House - Episode 8 (Season 2)
A complicated episode of House, but an interesting one. This medical review contains a bunch of spoilers, so don’t say I didn’t warn you…
As the story begins, we discover that House and Chase are facing a hospital disciplinary hearing over the care of one of their patients. This episode takes place mostly in overlapping (and sometimes contradictory) flashbacks. While this is a good storytelling device, it makes for an awkward discussion of the medicine so I’m going to approach the case chronologically.
Kayla, a young mother, is experiencing severe abdominal pain as well as joint pain in her legs. A clinical exam reveals uveitis, a type of eye inflammation. The team considers a variety of diagnoses including gonoccocal arthritis, rheumatoid arthritis, and Takayasu Arteritis. They finally settle on a diagnosis of Behçet’s Disease after finding some genital ulcers on a pelvic exam. Behçet’s Disease is very rare chronic inflammatory disease. Symptoms include mouth and genital sores, uveitis, arthritis and skin rashes. Abdominal pain can also be a symptom. Chase starts Kayla on some medication to calm down the Behçet’s, some antacids for the stomach pain, and performs a skin test to confirm the Behçet’s known as a pathergy test.
When Kayla comes back to the clinic two days later to have her pathergy test read, she complains to Chase that she is still having abdominal pain. Her test is positive, so he refers her to a rheumatologist. He also prescribes some stronger antacids and sends her on her way. He does not perform an exam or ask any more questions about her abdominal pain.
Two hours later Kayla is brought to the Emergency Room after vomiting a tremendous amount of blood. Chase performs an endoscopic exam and notices a stomach ulcer. He cauterizes it to stop the bleeding, but a second stomach ulcer has perforated, spilling the stomach contents into the abdominal cavity. This is very dangerous and Kayla develops peritonitis and then a severe bacterial infection known as sepsis. This leads to kidney damage and liver damage. A blood clot forms in the liver, leading to even more liver damage. Kayla’s best hope of survival is a liver transplant. Despite the fact that she’s too sick for a transplant, House browbeats Cuddy into placing her at the top of the transplant list.
Unfortunately, Kayla has type AB- blood, the rarest blood type, so it will be unlikely that a liver will be found in time. Her brother offers to give Kayla part of his liver, a type of “live organ donation.” He has lab tests to prove that his liver is in good condition and will match her genetically. House blackmails one of the transplant surgeons into performing the operation, and both brother and sister do well.
At a follow-up visit 2 months later, Chase notes that Kayla has a low-grade fever, unusual for someone on immune suppressant medication. He orders some blood cultures and other lab tests, as well as a chest x-ray. One of the blood cultures grows Strep. This usually means that it was a skin contaminant (If it had been a real infection, Strep would have grown in more than one sample. Strep commonly grows on the skin, and a single positive culture suggests that her skin was not cleaned off well enough before the sample was drawn). Her liver enzymes are elevated, signifying liver damage. Chase chooses to believe that Kayla has a Strep infection, but Foreman believes Kayla’s body is rejecting the liver. Her brother comes in and demands to know what is going on with his sister. House looks him over and deduces that he has Hepatitis C and that he faked his liver tests to so that his sister could have the transplant. He transmitted Hepatitis C to his sister and because of her immune suppressant medication, she deveoped a severe infection. In addition, his liver was cancerous (from the chronic Hepatitis C) and he gave this cancer to his sister hidden inside the liver transplant. At this point, there’s not much that can be done for Kayla. She has Hepatitis C rampaging through her body, and because of the liver cancer, she isn’t eligible for a second transplant. Her brother wants her to get a “black market liver transplant” in Mexico, but Chase advises against it. Kayla returns home to her children and dies a week later.
There is no doubt that Chase should have performed a better exam. Abdominal pain is never something to be taken lightly and people can die from gastrointestinal bleeding in a remarkably short amount of time. Both he and House know he screwed up. The question of the episode is why did he screw up. At one point, Chase confides to Kayla’s brother that he killed her by missing her ulcer and blamed it on being hung over. Unsurprisingly, her brother files a malpractice suit against Chase. In reality, Chase was not hung over, but instead had just been informed that his father had died. This threw him for a loop, and he wasn’t really paying attention to what Kayla said. He tried to call her back a few hours later, but by then it was too late and her ulcer had burst.
