House - Episode 16 (Season Three): “Top Secret”
The first of nine new House episodes in a row, tonight’s show featured a Iraq veteran suffering from Gulf War Syndrome, though little attention was actually paid to the controversial diagnosis. Medically, an above average episode, though it felt fairly light otherwise.
House is asked by Cuddy to see a patient who just happens to be the nephew of one of the hospital’s benefactors. Strangely, House has just had a dream about the patient, and is sure that he has seen his face somewhere before (he probably recognized him as Riley from Buffy the Vampire Slayer). John is a thirty-four year-old sergeant in the Marine Corps who recently returned from a two-year tour of duty in Iraq. John believes that he has Gulf War Syndrome and complains of chronic fatigue, intermittent rashes, joint pain, and frequent sore throats. While Chase seems predisposed to believe that it might be Gulf War Syndrome, the rest of the team suspect that he must have another diagnosis because there has never been any definitive medical proof of Gulf War Syndrome — in fact, there is medical evidence against it. House orders a blood work-up including tests for HIV, Hepatitis C, Malaria, schistosomiasis (a parasitic infection acquired from contaminated fresh water. Schistosomiasis does not occur naturally in the US, but does in Irag), and Acinetobater baumannii (a bacteria that can cause health-care related infections and has been seen with some frequency in soldiers who have served in the Middle East).
John’s physical exam is normal. He describes a frequent rash of black dots on his palms and soles, but he doesn’t have the rash currently. He also mentions a cough and sore throat, as well as chronic joint pain and tingling in his legs. Nothing shows up on exam. His routine blood work is also normal, except for his potassium which is a little low. Chase suspects John may be suffering from the after-effects of chemical warfare medication, military pre-deployment vaccinations, or toxins encountered in Iraq. He also mentions that John could be suffering from radiation poisoning from depleted uranium (depleted uranium is used in artillery and tank shells because it is extremely dense and has very good penetration). He wants to order a special urine test from England No one else agrees with his suspicions and House orders a polysomnogram (sleep study) figuring that poor sleep may be at the root of John’s problem.
The polysomnogram is normal, but John starts to complain of a foul smell. Foreman discovers that John has a nasty oral infection that is causing the odor. The team describes it as “bacterial vaginosis of the mouth.” (Bacterial vaginosis is an overgrowth of normally occurring vaginal anaerobic bacteria. It is a common cause of vaginal infections and is not usually considered to be sexually transmitted.) John is started on antibiotics for the infection (metronidazole is the most common). His HIV test is negative and there is no evidence of diabetes or other endocrine problems. Cameron suspects an autoimmune disease such as Sjogren’s Syndrome, but Foreman rules that out (but you’ll notice that he doesn’t rule out any other autoimmune diseases). Foreman suspects lymphoma, a cancer of the lymphatic system. House agrees that it is cancer, but suspects it is a parotid tumor (the parotid gland is the large salivary gland on the side of the jaw). He criticizes Chase for not sending John’s urine to England for the uranium test. Wilson performs a parotid biopsy, but the results are inconclusive. He next performs a sialogram (a test to look for blockages or obstructions in the salivary ducts), but it is normal. During the test, John suddenly becomes deaf. Wilson obtains a head CT which shows 6 tumors in the brain.
House is having problems of his own. He has been unable to urinate for three days — a side effect of the Vicodin — and has painful bladder distention. He tries some alfuzosin (brand name: Uroxatral) ( a drug that relaxes the prostatic and bladder muscles), but it doesn’t help. There is a funny scene in the clinic with a patient with diabetes insipidus (a condition where the kidneys are unable to concentrate the urine correctly, and thus the patient is urinating frequently and always thirsty).
A brain biopsy is scheduled, but just as Foreman is about to cut (or drill) into John’s skull, he realizes that the tumors aren’t showing up anymore on the scanner — they’ve disappeared. Looking over the symptoms, the team now considers the diagnoses of infection or infection plus cancer. Chase arrives with the tests from England showing that John does have evidence of depleted uranium in his urine. Since House no longer suspects cancer, he is not interested in the urine results. He tells the team to continue John on the antibiotics and monitor his symptoms. He goes home to catheterize himself and sleep. While House is gone, the Young Guns decide to go ahead and treat John for presumptive uranium poisoning, but the treatment does no good and may actually have worsened the situation. John now complains of paralysis to the abdomen (though the show confuses paralysis and lack of sensation, which are two different conditions).
When House arrives the next morning, he’s cracked the case thanks to another dream about John. He is aware that John is showing a lowered blood pressure and a lower hematocrit (signs of blood loss) and House announces that John has Hereditary Hemorrhagic Telangiectasia (also known as Osler-Weber-Rendu Syndrome). This condition can lead to AVMs (arteriovenous malformations) which cause frequent bleeding. Epistaxis (nosebleeds) are one of the earliest symptoms. House states that an AVM in the spine led to John’s neurological symptoms, and one is his lungs led to the joint pain as well as the mouth and brain infection.
Overall, the medicine wasn’t too bad this time. Hereditary Hemorrhagic Telangiectasia is a logical diagnosis and fits most of the symptoms. However, I do have some concerns. I don’t understand how an AVM in the lung led to the blood not being “filtered” and this “dirty blood” led to joint pain and mouth and brain infections. First of all, very little filtering occurs in the lungs, (mostly gas exchange exchange) — blood is filtered in the liver, kidney, and spleen (depending on what you are filtering for). Similarly, what exactly is this “dirty blood” and how does it cause joint pain, because I’m sure my patients with long-standing arthritis would love to know. Is House saying that John’s joints are infected? All this still doesn’t explain how a vaginal pathogen managed to end up in John’s mouth, let alone survive there and cause an overwhelming infection.
