroid biopsy. Lue refuses and shouts in Hmong, a language he doesn’t know, before suffering a seizure. These neurological symptoms have the team again changing their differential diagnosis, which now contains scleroderma and Rasmussen’s encephalitis (an inflammatory disease of the brain in children). An MRI is checked, but is normal. Lue again suffers a bad dream of someone choking him, but this time he awakens with bruises on his neck. The team now considers the diagnoses of a coagulopathy (easy bleeding because of problems clotting blood), anemia, vitamin C deficiency, or leukemia. House suggests liver failure, which the team takes to mean hepatic fibrosis. A liver biopsy is checked, but is negative.

Adams and Taub walk in to check on Lue, and find him levitating in bed, briefly, his grandfather beside him. They insist to House and the rest of the team that the levitation was real, but the others suggests muscle spasm, tetanus, or hypocalcemia (low blood calcium) as possibilities. House favors the hypocalcemia suggestion and wants the team to “pump up” Lue’s electrolytes and start him on a beta-blocker. Meanwhile, Lue’s mother is coming around to his grandfather’s way of thinking. She wants to perform another Hmong exorcism. Foreman convinces her to wait twenty-four hours, but when Lue becomes unresponsive, she and the grandfather proceed with the ceremony. While the ceremony proceeds in Lue’s room, the team goes through other possible diagnoses. Brugada and Long QT syndrome (inherited heart rhythm disorder) tests are all negative. Carotid aneurysms are suggested, but dismissed. Kawasaki’s disease is suggested and Adams immediately wants to proceed with cardiopulmonary bypass. House mentions that he thinks Lue has a PDA (patent ductus arteriosis). The ductus is a bypass in the heart important for the fetal circulation, but it should close shortly after birth.) that was infected and is causing the symptoms. After a heated discussion with the team, he allows them only to treat their suspicion – Kawasaki’s – but after Lue starts crashing, Adams slips him ibuprofen, the treatment for PDA. Lue recovers, but his mother and grandfather credit the religious ceremony, not any medical treatment.

This week demonstrated some of the most inept and nonsensical medicine I have seen yet on House. For pretty much every diagnosis, just ask: “Do the symptoms fit, at all?” The likely answer is NO. Rather than waste your bandwidth and mine by repeating that over and over, I’ll just hit the highlights (lowlights). As always, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

A previously normal eight-year child suddenly begins to have PDA symptoms. His mother never noticed difficulty breathing before – it just started now, eight years after developing the PDA? Maybe that was the mysterious “PSA infection” House was referring to which was supposedly treated by the antibiotics – yet the patient’s symptoms worsened after the antibiotics.
A PDA severe enough to cause symptoms at rest and no murmurs on exam, or abnormal echocardiogram? (admittedly, a standard echocardiogram is not the best way to diagnose a PDA, but there should have been signs in one that severe, particularly one that’s “infected”).
I’ll agree that a PDA can cause some shortness of breath or respiratory distress, but that’s different than a sensation of being choked. Furthermore, how does the PDA explain the seizure, speaking in tongues, or bruising.
As a side note, another repeat final diagnosis. Seen previously in episode #513, “Big Baby“

Right after Adams suggests URI, House has her start IV antibiotics for pneumonia – which is a lower respiratory disease.

Exactly what evidence for Kawaski’s is there? Where was the fever, rash, conjunctivitis, induration of the skin on the extremities, mucosal erythema, and cervical lymphadenopathy?

See if you can spot the theme:
How about some actual evidence for liver failure before poking a hole in the liver.
How about some actual evidence for Hashimotos before poking a hole in the thyroid.
How about some actual evidence for Kawasaki’s before poking a hole in the heart. (Stopped before they got this far, but they did suggest it and start the paperwork)

How about checking for low calcium before treating it?

I can find no evidence that beta-blockers are indicated for hypocalcemia.

The medical mystery was interesting, and maintained interest throughout the episode. I give it an A-. The final solution wasn’t great. The final diagnosis didn’t fit well at all from both a time course and a symptom point of view, plus — for the second week in a row — it was a retread. I give it a D-. I realize they were playing a faith versus medicine angle this week, which is a shame, because the medicine was horrible. The team leapt from diagnosis to diagnosis, without logic, and abandoning previous attempts at the drop of a hat. It earns a weak D-. They rushed to risky procedures with no good reasons or proof. The soap opera was fair. The House and Dominika scenes were good, but the House-tells-the-team-what-they’re-secretly-thinking has been overplayed this season. I give it a C+.

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