Chase is reprimanded by the committee and suspended for a week. In addition, the committee is distressed by House’s actions and places him under another physician’s direct supervision for the next month. Cuddy chooses Foreman to be that supervisor.
The medicine was fairly straightforward this episode and almost error free. Chase should have been more concerned about the abdominal pain, and taken a better history to find out what medication Kayla was taken, but his mistakes were the basis of the episode. I’m surprised that the team would accept her brother’s lab values without confirming them, and that goes double for the surgeon (blackmailed or not). I will make my usual complaint that the team is performing tests themselves that are best left to specialists (such as endoscopy). I also wonder why Foreman, a neurologist, was consulted for someone having abdominal pain and arthritis.
The soap opera was more restrained this week, focusing mainly on House and Stacy trying to salvage their professional relationship. I expect more fireworks in the next episode when Foreman is in charge.
This episode earns a B for the mystery, another B+ for the solution, and a B+ for the medicine overall (it was competent, just not as exciting medically as usual). The soap opera earns yet another B.
UPDATE:
My boss just reminded me of a scene I forgot to mention, when Chase performs a pelvic exam on Kayla. First, he performs an unchaperoned exam — that’s a lawsuit waiting to happen. Then, while his hands are still gloved and contaminated from the exam, he flips through her medical records. You use gloves for a reason…
December 1st, 2005 at 12:18 am
links for 2005-12-01
loveligoods.com nice cards and scarves (tags: custom card scarf online store) winewaves: Fat Bastard Vin de Pays D’oc Chardonnay 2004, $6 costco of winemaker Thierry Boudinaud and Londoner Guy Anderson, Fat Bastard was a term Thierry applied to the i…
December 1st, 2005 at 6:41 am
I always enjoy your House recaps, especially the medical explanations. I don’t get too wonky about the good/bad medicine because first of all, the show really isn’t about the medicine and second of all, it’s just television. Pretty damn good tv, but just tv, all the same.
December 1st, 2005 at 1:52 pm
The glove thing really really bothered me too. There is not one doctor alive who would do that. I was glad to find your site. The good/bad medicine really bothers me in any medical show, so I rarely watch medical dramas. On the other hand, I really enjoy lawyer/cop dramas, I wonder if lawyers or cops get bothered be their TV potrayal as well.
December 1st, 2005 at 1:55 pm
I love your reviews! I’ve always been extremely interested in medicine and it’s great to get an informed perspective!
I was wondering - I believe House mentioned at one point that his specialities were nephrology and diagnostics. This is seems like a very strange combination to me, both from the standpoint of why a physician would choose those two seemingly unrelated specialities and why the writers would choose nephrology (doesn’t seem very sexy to me!)
Also, is it normal to have multiple board specialities like this? (I had an ex whose father was an md. I was once told he had practiced as an internist, a psychiatrist, and a hemotolist/oncologist. He was certainly an extremely intelligent man, but is that possible?)
Thanks!
February 16th, 2006 at 4:14 am
The reason I liked this episode is that it helps to debunk the myth that doctors are somehow above error and in fact should be, as though they are not human, susceptible to being less than perfect because their minds are on something that would throw any of us off our game. I was glad he was not fired for being fallible.
What I didn’t like was the liver screening process being non-existent–truly unforgivable, both on the part of the brother failing to reveal what’s up , and the team not running the appropriate tests (if you don’t reveal this stuff and your sister dies, are you or the doctors who failed to test responsible? Manslaughter?). Even a routine liver function test, non-specific, should have shown abnormalities that indicated that further tests needed to be done.
December 17th, 2006 at 4:28 pm
I’ve just watched the episode and I have a question about some of the medicine in it: although organ transplants are usually done within the same blood group, isn’t type AB the “universal recipient”? So, actually, the AB- patient should have been able to receive any RH- liver, not just AB-, a one-in-seven chance.