I wasn’t too keen on the whole “dreaming about the patient” concept either. For a show which prides itself on being (more or less) realistic and factual, the dreaming aspect seemed out of place.
I give the medical mystery a B and the ultimate solution a B+. The medicine was above average, but I’m deducting for “bad blood”: C+. The soap opera/non-medical content, despite Cameron and Chase’s best efforts, only struck me as so-so and deserves another C+ .
Last week’s House review
A list of all previous House reviews
A story from medical school involving a urinary catheter
March 27th, 2007 at 11:38 pm
The dreaming aspect of it was pretty contrived, since it was only to get to the scene where Cuddy was pleased that she was the reason House remembered Riley-Guy at all.
Not entirely happy with the sex-o-rama Cameron and Chase are on, but I can sort of understand Cameron just wanting sex. The scene where House interrupts them at the end was priceless.
I never thought I would see or hear so much relating to urine/pee in one episode.
March 27th, 2007 at 11:50 pm
Thanks for posting these.
I was wondering what you thought abut House’s inability to urinate. Is that a real side-effect? Is it a problem that will re-appear or continue to get worse? Is it reasonable that House waited over three days before using a cath?
March 27th, 2007 at 11:57 pm
Yes, the dream aspect felt a little contrived, but I was willing to let it slide in this episode since I felt the humor was great in the episode. From Wilson’s knowledge of the Village People to House with the water bottle to poor, poor Chase it was full of good laughs.
March 28th, 2007 at 12:31 am
For a second there I though they were going to let us know what happened to House’s leg, and than, it’s a dream, of course. I loved the following lines and they’ll make me laugh until next Tuesday:
- Did you just take two Vicodin? No; antidepressants. I was told to take two every time you walk in the room.
-Pills make all my dreams come true. Did all your dreams come true? Two: one in my sleep and one in the shower.
- Have you ever appeared in a Porno? (This is classic!)
- Have you ever tried to ride a bike with a descending bladder?
I just don’t get what is going on with Allison! From being SO professional to a sex-a-holic!
And what is with making all women wear super-high heals in this show?! Wishful thinking, guys!
It is so nice to see House smile, even when Cuddy tells him off.
* Sorry to all of you who TiVo this show and are going to check for possible mistakes in the quotes. I was trying to write them down as the show went on.
March 28th, 2007 at 12:36 am
I liked it. And anything that can make Cameron’s character more than one-dimensional is a welcome addition, even if the highest they can get her is two-dimensional.
March 28th, 2007 at 1:39 am
Okay, sorry to ask another newbie question: John, the patient, occasionally had a rash of black dots on his palms and soles — but that, in itself, wasn’t enough to narrow down the diagnosis. When you see that kind of particularly oddball condition, isn’t there some big index you can consult that narrows the diagnosis to, I dunno, five or six possible diseases? How many different ways can a human body go wrong so as to produce such a weird condition?
March 28th, 2007 at 1:42 am
I thought the episode was sort of weird - still good - but weird. They also really enjoyed their urine this episode. I agree that the dream thing seemed out of place and it’s weird that they’re bringing all this Cuddy and Cameron stuff in together so quickly. I can’t quite tell what they’re trying to set up. Maybe that’s the point?
March 28th, 2007 at 1:48 am
I didn’t have a big problem with House dreaming about the patient–he has the case on his brain, and he’s clearly a bit out of sorts with his, ahem, problem–but the show was darned disjointed. Even with the dream, the diagnosis seemed to just appear out of thin air.
I do agree that it would be nice to have the solution come from hard thinking once in a while, rather than hinging on a chance saying or observation. In my experience, a lot of scientific mysteries are solved that way.
March 28th, 2007 at 2:23 am
The scene at the end, when House discovers Chase and Cameron, was worth the price of admission alone. I’ve never been on any heavy pain meds, but knowing what a catheter is and what a hassle/pain it can be (my mother has one), I kind of had a hard time believing he catheterized (if that’s the right word) himself. Also, he went to bed with the bag more than half full. It looked to be a bag worth about 8 hrs on my mom (emptied that often, and usually pretty full), who is under 5′ tall and, when healthy, was just over 100 lbs. House never played linebacker, but he’s been saving up for three days. You’d think at first he’d just about have to run the tube straight to the toilet, or just leave the valve in the bag open and hold it over the can. Also, people who have had a catheter typically have to retrain the muscles around the bladder because they quit holding the bladder closed, which is the problem my mom’s facing at the moment (only had the catheter in a week or two when the HMO started discussing whether or not weening off was an option). I’m not a doctor, but I’m pretty sure ramming a plastic tube into the area around those muscles won’t do them any favors, let alone miraculously cure a narcotic side effect.
Other than that, I liked the episode, though I had a hard time thinking Cameron (little miss ethics) would be willing to abandon her post for a sexual escapade.
March 28th, 2007 at 2:29 am
My problem with the dream sequence is that in it, House finds out exactly what the Young Guns did behind his back (treat the guy for uranium poisoning). Is House telepathic? Or did the scriptwriter cheat?
March 28th, 2007 at 4:00 am
Throughout this show, we often would see House get a sudden “100-yard stare” on his face, seemingly lost in thought, after those chance sayings or observations of which Brian Tung refer. Thereafter he would have the ultimate diagnosis. For this episode, I believe the final dream sequence was an insight for us as to how House’s thought process works during those lost-in-thought moments. However, as for the first dream, it was a deviation from the show’s premise, and I agree, out of place.
March 28th, 2007 at 4:02 am
Re. Allen Varney
I thought at that point the symptom wasn’t manifesting and the docs were sceptical if the guy was sick at all.
