House - Episode 22 (Season 2)
A very somber (but sadly, not sober) episode this week. As usual, there are significant spoilers for this week’s episode of House ahead, so don’t come crying to me claiming nobody warned you.
A husband returns home to find his wife Kara have a seizure in the bathtub and their four-week old son Mikey drowning. By the time they reach the hospital, Mikey has resumed breathing and Kara has stopped seizing. Mikey is taken to the neonatal intensive care unit (NICU), where Chase happens to be working. Kara’s case is tackled by House, Cameron, and Foreman. Her calcium is elevated, and the initial concerns are hyperparathyroidism, cancer, and a “calcium-mediated neurotoxicity” — but apparently all those were ruled out in the ER. The next diagnoses considered include polyarteritis nodosa (a rare inflammation of blood vessels), Whipple’s disease (a rare type of bowel infection), a Strep infection, and vasoconstriction (a sudden narrowing of important arteries). The Strep test is negative, and when she is undergoing angiography, Kara suffers some sort of massive muscle contraction/seizure.
Meanwhile, Mikey’s oxygen levels suddenly drop. Chase listens to his lungs and diagnoses a collapsed lung (pneumothorax). He performs a needle thoracostomy and then acquires x-rays. He thinks the x-rays show a chemical pneumonitis (an inflammation of the lungs caused by an inhaled — or swallowed — irritant), but House disagrees and thinks the x-rays look like a bacterial pneumonia. He suggests placing Mikey on antibiotics and ECMO. Chase decides that House must be correct and starts the antibiotics and ECMO (extracorporeal membrane oxygenation — a big machine that oxygenates the blood and removes carbon dioxide).
In terms of Kara, the doctors are now considering a lithium toxicity and a myelogenous meningitis (a rare complication of leukemia where the cancer cells invade the lining of the brain). An MRI shows no brain tumor, but it does show a subarachnoid hemorrhage. It turns out that Kara has a bleeding disorder and her blood is not clotting as well as it should. Foreman’s search of Kara’s apartment turned up no lithium, but it did show a hidden bottle of vodka. When the team discovers that Kara is a former alcoholic, House suspects that she started drinking again and is now suffering from delirium tremens (a dangerous form of alcohol withdrawal). The liver damage from the alcohol would cause her bleeding problem (though they never seemed to run any liver tests). Foreman thinks it may be a conversion disorder, basically her body is having seizures to cope with the severe stress in her life. House overrules him and they place Kara in a phenobarbital coma to essentially sleep off her delirium tremens.
Kara’s feeling better when she awakens from her coma, and she is delighted to see her son (who appears fully recovered) and her husband. A short time later, House discovers her trying to suffocate Mikey. Chase resuscitates the baby and rushes him back to NICU. The team is now concerned that Kara has postpartum psychosis, especially after she admits that she hears voices telling her to kill her son. To ensure there is not some other neurological condition going on as well, they attempt to cause a seizure in her with sleep deprivation and strobe lights. Ultimately they succeed in setting off an atypical seizure that causes them to think that Kara is suffering from some sort of progressivedelirium. The possible diagnoses at this time includes Wernicke’s Encephalopathy (neurological disease caused by a severe thiamine deficiency – common in alcoholics), lithium toxicity, Whipple’s Disease, and pellagra (neurological disease caused by a severe niacin deficiency). Pellagra is the best fit, so they start her on niacin supplementation.
In the NICU, Mikey is not doing well. The lack of oxygen has severely damaged his kidneys and he has developed hyperkalemia (high potassium). Chase tries medication to bring the potassium level back to normal but it doesn’t work, and Mikey suffers a fatal arrhythmia (an abnormal heart rhythm — ventricular fibrillation in this case).
Kara is not improving despite the niacin, and complains of stomach pain shortly before vomiting blood. House has an idea but needs an intestinal biopsy. Because he suspects a disease that has a genetic component (and because Mikey has been breastfeeding and essentially eating the same food as mom), he can test the baby. A post-mortem examination of Mikey’s intestine reveals celiac disease, an autoimmune disease tied to eating food with gluten (wheat protein). This has caused malabsorption of vitamins (niacin, leading to pellagra and vitamin K, leading to a clotting disorder) as well as led to the development of a stomach cancer.