December 29th, 2006 at 3:07 am
Did it baffle/annoy anyone else that Chase concocted a story involving alcohol to explain wy he made the error? Being hung over calls into question Chase’s character in addition to his professional ability, and opens him up even further to a lawsuit. Why blab to the patient’s brother at all, for that matter? Let the lawyers do the talking, for heaven’s sake! I suppose the writers are trying to add complexity to Chase’s character (he makes mistakes, his family was dysfunctional and he resents his father, etc) and drama to the episode (his relationship with Dad is so unresolved that he wants to keep his reaction to the death a secret). But I just didn’t buy that Chase (or any doctor in any universe, TV Land or otherwise) would rather appear to be recovering from a binge than mourning the death of a family member! Thoughts…
January 8th, 2007 at 8:15 am
Re: Kellibuzz: He wanted the brother to sue, because the family was low on money and about to move. He also probably was feeling alot of self-loathing regarding his mistake, and wanted punishment.
May 24th, 2007 at 11:10 am
I was under the impression that Wilson became the supervising doctor.
May 31st, 2007 at 5:57 am
Yes, the blood type issue was completely misrepresented. In fact, when transplanting organs, only ABO compatibility is even considered. Unlike blood transfusions, Rh factor is irrelevant. (I am a Medical Technologist who worked for 11 years in the Tissue Typing lab for a very large solid organ and bone marrow transplant program, so I know whereof I speak.) So, an AB recipient would be eligible for an AB, A, B, or O type liver.
May I also add that I initially found it hilariously ridiculous how that they show the trio doing their own lab work (especially the esoteric tests), imaging and specialized medical testing. But, I’ve learned the general level of writing and acting usually outweigh the incredulous aspects of the show. (And, gosh, what WOULD those three do with all their spare time since they’re usually only have one patient?)
June 6th, 2007 at 9:07 am
I agree with Tech Speaking about the role of the 3 younger doctors in testing. Sure, it may not be accurate, but how interesting would it be if all 4 of the docs just wandered around the hospital waiting for stuff to get done by other people? House already does that, and I’m not entirely certain what he does with all of his free time. After all, having one or two (I believe they’ve mentioned that occasionally they have more than one) patient at a time can’t possibly take up the time of 4 fully qualified doctors…can it?
July 8th, 2007 at 11:48 pm
I think Chase asked Foreman for a consult because he wanted somebody from the team and he couldn’t ask Cameron because things got weird after they slept together.
November 29th, 2007 at 12:53 am
I don’t understand the last comment about the unchaperoned pelvic exam. The only time that I’ve ever had a pelvic exam with more than 1 person in the room was when the observing nurse practitioner was new.
December 14th, 2007 at 3:49 am
Seraphene: Was that one person in the room with you of the opposite sex, though?
Tiffany: Kidney conditions affect more than just those organs. Preparing for post-transplant care can mean facing just about any problem, with one of the most common(?) being infection. Infections can present in many ways, and often the challenge is figuring out exactly what the problem really is.
It’s never been directly explained in canon but assumed House just happened into these specialties through his inability to let go of puzzles once he’s discovered them. Internal Medicine (residency or whatever) -> Nephrology -> Infectious Disease -> Diagnostics
Panthoryn: You were wrong… Foreman gets put in charge and he hates it, but he likes it. It ends up a permanent position in season 4, because Cuddy likes someone else dealing with House.
December 26th, 2007 at 8:49 pm
Not sure if I missed this or not, but was Bechet’s the underlying cause of the gastic ulcers? It kinda went really quickly from a diagnosis of Bechets to her peritonitis..
January 1st, 2008 at 10:21 pm
There should be “SPOILERS AHEAD* warning signs on some comments too……
May 25th, 2008 at 8:48 pm
Low Singer: They must have more patients than we get to see as the case of the week. This single episode played over three months. They definitely don’t sit on their ass for three months, waiting for the patient to come back. Also, remember House telling his class about three cases at the end of the first season. They all happened at different times in his life, and to other people than he says, but in House’s story, they happened simultaneously. So, we’re definitely not seeing the whole story.
I’m not entirely sure where we are chronologically. This case took 3 months, but the previous episode ended in an anxious Cameron counting the days until her HIV test. I hope they didn’t hit a reset button.
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