What bugged me was their obsession with DU, especially their fears of radioactivity. The stuff, as mentioned in the FAQ, is really more of a heavy metal toxicity concern than a radioactivity one. I can understand laymen freaking out over the term “uranium”, but doctors of this calibre really should know that if their tests didn’t show uranium then the odds of it being the culprit are infinitessimal. Makes them look like grasping at straws and the writers look like they’re being deliberately provocative.
Which is why their complete dismissal of Gulf War Syndrome looks pretty good in contrast.
I actually quite liked the soap drama. As mentioned, anything to improve Cameron’s character is well-received. But having only seriously watched since the end of Season 2, I have to ask: was there a point where the Ship of Cuddy was still actually in the harbour, as she suggested?
March 28th, 2007 at 5:24 am
“Irag” should be “Iraq”
March 28th, 2007 at 6:02 am
I have not seen the episode yet, so I could not really say anything specific.
However, from the HHT webpage one reads:
“The capillaries between an artery and vein in the lung have functions in addition to slowing down the blood in an artery before it enters the vein. These capillaries also act as a filter for impurities (clots, bacteria, air bubbles) in the blood, before the blood circulates to the brain. Someone with a lung AVM above a certain size is thus at significant risk for stroke (what happens when a clot goes to the brain) or brain abscess (a brain infection that can result from a bacteria getting to the brain).”
I think it partially accounts for the “bad blood” thing.
March 28th, 2007 at 6:39 am
Re: MrBuddwing
House assumes that everyone lies/people aren’t to be trusted. That dream sequence knowledge was House’s conscious leaking into his subconscious; if House told them not to treat the guy for uranium poisoning, he’s going to assume rightly that Foreman went ahead and treated him for just that.
But then again, it’s what it is at face value–a dream sequence.
With that, does anyone think that his catheter falling out might’ve had something to do with a possible flow of blood to his…erm…corpus cavernosum? Give a whole new meaning to “wet dream”, particularly that little bit in the dream about Cuddy saying seductively, “I’m ALWAYS here, House…” LOL!
March 28th, 2007 at 6:55 am
Am I the only one who felt his IQ drop 5 points every time they pointed at the mouth and said vaginosis? I understand bacteria that is commonly found in one ended up in the other, but would that really make it vaginosis?
Taboo, they explained about House’s leg. See the episode Three Stories from season 1. Fox.com has a recap. Also the quote was “distended” bladder.
I love these review of the episodes.
March 28th, 2007 at 7:12 am
Official Comment
LJD,
Opiates such as Vicodin can cause urinary retention, though it’s uncommon. In real life, it would likely be a recurring problem.
Allen,
In this case (and many others), the symptoms John had were all very common ones: rash, sore throat, joint aches. It could be hundreds of different conditions, from the flu to depression to lupus to hypochondriasis.
G T,
Assuming we take the HHT page at face value (and I think it’s overstating things a bit), that would explain the brain infection and possibly the oral infection (though not that specific infection). It still doesn’t explain the joint pain, unless the writers are suggesting that John has septic arthritis. If that’s the case, then there’s no way the VA doctors or House’s team should have missed it because it has a different presentation than run-of-the-mill joint pain.
March 28th, 2007 at 7:52 am
A great episode, I loved the clinic scene and though it was quick, another little hint about Cuddy and House’s past!
Is it just me, or did that cath tube look huge?? My wife is an RN and when she was in school she had a catheter and simulator (very amusing when she’d forget and leave it on the table when company came over) and the tube seemed much smaller, though the inflatable bit did look a mite uncomfortable…
March 28th, 2007 at 8:31 am
I thought the writing on this week’s ep was back in line with what I enjoyed during the first two seasons, hoo-rah! House’s obsession with where he’d seen the patient before (”have you ever been in a porno!?”) cracked me up, and Cutty was especially sexy. The sex sub-plot with Cameron and Chase seemed pretty realistic and added some nice sizzle.
I admit, I barely even paid attention to the medical plot. I was pleased that there was a reasonable explanation to House’s dream…I’d hate to see the show veering off into spiritualism…
March 28th, 2007 at 8:43 am
Scott, the HHT page is not overstating things at all as this disorder runs in my husband’s family and we deal with it on a daily basis. I was very upset last night after House made his diagnosis as it just felt like someone read (more likely skimmed) something about this disorder and didn’t put a lot of research into it.
March 28th, 2007 at 9:13 am
“Bacterial Vaginosis” is the best band name EVER.
March 28th, 2007 at 10:17 am
It must have been a TV first for a guy to do the cath thing to himself. Ouch! The tube did seem huge! Thanks Geek for correcting me. I’ll look up past episodes to find out about House. (Can’t keep up with all the good shows.)
Maybe it’s just me, but I miss the fun House had with the Clinic patients. Lately the scenes are not that good.
And about Cameron’s character being developed - I hate to disagree. They are just making her strange, not two-dimensional. If she ever had any character, she wasn’t the let’s-get-it-on-while-we-are-at-work kind of girl. Maybe Chase is right and she is just trying to get to House. So sad. :(
To Keith, I don’t think I ever pay attention to the medical plot when watching the show. I can’t resist watching House being so rude (to say it politely) and get away with it. Don’t we all wish we could be that way at least for one day, and get away with it?!
For me, it’s fun to come to this site and find about the medical details later.
March 28th, 2007 at 10:41 am
MrBuddwing
They also told House that they treated the patient for uranium poisoning before he went home to sleep.
To me the whole “Cameron wanting sex” subplot is just a very very thinly veiled attempt to incorporate the actor’s off-screen romance into the show (they’re engaged). It’s totally out of place within the context of the show.
March 28th, 2007 at 10:45 am
One odd note that She Who Must Be Obeyed noticed: Riley’s medical file indicated that his last physical exam was in 1988. How could that be the case, considering that he’d been in the Marines and was now trying to get a diagnosis for his health weirdness? Would military exams not be listed on his civilian file for some reason?