As the episode ends, both Kara and her husband are trying to come to terms with their son’s death — and having a hard time of it. Foreman is struggling to regain the skills he lost, and did I mention that Cuddy is looking for a sperm donor?
Kara’s medical care wasn’t that bad, but the pediatric medicine was sub-par. First, Chase is an adult intensivist, not a neonatologist, and the two are not interchangeable. Second, why did Mikey develop a pneumothorax? Infection (or pneumonitis) are not causes of a collapsed lung. Third, speaking of a collapsed lung, a needle thoracostomy is for treatment of a tension pneumothorax, not a spontaneous pneumothorax. The needle simply converts the tension pneumothorax into an open pneumothorax, which they neglected to treat. Fourth, I know ECMO machines look cool, but pneumonia is not an indication for using one (though bacterial sepsis can be an indication).
In terms of Kara’s treatment, isn’t it ironic that she was found to have a cancer after we were told in the beginning that the ER had categorically ruled out cancers? For Foreman, I’m glad to see he’s recovering, albeit slowly, but why is everyone convinced it was the biopsy alone that caused his problems. Meningitis takes at least a month of convalescence (which does not include going to a stressful job) before a person is anywhere near recovered. Finally, shame on House and Wilson (especially Wilson, as an oncologist he should know better). Tumor markers can be used to follow an established cancer or to check for a recurrence, but have no use in screening for tumors (except maybe the PSA — prostate specific antigen — in men, and even that’s open for debate).
The mystery was interesting and gets a B and the solution logically followed, earning a B+. However, the medicine and in particular the pediatric medicine was bad enough that I can’t give a higher grade than a C-. The soap opera component, particularly the Wilson/Cuddy “date”, had potential and deserves a B+.
Still want more great medical reading? This week’s Grand Rounds — the best medical blogging of the past week — are being hosted by Tara over at Aetiology. As usual, there’s an incredible amount of fascinating reading.
May 10th, 2006 at 12:28 am
Why did Wilson run a PCR to check for cancer markers? Isn’t he looking for protein markers? and isn’t PCR only for DNA?
May 10th, 2006 at 12:50 am
If the culpret was celiac disease, why wasn’t the effect of poor nutrient absorption caught during pre-natal care? If the celiac disease was affecting the baby due to nursing, would it also have affected him in utero? And wouldn’t the baby be a strong candidate for failure to thrive? It just seems like someone would have picked up on there being a problem long before it became severe enough for TV fodder.
May 10th, 2006 at 4:18 am
Didn’t it seem like Foreman’s head healed ridiculously fast and well? I guess there was a time gap between Euphoria and this episode, but Foreman’s bald head should still be showing some kind of marking where they cut into his head. Right?
May 10th, 2006 at 7:28 am
Official Comment
W,
Good catch. Cancer antigens are protein and PCR, a DNA technique, would do nothing.
Tom,
Yes and no. The show was implying that the recent stress in terms of bills and the birth of a child led to the celiac disease, so it wouldn’t affect the baby in utero. I would think there would be failure to thrive, but maybe his celiac disease wasn’t that bad yet. In reality, four weeks of celiac disease is not enough to lead to the malabsorption symtpoms Kara was showing.
Rob,
I’m not sure. The biopsies were not open biopsies, but more very large needle biopsies, so they may be heal quick and be hard to see, anyway.
May 10th, 2006 at 9:13 am
I’ve been checking this site for a while. Thanks for the always informative commentary and debate. Reading your reviews, I’ve always wondered: Do you need to do research to critique the average episode of _House_, or do you already have a rough knowledge of all these obscure ailments? If so, does it mean you are particularly well-informed, or do all doctors typically carry such knowledge?
(Obviously, I’m no doctor, so please forgive me if my question is very elementary.)
-Andy Holman
May 10th, 2006 at 9:15 am
As always, great review of the episode. I would’ve given the soap opera aspect a little more since it was kind of interesting how on-edge House was throughout the entire episode. heh
But a question - celiac desise, since it’s autoimmune, does that mean it’s an allergy or is it a treatable condition? Does she have to stay away from gluten for the rest of her life?