March 28th, 2007 at 11:50 am
As an HHT patient, I can verify that the pulmonary AVM’s are significant, as they are typically missing the capillary that reduces pressure from the arterial side and serves as a filter (that will prevent strokes). When detected, they are commonly surgically embolized (plugged), which was done in my case.
What is unrealistic, however, is the “frequent rash of black dots.” HHT patients typically have tiny avm’s called telangectasia that appear at the skin surface on their fingers, lips, tongue, face, etc. They are red, rather than black, and do not occur as a rash. They are generally permanent, and sometimes emerge through the skin and bleed, requiring cauterization or other treatment.
BTW, I don’t watch the show. Just interested in the subject.
March 28th, 2007 at 11:53 am
This was an episode that I made a few predictions on and weirded out my boyfriend. I predicted that he would cath himself, and I got to explain to my boyfriend why/how it was done (hooray for learning things in nursing school!).
I also thought, as he was heading to bed, “Hmmm… he didn’t inflate the bubble. It’ll slip out…” And then, however many minutes later, after the dream sequence, the thing is out! I was vastly amused.
March 28th, 2007 at 12:06 pm
I liked this episode alot more than the Dave Matthews one. “Have you ever been in a porno?” had me rolling on the floor. It was the best line of the episode… There’s no way House could have catheterized himself. Urine foley catheterization is a sterile technique procedure. House should have had (sterile)gloves on. He didn’t. The syringe he is seen using to put lube on the catheter doesn’t contain lubricant. It’s used to inflate the balloon in the catheter. I think this episode is setting up House and Cuddy sleeping together in a later episode…
March 28th, 2007 at 12:44 pm
I got the impression House and Cuddy *did* sleep together… but than maybe House was just making a sarcastic comment (wishful thinking) when he said: “You gave me everything I asked for (the job), because one night I gave YOU everything you asked for”
About House not doing the cath procedure correctly - well, it’s House, he isn’t in any way conventional, and when you haven’t peed in days you don’t care about gloves, you just want it out. Not that that’s ever happened to me - but I can imagine. :)
March 28th, 2007 at 1:38 pm
Official Comment
Chris,
Speaking from personal experience as both a former military physician and now as a physician in a heavily military town, there is a definite disconnect between a patient’s military medical record and his civilian one. It take several months to get a copy of the military record after they are requested, and about 20% of the time there’s “no record on file.” The VA is better, but still usually takes several weeks.
March 28th, 2007 at 1:38 pm
An interesting episode of one of the more interesting shows to be produced in a long time.
I appreciate this site and everybody’s observations.
I was thinking (I’m not a physician, nor do I work anywhere in the health fields) that House’s urine retention is coming from hepatic toxicity and acute renal failure not from hydrocodone side-effects, but from acetominophen. The problem with the pills isn’t hydrocodone per se — but with their ‘filler.’ Plus, it seems that House likes to knock back a few stiff drinks. That on top of a pile of Tylenol — not good. So, anyway, my thoughts there.
The Cameron/Chase thing has quickly become tiresome. I find Cameron’s character to be somewhat too annoying too often.
Cuddy appears to be getting a bit more development in character.
Thanks.
March 28th, 2007 at 2:46 pm
Re: the catheter: looked like a #14 or #16, a bit larger but not outrageous. Usually we use a #10 or #12. Self-cath: many people do that several times a day, including my father-in-law who had no medical training whatsoever. It was unusual though to use an in-dwelling catheter rather than an in/out (just what it sounds like). If that was his first time with urinary retention you’d think you’d just want the bladder drained and see what it does once the pressure is off. In-dwelling catheters can cause unpleasant spasms, but you wouldn’t have a huge problem with incontinence if you only use it for a day or two. Just my take on it.
March 28th, 2007 at 3:07 pm
Official Comment
NMASRS,
I was surprised he was using a Foley instead of and in-and-out cath as well at first, but then I realized he planned to sleep with it in, and his decision made more sense. On the other hand, given how long it had been since he urinated, it was remarkable how little urine actually came out with the cath.
March 28th, 2007 at 4:09 pm
What were the things in the patient’s head that looked like tumors? Is it plausible that they could have appeared and disappeared so quickly?
March 28th, 2007 at 5:14 pm
I was also deeply upset that they were concerned about the almost nonexistent threat of radiation from depleted uranium while being completely unconcerned about the very real heavy metal toxicity issues with the stuff. Was expecting to see a C or lower medicine grade based on that, in fact…
March 28th, 2007 at 6:26 pm
As a ‘victim’ of a malfunctioning (or malinstalled—I really didn’t care which) catheter years ago, I found the relative scenes hilarious, if excruciatingly so. Last night’s show could’ve ended with House on the john and I would have pronounced it a satisfying denouement.
If great cinema is a collection of great scenes, then the show was teeming with them, just about all having been previously mentioned (let me add one: Cuddy’s fleeting, over-the-top and purely sexual smile/leer(?) near the show’s end). I’m glad ‘House’ is back, and back with its old edge.
March 28th, 2007 at 7:20 pm
Rather than Top Secret, I think this episode should
have been entitled Pissin’ and Moanin’…the former
for House, the latter for Cameron/Chase. Yawn…I thought only 2-3 year olds were so interested in
bodily functions.
March 28th, 2007 at 7:34 pm
“Bad blood” from the venous side can cause joint pain. Consider hypetrophic pulmonary osteoarthropathy (HPOA). Joint pain is a feature of that syndrome, and since HPOA can arise in many different pulmonary disease processes, one might suspect that a right-to-left shunt is operative. But the case is clinched because right-to-left cardiac shunting can also cause HPAO. So I have to think that, yes, there is some humoral factor in venous blood that can cause joint pain if if reaches the systemic circulation. Certainly there are humoral factors that are “filtered out” by the pulmonary vasculature which otherwise cause bone growth (clubbing). So, yes, venous blood is clearly bad when on the systemic side.