May 10th, 2006 at 12:11 pm
Celiac Sprue is an autoimmune disorder of the intestine (mainly the jejunum) that causes blunting of the villi (absorptive area) and lymphocytic infiltrate (your body’s defenses). I suppose you could treat this disorder with immunosuppresants (like cyclosporin) but this would lead to a whole host of problems much worse than just a gluten sensitivity (like cancer and severe infections because your body would lose the ability to fight back!) So yes, kara (and everyone else with celiac sprue) will have to stay away from wheat and grain products for the rest of her life, or until her body no longer makes antigliadin antibodies … but this diet is really no different than the Atkins diet right?!
May 10th, 2006 at 1:18 pm
When the father found the baby under water, would it have been helpful to hold the baby upside down (by the feet) for a few seconds to let water drain out of his lungs? We didn’t see whether the baby resumed beathing spontaneously, or whether the father or EMTs did artificial respiration.
May 10th, 2006 at 2:20 pm
Did anyone else notice Chase’s prayer before he performs the intestinal biopsy on the baby?
I wonder where that will lead if anywhere.
May 10th, 2006 at 5:48 pm
I have celiac disease. The gluten free diet is for life. The gluten free diet is not like an Atkins diet as the smallest amount of gluten will cause continuing autoimmmune reactions - there is no safe cheating. It is not a rare disease. CD affects 1:133 asymptomatic peopel and 1:52 of those with symptoms. Neurological problems are very common in those with CD - ataxia, seizures, depression, peripheral neuropathy to name a few.
The House episode gets an A in my book for doing a program on CD but only gets a C+ for the content and presentation of CD. I was glad to see they used atypical symptoms. Although she c/o stomach pains, she did not have the so called typical diarrhea and weight loss. Dr. Peter Green states that 97% of the people with CD remain undiagnosed. So many of the diseases that are presented on House are rare. Too bad they did not mention how common CD is(or did I miss that part of the show?)
May 11th, 2006 at 1:53 am
It always bothers me too see them run PCR tests and the like on the LightCycler (that’s the name of the machine they use for the PCR) because they seem rather careless with the preparation (no gloves and preparation outside a fume hood), and then the tests generally take almost no time at all. Pretty good episode otherwise.
May 11th, 2006 at 9:10 am
There was something I remembered when I was rewatching the episode - are we sure that Chase is *only* an adult intensivist? Is it common for doctors to specialize in multiple areas, sort of like a student double-majoring (which isn’t that uncommon - I’m doing it)? The reason I ask is it seems that Chase’s talents for neonatal care have been called upon before.
In Maternity (Episode 4, Season 1), when they were trying to diagnose the epidemic that plagued the babies in the maternity ward, House referred to Chase’s expertise on how many vials of blood they could safely draw from the babies without exsanginating them. I vaguely recall 1 or 2 other similar incidents, but I can’t be bothered rewatching all of my DVD’s to find them.
*shrugs* I mean, I’m not a doctor and don’t know the process people go through to become one, but it might better explain why Chase chose to work in NICU. Any further thoughts on this?
May 11th, 2006 at 11:53 am
I thought the soap opera was superior, in that they did not tie up loose ends in the patients. With one patient dead and the other choosing to die, this was an unusually dark episode. House didn’t persist in battering the patient to accept treatment, which was unusual for the show but made sense in light of the enormity of what she had done.
I also like how House and Cameron are reacting to Foreman. It is very much like family dynamics, where one person’s change, even for the better, throws everyone off. I suspect this is the real reason behind Chase running away.
But oh, for season-closer revelations! Do we think Cuddy will ask House to be a sperm donor? Do we find out why Chase is poor? What happens with Foreman? This is juicy stuff.
May 11th, 2006 at 4:49 pm
I agree that the medicine for this episode is crap. Let me add (as a nephrologist) that SPS (or Kayexalate) is not absorbed (contrary to House’s statement that it is not working because of malabsoption). That is how it works–it is a resin that works in the gut by exchanging sodium for potassium, then excreted as stool. That’s how potassium is lowered. In fact, if the baby has inflammation in the gut it would probably make potassium more available to the resin.
And if he was on dialysis, why the heck do you need Kayexalate!?