Re: the dreams. Yes, they step outside of the show’s “formula,” but that’s good (lest the show become stale). Plus, the dreams were not treated mystically. House attacked the opening dream very rationally. I’ve had solutions to technical problems come to me in dreams. It’s spooky, but never unwelcome. :-)
Jeff R. makes a good point about heavy metal toxicity from uranium. I forgot if Chase mentioned the concentration. It might be possible that the concentration was too low to be associated with chemical toxicity.
Yok
March 28th, 2007 at 7:42 pm
I’m new, female, and a radiation oncologist. LOVE HOUSE.
Hmmm… loved “Have you ever been in a porno?” soooo much.
As for the catheter, the syringe he was using at first actually IS to lube the catheter. It’s called a lidocaine jet… often for caths that are going to be painful, lidocaine jelly is used to numb up the urethra. In fact, in women, the tip of the syringe can be inserted directly into the urethra and the lidocaine “jetted” up in there before catheterization. Later, if a Foley Catheter (indwelling) is being used, there’s a balloon on the end of the cath that goes into the bladder, and a second syringe must be used to inflate said balloon with sterile water. (House didn’t do that, so he woke up with wet sheets instead.)
As for self cathing, I happen to do it to myself all of the time due to a disease called interstitial cystitis (I do have urine retention on occasion, but I also give myself treatments intravesically) — I’m a woman, so it’s a bit easier to do physically as the urethra is shorter than a man’s, but it’s also easier to get an infection. Still, I’ve cathed without gloves in emergencies before with no harm done. Usually a good hand wash is sufficient in an emergency — in a hospital setting, nurses and doctors would NEVER cath a patient without gloves, but at home with our own bodies, we behave a little differently. (DO NOT use that as an excuse to screw up your own treatments for whatever diseases you may have!!!) When I cath I use a 12 or 14 French sized catheter, and I wouldn’t imagine House’s Foley was any bigger than a 16Fr.
Okay, anyway, what’s the deal with Cameron? She’s getting nastier as the show goes on… are they setting it up so that she’s trying to be more “House-like?” She was annoying when she was wimpy and she’s annoying when she’s not… IMHO.
March 28th, 2007 at 9:14 pm
I have a question. This is from 11th grade AP Biology, so it could be completely wrong, but I remember the teacher telling a story about some woman who had refrained from urinating for something like a day and she ended up dying because her bladder burst. I have no idea if the teacher was just making stuff up, but if not, how could House go three or four days without urinating at all? It seems like there would be more some more serious consequences than just minor discomfort.
March 28th, 2007 at 9:32 pm
Robin, Re: bladder rupture. Anything’s possible. But note that new urine will stop entering the bladder once the pressure in the bladder equals the pressure in the kidney’s filtering tubules. (There are no muscles in the kidney to pump urine into the bladder. — I don’t know what the muscles in the ureters do. — My guess is that urine must flow “downhill” or not at all.) I don’t recall what the pressure in the filtering tubules is, but it’s certainly less than systolic blood pressure.
The serious consequencs of being unable to pass urine is: renal failure. Less serious: predisposition to infection.
So here’s a question: House, with his distended bladder, drove Wilson’s car home. Should he have fastened his seat belt?!
Yok
March 29th, 2007 at 3:14 am
I didnt like the episode because of those dreaming sequences.
I am willing to accept such scenes in LOST, but not in House.
March 29th, 2007 at 10:38 am
Good question, Yok. Good points, too.
Regarding seat belt use: In the event of an accident, surely repairing a ruptured bladder is vastly preferable to repairing a fractured pelvis and significant internal injuries, brain injury, spinal cord injury, etcetera, that would likely be the outcome of a serious impact on an unrestrained driver.
Regarding the Foley: Why not let the stream flow into the toilet until the bladder is empty, and then use the collection bag? Further, no one would be silly enough to expect a Foley to stay in without the bubble being inflated. Obviously they wanted the ‘nice visual’ of House with wet sheets, but then… a lost Foley does not normally cause that kind of incontinence, especially after just a few hours in, does it?
Regarding the dream sequence: I appreciate the fact that the writers insist on a rational explanation for everything. (Remember the teenage evangelist/herpes kid?) It would be a complete cop-out if the writers went all ‘mystical’ on us, and I would stop watching immediately. We have enough of that kind of bullsh!t on a daily basis, what with horiscopes, psychics talking to the dead, hauntings and other popular mythologies. I’m sick to death of all that crap. House represents a welcome reprieve from the anti-science, anti-rationality, pro-religious garbage polluting the media.
March 29th, 2007 at 12:07 pm
I didn’t think it was weird/spooky that after House woke-up he had the correct diagnosis for the Marine. I do it when I’m trying to work something out;part the creative process. I thought everyone did that too.
March 29th, 2007 at 7:00 pm
Cheryl: My issue isn’t that he had the correct diagnosis when he woke up. It’s that there was precious little (the nosebleed, maybe) in the dream to suggest the correct diagnosis. It’s as though Kekule thought up the correct arrangement for benzene after dreaming about eating asparagus for dinner. Maybe I missed something, but whatever it was, it wasn’t obvious to me.
I don’t have any inherent problem with the notion of working problems partly through dreams. It’s a gimmick for a TV show, though, and as such will wear out through overuse. Besides, it’s not an integral part of the creative process. I do think that not explicitly thinking about a problem is an integral part of it, but you don’t have to be dreaming in order not to be explicitly thinking about something. You could be eating asparagus for dinner. :)
March 29th, 2007 at 7:35 pm
Personally, this episode was almost the straw that broke the camel’s back for me. Anytime Cameron goes ridiculously out of character, it ruins it. I almost quit watching last season when she did meth and slept with Chase. But the season redeemed itself. The idea of Cameron 1. ditching on a medical procedure 2.to have sex with Chase almost made me walk away from the tv. Its just bad writing.