May 11th, 2006 at 6:30 pm
I was disappointed that they didn’t treat her depression as part of CD (because it is). Her depression should not have been acceptable, and therefore let go… esp. because she was obviously sufferring from severe depression before the baby had even died!
Oh, and babies don’t usually show villous atrophy very well because there hasn’t been enough time for visual damage to occur… It’s usually more vague and response to the diet that diagnoses them.
My son was born celiac (though seemed fine when he was born - as most CD infants do) and it became extremely apparent over the course of three years (the specialists couldn’t figure out what it was) that he was having some real depression issues at the age of 3. Four days into a whole food, (meat, veggies & fruit only), he turned completely around. Now, if he is contaminated, it appears as a ‘cold’ and his attitude begins to go ‘down’.
I also have sufferred depression, severe in my late 20s but have not had issue with it since going gf with my son (I was about 35). The only time I begin to feel blue… when I’ve been contaminated (touched something gluten and not thought well enough to wash my hands).
A real ‘House’ would’ve made her accept treatment.
I love this place! Great reads, both the reports and people’s comments!
May 12th, 2006 at 1:02 am
Great site. I’m a med student and this clears up all the things that seem not to make sense when I watch the show (which I still think is great regardless).
Chase working in the NICU seemed very weird to me, since the doctors who work there (neonatologists) are pediatricians who’ve then done a fellowship in neonatology. They don’t treat adults, and no one else treats the neonates (at least not at a major hospital). While it is possible to do a med/peds residency (internal medicine and pediatrics), that still wouldn’t make Chase a neonatologist unless he’d done the fellowship. But he’s doing a fellowship with House… so how many fellowships is this guy supposed to have done? He doesn’t seem old enough for that no matter how smart he is.
May 12th, 2006 at 1:26 am
Wasn’t it House that resuscitates Mikey after the mom tried to sufficate him, and not Chase?
May 12th, 2006 at 4:44 am
KimS - I dunno if it makes it an easier pill to swallow, but I think that in the show they had been fairly convinced that they had successfully treated her for the celiac disease and gotten her back to ‘normal’. So they figured the depression was just from having accidentally killed her son, which . . . is a pretty darn good reason to not want to live, I’d say. (Note: not saying she’s right.) Granted it had only been maybe 2 days since they’d gotten her ‘uncontaminated’, which may not be long enough but . . . hey, it’s TV. :)
Keep in mind I am painfully aware that everything I just said may just be me talking out of my ass, and, if so, I apologize. :)
May 12th, 2006 at 8:09 am
Dustin: You are funny! However, she was depressed *before* the baby died which means her decision to die is probably just a natural progression of the pre-existing chemical imbalance (stemming from lack of B vitamins IME)…
Also, your point earlier about Chase having some kinds of neonatal knowledge about babies because of the ‘blood’ question in another show is a good catch. There must be some more info. coming up on him. Someone else made a point about the prayer he did… I also think that’s going to go somewhere.
What a great show! So intriguing!
May 12th, 2006 at 12:38 pm
A question I had watching this episode was “who pays?”
This is a poor couple, buried in debt. Is it reasonable to expect that they’d have insurance that would cover the cost of the treatment we saw and the treatment the wife was refusing at the end?
Actually, “who is paying for all this?” is something I often wonder about when I watch HOUSE. He performs a kajillion tests on his patients, one or two of which are revelent to the problem the patient has. Up here, I’d expect OHIP to cover it but I understand matters are handled differently down south.
May 12th, 2006 at 1:21 pm
Well, the ARE a teaching hospital with a free clinic. That might explain a few things. Also, I’m pretty sure most hospitals and doctors must treat a patient regardless of their ability to pay for the treatment, especially if it’s life and death (which House’s cases always are). At least, that’s they way it was at the University of Washington Medical Center when I was in the ER.
May 12th, 2006 at 1:59 pm
James, the episode in which House travels to Baltimore with Stacey addressed this exact issue; the accountant was reviewing tests House had ordered because of the costs.
May 13th, 2006 at 7:42 pm
You said that it was not fitting the symptoms of the illness-of-the-week for the baby to get a collapsed lung. But I thought the baby’s lung collapsed because the mom was crushing him and the pressure impacted his chest, not because of the disease itself.
May 16th, 2006 at 6:42 pm
Teaching hospitals are (as far as I know) tax-assisted hospitals. They treat everyone regardless of their ability to pay. The tax payers support the treatment of indigent/charity patients. And, since they are just tax-assisted, they rely on charitable contributions and donations from the community and other organizations for support. Because, they are a tax-assisted facility, they have to comply with very strict rules governing the over-ordering of tests to “Rule Out” disease; in fact, the term “Rule Out” is becoming extinct!
Did anyone hear the term MALT (mucosa-associated lymphoid tissue) lymphoma used in the numerous possible diagnoses? That particular lymphoma is not usually associated with celiac (this is what my pathologists tell me), but enteropathic-type T-cell lymphoma is usually associated with celiac.
Also, in one of the prior episodes, I mentioned that it was very strange that Dr. House and his residents were trained in every specialty of medicine - they are internists, neurosurgeons, gastroenterologists, pathologists, microbiologists and neonatologists, and the list goes on! They do have, however, an oncologist on the staff!!
Aside from all these little “nuances”, this is a great show!
October 5th, 2007 at 7:51 am
Is it just me, but didn’t Wilson organise PCR tests. He ended up getting high high levels of estrogen? How you you be able to detect estrogen with a PCR and how is it a cancer marker?
December 16th, 2007 at 7:53 am
about those PCR-stuff … I would say it is very much good for checking for cancer, because the proteins which cause the tumor cells’ mad actions are coded for in the DNA (which is mutated in that case) …. ok, until there we don’t know if the genes are expressed, BUT: we know they are there!
And I don’t think the show told us that the Estrogen was detected by the PCR (which obviously is not possible). But by house diagnosing Cuddy’s “frozen joghurt” diet!
January 2nd, 2008 at 6:47 pm
Actually, that’s not true. Defects in the genes themselves can cause cancers, but there are tons of epigenetic (weird behaviour on the chromosomal or higher level) and post-processing (RNA, proteins) level that can contribute to cancers. There are also a lot of genes that Wilson would have to test for and I doubt the spoon he had would contain enough genetic material to run a single PCR test unless Cuddy vigorously gouged the inside of her cheeks with the spoon. Even beyond that, Wilson sure as hell isn’t going to find a genetic cancer marker from buccal cell samples.
I just watched the episode again and House definitely said that Cuddy had higher estrogen than usual while waving the PCR test results. Plus, there was no way that you can gauge that a woman’s estrogen level is higher than norm by observing her frozen yogurt habits. So that was an error on the show too.
One of the previous posters, Andy Holman, asked Dr. Scott whether he had to do any research to recognize all of the diseases we see on House (especially the exotic ones). I’m somewhat curious about that too..
February 24th, 2008 at 3:25 am
About Cuddy’s estrogen levels - I believe House was saying that they are high (which he found out from the PCR test) when they shouldn’t be because he thinks she’s at the wrong time of her monthly cycle based on his observations of Cuddy’s frozen yogurt indulgences. I’m not really certain when he thinks her estrogen should be high, but it seems like he’s saying it should coincide with the frozen yogurt splurge but that happened entirely too recently. Thus, he concludes that she’s on fertility treatment.
March 1st, 2008 at 11:49 pm
Rob’s right, though. No way you can detect estrogen with PCR. It’s about as logical as using PCR to test a patient’s sodium levels. Oddly, I caught that, while letting the ridiculousness of using PCR *at all* to look for cancer slide right past me.
I can totally buy House finding a pattern in when she yogurt binges, though. Spot on characterization.
June 16th, 2008 at 5:39 pm
Delirium tremens is not a “dangerous form of alcohol withdrawal.” It is acute delirium that is often - but not necessarily - a *symptom of* alcohol withdrawal. I am pretty sure that barbiturates can cause it too. There are probably other etiologies.
July 20th, 2008 at 9:56 pm
P.C.R.= Polymerase Chain Reaction is a way to amplify a small sample of DNA. I wouldn’t call it a test. After you do PCR on a sample, then you can do other DNA tests on it, run gels, whatever.
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