And the idea that Foreman would not report them is ridiculous.
March 29th, 2007 at 7:36 pm
And bladder rupture is completely a real phenomenon. Remember the news recently: the woman who died from attempting to hold her pee in to win a Nintendo Wii.
March 29th, 2007 at 7:52 pm
I thought the woman died of water intoxication, not of a ruptured bladder.
March 30th, 2007 at 5:12 am
you probably will not burst your bladder just by drinking - you’d need some trauma to get that to happen. the ureters do pump a little bit but not likely enough to pop your bladder, unless you had previous surgery or something. the kidneys would have swollen up and failed before that.
also, Foreman did not believe that they did go off to have sex. This looks to be part of Cameron’s development. Remember, in the first season (i think) she showed off a little of her power over Chase with just her words. Really, they are all taking on qualities from House, even while he continues to shock them with his actions.
March 30th, 2007 at 10:29 am
I’m not too keen on the direction they’re going with Cameron either. I want to know how we’re supposed to buy little-miss-morals being such a good liar in the scene where Foreman is pressing them about where they were during the sleep study. The only thing that redeemed that scene a little was the incredulous/hurt look on Jesse Spencer’s face.
March 30th, 2007 at 7:27 pm
Matt, the woman with the Wee-Wii died from hyponatremia where the water washed all the salt and potassium out of her blood and into said bladder. The electrolyte imbalance caused her heart to stop. (Same thing as the kid in House vs God)
As for the dream I understand the antipathy for it, but House was constantly trying to rationalize it and didn’t stop until he had. The second dream is a variant on his 100 yard stare. The one thing that bothered me was the news reports were the same in the dream and reality.
March 30th, 2007 at 9:33 pm
Oh, happy tuesday.House was on, almost on time. And then wednesday morning to look forward to synopsis and remarks. It just seems like the writers of the show are trying out differant things just to keep us rabid fans intrigued. I have to admit that I like the dream sequence device,as I am not sure it IS a dream until it is revealed as one. Like in ’six feet under’s’ visions and interactions with dead people ect. I know that as a writer myself,I write to intrigue and amuse both myself and others. I just found myself shrieking to my ‘House’ mate, “oh no, House’s nose is bleeding”. Where are they going with this? Because House does seem to be emerging as patient of sorts himself.
March 31st, 2007 at 3:56 pm
In this episode some of the “Young Guns” say that House would not approve of any test results should the tests be done by the hospital specialists. To me, this answers the question of why the Young Guns actually do all the tests themselves. Something that you have wondered yourself quite a few times here I believe?
March 31st, 2007 at 9:47 pm
Whoops. Yeah, you guys are right.
I guess I need to return my urodynamics degree.
April 1st, 2007 at 4:38 pm
Cerre: It answers the question of what the justification is within the context of the show. It’s still not realistic, but it’s a detail I’m willing to let be unrealistic. Your mileage may vary, of course.
Mongo: As long as they keep the dream/hallucination down to a minimum, I’m OK with it in general. I thought the original dream was OK; I thought the 100-yard-stare dream was silly and didn’t contribute enough to the diagnosis to be worth the trouble.
April 1st, 2007 at 6:15 pm
I might’ve missed it, but what happened to the magically appearing and disappearing brain tumors?
Also do I wonder why there wasn’t a single reference to House’s alleged cancer from the previous episode. Are they using different writers for each episode? That would also explain Cameron’s ‘character development’.
April 6th, 2007 at 8:00 pm
I think the point is that Cameron is… an adolescent of sorts.
She always is amazed at the things she learns from patients and from her colleagues - the wife who tried to poison her husband (no one is happy), the woman who donated part of her liver to have her lover in debt to her, the HIV positive patient who supposedly celebrates life - etc.
She’s “growing up”, changing, learning new things. And she is a woman, and probably has small amounts of social interaction. Chase is pretty, he’s there and is a viable option for a sexual outlet, especially if she already slept with him. House would’ve been her first choice if he’d only be willing.
She isn’t as innocent now as she was before - Foreman “stealing” her paper and stabbing her with the syringe is an immediate example of the things that might make her less moral. That’s why she lied - she knows how to manipulate, like mostly everybody else in the show. Everybody lies, so to speak.
I actually like the new Cameron. How longer do you think she’d remain Polly-anna doll without becoming annoying or unbelievable?
April 8th, 2007 at 6:10 am
With all due respect, citing MSNBC and Reason online is not precisely using reliable sources. Especially the latter, a highly problematic and politically biased outlet with, sorry, poorly trained personnel and an outdated article doesn’t particularly contribute to the solidity of your review. As for the VA study, the key problem lies in this excert from the MSNBC article: “Tuesday’s report is the latest in the important series, which the VA will rely on to determine whether Gulf War veterans are eligible for special disability benefits if they are found to suffer from illnesses that can be linked to their service.”
That is: The VA funded the report, and the result is likely to save the VA a whole lotta money. I would call this competing financial interests if ever there were some. Now you will say the IOM is above such primitive issues as money, but I say they’re composed of human beings just like any other institution, and as a scientist, I’d flat out refuse to handle such a loaded gun. The study was a meta-study of a selection of published studies. That usually offers plenty of discussion material in and of itself as to the inclusion criteria. Given that other metastudies (Psychol Med. 2006 Jun;36(6):735-47. Epub 2006 Jan 26., BMC Musculoskelet Disord. 2006 Sep 20;7:74.) seem to suggest that when you focus on specific subsets of symptoms such as pain, you do get a consistent impression, and given that many studies suggest that psychological/psychiatric problems are involved (Philos Trans R Soc Lond B Biol Sci. 2006 Apr 29;361(1468):543-51) dismissing “Gulf War Syndrome” as such is highly problematic. When you look at AIDS, a syndrome that actually IS caused by one specific cause, the manifestations can still take a host of different forms -all of which are still characteristic for the syndrome as such. Just because one or the other doesn’t manifest in a given patient doesn’t mean that he or she doesn’t have AIDS, rather, for the individual stages of AIDS, a SET of possible symptoms is defined. Given that Gulf War Syndrome potentially has an entire array of causative factors, from physical to psychological, and that psychological factors can manifest themselves in a wide variety of fashions, flat out statements such as “there is no Gulf War Syndrome” are in my eyes highly problematic.
April 10th, 2007 at 5:35 pm
Oliver, nowhere in this review or discussion was the statement “there is no Gulf War Syndrome” made. Some characters in the show did made this claim, perhaps you should take it up with them. Scott correctly labeled the syndrome “controversial” - I think its controversiality is unarguable. Scott did choose two links that argue against the existence of GWS, however, for which he can be taken to task. The Reason source was appropriate to demonstrate that the existence of GWS is controversial, but the MSNBC article wasn’t a good general (& neutral) article on GWS (which is what would have been useful in context). Ah, it’s the MSNBC article that made the “there is no GWS” claim to which you object.
Your comparison with AIDS is appropriate - as you say, no individual will necessarily manifest all associated signs. It is possible, however, to state that as a group, AIDS sufferers have significantly higher incidence of certain physiological signs than non-AIDS sufferers. The evidence for this is less clear (so far) for GWS, and unfortunately, many of those markers that do (sometimes) show differences are the least susceptible to objective measurement. Patient’s rating of “pain” scores are less reliable than cell counts, for instance. Not that the evidence is strongly against the existence of GWS - I’d argue it’s slightly in favour - but the burden of proof is on those claiming the existence of something, not those denying it.
April 20th, 2007 at 7:31 pm
Gary,
the statement was made in the sources cited by Scott, and no, Reason does NOT demonstrate that the existence of GWS is controversial. It doesn’t have any more weight than the average Joe on the street. The fact that it labels itself “Reason” is pure and utter marketing and doesn’t give it any more authority than anyone else.
As for your comments about “burden of proof”, they are in my eyes misleading. The concept of a syndrome exists precisely to cover less-than-clearly-defined circumstances. A set of symptoms that often -but by no means always- run together. The burden that is on our hands is helping those people who suffer. What the doctor writes on the sheet is a secondary issue. Large parts of the problem MAY very well be mental. But do we really want to go back to those times when mental problems were described as a lack of willpower and guts? Modern neurosciences have moved well beyond that. Take another syndrome: Irritable bowel syndrome. It is extremely prevalent, but for the potential causes in each individual case, you could basically take a medical dictionary and open a random page: Stress, bacteria, allergies, parasites, you name it…. Likewise, the characterization is extremely broad -so broad, in fact, that academic literature has seen one or the other suggestion that some of the diagnoses of IBS might actually mask a different gastrointestinal problem and have been looking for symptom overlaps. IBS was for quite some time seen as a psychosomatic issue. But that didn’t seem to suggest to anyone to consider it a fluke. Instead, today we know that one way or other, serotonin signaling seems to be disturbed in the GI tract of people suffering from IBS. We still don’t know precisely how it happens. We still can’t pinpoint the precise causative chain that leads to IBS in a patient. But it is considered very real.
We speak of a syndrome precisely because we have little to no precise idea what the heck is going on. I’m all for evidence-based medicine. But that doesn’t remove the burden of taking a look at the patient and finding out how to help this specific person. That “medicine” today unfortunately moves towards a more and more budget-driven than evidence-driven medicine is a totally different issue and -in my eyes- a very real problem. Aside from it resulting in people being given second-rate care in all too many circumstances, it also leads to those who have to pay the bill all too often denying the very existence of a problem to begin with.
April 26th, 2007 at 6:41 pm
Oliver, Reason is just one of many sources Scott could have used to demonstrate that the existence of GWS is controversial - perhaps not the best, and I’m not giving it credit for calling itself “Reason”. :)
Treating the patients is, indeed, the first priority. IBS is a good example where labeling a “syndrome” is useful, as while the distal causes may be somewhat varied, recognizing the collection of signs & symptoms can aid in treatment - and in searching for those varied causes. That doesn’t mean that anytime someone calls something a “syndrome” it is useful, and in fact it can be counterproductive if the supposed syndrome is in fact a loose collection of unrelated conditions with no commonality in cause or effect. Chasing shadows doesn’t help the patients. In any case one has to treat the individual patient, but the bigger-picture public health issue is made worse, not better, by incorrectly lumping things together into a syndrome. This is why I’m talking about burden-of-proof - it has nothing to do with a particular patient, whose condition must be evaluated appropriately.
Shall I, now, declare “Boston visit syndrome” as collecting all health conditions striking people who have visited Boston within the last two years? In what way does this help individual patients, or researchers in pursuing long-term public health goals? If, on the other hand, I can show that those visiting Boston have significantly greater incidence of autoimmune disorder, this won’t change treatment, but it’ll be useful to direct research into prevention and, perhaps, treatment.
The GWS “diagnosis”, of course, comes down much more to financial interest than some - the US government has a cynical interest in finding GWS fictitious, and anyone who has served in the gulf & is now sick - regardless of the provenance of their illness - has an interest in a recognition of GWS (and the broader the syndrome, the better). So naturally this isn’t just an academic discussion - people’s livelihood, and health, depends on the findings. So far the evidence is not overwhelming. (I should add that the government should have an overriding interest in finding the truth, above financial considerations, but… hah! Political appointees vetting the findings of the government’s own scientific advisory panels?)
And, to quote… “We speak of a syndrome precisely because we have little to no precise idea what the heck is going on.” The point, actually, is that NOTHING may be going on. People get sick, sometimes with no apparent cause. Stating without evidence that this relates to a particular part of a patient’s history isn’t likely to help, and can hurt if you’re wrong and overlook another possible cause because of premature diagnosis.
April 27th, 2007 at 8:36 am
Gary, I think you miss the point about “Reason”. Citing “Reason” as to GWS being controversial is like citing the editorial pages of WSJ for global warming. Just because the editors of one or the other form of media outlet think something is controversial doesn’t mean that it is, indeed, controversial within the relevant expert community. Just because John Doe editor doesn’t believe in gravity doesn’t mean he can jump safely from the Empire State Building, nor that gravity is suddenly a controversial concept. Anyone can write anything, especially in his own media outlet and ESPECIALLY on the internet. If I were to treat everything controversial I find a bunch of pages on the net doubting it for, not only would there hardly be anything that’s generally accepted, living in Germany, I might get into serious legal troubles where I live should I profess some of those doubts openly.
April 28th, 2007 at 4:30 pm
Sorry Oliver, I’m just saying Reason is one, of many, sources Scott could have used, and I think it’s an adequate one for this forum, and for such a minor point. He could have given a dozen sources that deny, or are skeptical, of the existence of GWS - but why should he? He generally tries to use sources that are lay-friendly, as is this blog itself. Sure the 2006 Lancet study might have been a better source, but not in the spirit of this venue. Calling the existence of GWS “controversial” is on par with calling Venus “cloudy” - most people already know it. And, in fact, it is indeed controversial within the relevant expert community, in a way that global warming is not. Indeed, it _should_ be controversial, because it has not been well-demonstrated yet.
Your gravity analogy isn’t too applicable, because gravity has, in fact, been conclusively demonstrated to the satisfaction of experts for centuries. GWS hasn’t earned that trust yet. Even so, in your example one would be justified in saying that there is _some_ controversy as to the existence of gravity, even as you mock those holding that other position (as we do for flat-earthers and young-earthers). If that editor can quote better sources to back up his claim - as Reason does - the controversy becomes less mockable. Scott isn’t saying GWS doesn’t exist, only that there are some who claim it does not. There are far more who say that it may exist, but hasn’t been conclusively shown.
Reason isn’t just a website, by the way, but a print magazine. I don’t side with them on much, but your disparagement of internet sources, true though it is, is misdirected here.
June 18th, 2007 at 1:45 pm
Yok,
RE: comment #37
Again I’m gonna have to pick on your definition of “clubbing” and “humoral factors” … For those of us that ARE medically minded, could you tell us what these humoral factors are? I read here a little bit and this is the second time you’ve mentioned these. As to the filtering process, the only things I’m aware that the lungs filter out are gasses (CO2) as Scott said. And clubbing of the digits is NOT due to bone growth it’s proliferation of the connective tissue.
RE: comment #40
The ureters are muscular tubes as you said, and as Mike eluded in comment 48, they act in a peristaltic manner much like the GI system, so if you decide to stand on your head your body will still produce urine.
I know these might sound a bit bitchy, but I really do try not to be. In other news, thanks to Scott for doing these every week, even for those of us that are still catching up with the old ones we TiVo-ed aeons ago.
July 12th, 2007 at 7:22 am
I was wondering…
When Chase first suggests either a side-effect of vaccines and anti-chemical warfare pills or a contamination with depleted uranium to explain the low levels of potassium, Foreman disdainfully answers ” did you go to a medical school in France? No trace of uranium in his urine and he was given the vaccines and meds two years ago without allergic or adverse reaction”
Is it just a FOX-ism (ZOMG zee French zey are so stoopid), which would be disingenuous in the realm of medicine, or is there an allusion I didn’t understand? I would be glad if I got annoyed for no reason.
July 21st, 2007 at 12:06 pm
For someone who is as allegedly rational as House, what I found ridiculous is that he was happy with the explanation that he knew that guy from making out with Cuddy for ten minutes two years ago, and doesn’t even feel the need to question or explain the glaring coincidence that he was dreaming about that guy at literally the exact same time that Cuddy brought in his file. So I guess knowing that you’ve seen the guy before but still dreaming about him for the first time just as Cuddy brings in his file lowers the odds of this event happening from “astronomical” to “piano falling on your head” unlikely.
September 10th, 2007 at 3:55 pm
@kent: That might be rationally explained: House dreamt of someone and later, when Cuddy brought the file in, his brain “connected” the photograph with his dream. It’s just that we, the viewers, saw this chronologically. After all, all memory is (probably) reconstruction by the mind, not a movie stored and replayed.
BTW: I loved the episode. It had fun, light moments (especially the part where House catches C&C making out - he really has figured them out) and it had a much better “tone” than the dreary Tritter arc.
Thanks again for the review!
October 9th, 2007 at 8:42 am
I don’t know if anyone answered this already, but yes it is possible that house has urinal retention.
This is caused by spasms of the smooth muscles controlling this;
same counts for obstipation. It’s a very common side effect of long term opiate/opiod
treatment, especially if House is really on a daily vicodin dosage of 80mg+; hydrocodone
(active opioid component of vicodin) is 1.5x more potent than morphine.
I know this condition only too good, as I have chronic pain which is also treated with opiods in my case.
July 17th, 2008 at 9:55 am
A point of amusement.
People who are saying they felt the dreams were out of place in a show with such realism - do you hold your life to such standards of realism, or is it just TV shows? Or maybe you just don’t dream, or have dreams that provide insight and/or appear inexplicable at first glance. I guess my life is just less realistic than yours then.
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