House - episode 6
A schizophrenic woman develops a blood cot and is admitted to the hospital. While there, she starts bleeding from her gastrointestinal tract and then is diagnosed with liver cancer. Ultimately, it is discovered that she is not schizophrenic, but instead has a rare condition known as Wilson’s Disease.
I was disappointed by this episode. The pathos element — the poor son, struggling to help his mother — was greatly overdone. Worse, the medicine was not up to its usual high standard. I’m pleased that the team was not dashing from diagnosis to diagnosis this episode, but I found it hard to believe that five brilliant doctors (six if you count the Chief of Staff) missed the obvious fact that the patient did not have schizophrenia. Simply put, 36 year-olds do not develop new-onset schizophrenia; it is a condition that typically starts in the late-teens and early-twenties. This information was telegraphed in the first scene, so I spent the rest of the episode waiting for Dr. House to finally decide that she wasn’t schizophrenic.
Wilson’s Disease, like kuru, is one of those conditions I call a “med school disease.” While it’s true the condition is very rare, it is mentioned over and over and over again in medical school, so it’s unlikely to be missed as long as it was.
There were a couple of other medical problems this episode as well, most dealing with bleeding and clotting — flip sides of the same coin:
1. The patient was low on clotting factors because of her liver failure therefore so she bleeds too easily. If her blood is so thin, then how did she develop the blood clot?
2. A patient with a pulmonary embolus would not be sent home from the Emergency Room on blood thinners. While someone with a deep vein thrombosis can be treated successfully as an outpatient, any patient with a pulmonary embolism is going to be admitted to the hospital, at least for overnight observation (the clots have a tendency to increase in size).
3. Why do the doctors keep running every test themselves? What do a critical care specialist and an immunologist know about performing and interpreting an ultrasound of the liver? That’s what ultrasound technicians and radiologists go to school for.
4. Call me a cynic, but I don’t think someone would get better from Wilson’s Disease that quickly.
This was the second weak episode in a row. So far, the series is ahead 4-2, but seems to be losing some of its early steam.
December 23rd, 2004 at 1:59 am
I find myself agreeing with you. I was annoyed when House took the responsibility at the end to save the kid’s feelings. And the subplot about his birthday went nowhere, really. I’m not sure what kind of development we were supposed to see there in House’s character… if it was ‘his orney behaviour is a front’, well, we got that by episode 1.
This episode also suffered from the 48 minute syndrome. On the bright side, I do find the interludes in the clinic to be moments of comedy. Not believable, perhaps, but still funny.
December 23rd, 2004 at 2:16 am
From my experience, those clinical interludes are all too realistic.
December 23rd, 2004 at 2:26 am
Apparently this episode was originally second in the production order, which might account for some of the off-seeming character moments (no excuse for the medicial snafus, though- even I caught the schizophrenia problem, and my medical knowledge is nigh non-existent). It struck me as one of the weaker episodes so far regardless, but at least some of the backstory bits might have fit more smoothly a few weeks ago. Fox might have been jumpy about hitting a new audience with technicolor blood-vomiting, though. Yikes.
December 23rd, 2004 at 2:24 pm
Thanks. I wasn’t aware this episode was “off schedule” — that does explain quite a bit, including the horrible hair cut that Dr. Chase was sporting. The copious hematemesis made for a rather…memorable…scene.
December 9th, 2006 at 6:34 pm
The medical aspects of this episode were incredibly silly.
1) The patient has a pulmonary embolism. Fine. But the standard of care for pulmonary embolism is anticoagulation (blood thinners). First heparin(or lovenox) then coumadin. This means that when she started throwing up blood, it would hardly come as a surprise that her blood was “thin”. You would not have to go reaching for cirrhosis.
2) All those fancy test (Protein C, Protein S, Factor V Leiden, Antithrombin III) are of very little use once you start treatment for the embolism. They will all be abnormal due to both the clot and the medications.
3) About the Wilson’s Disease, how the heck did she escape diagnosis for so long? She somehow developed the neurological complications, developed cirrhosis while skipping entirely the acute hepatitis-like stage? And Wilson’s usually presents earlier and women with this disease are commonly infertile.
4) So this is the sequence of events that this episode would like us to believe.
Woman is born with a genetic disease that causes her to accumulate copper in her brain and liver, but somehow is completely fine into adulthood and is able to get pregnant and raise a child into the teenage years.
Woman develops severe neurological and hepatic deficits due to this copper accumulation which causes her to be diagnosed as schizophrenic and thins out her blood but somehow never develops jaundice(turning yellow), ascites (fluid accumulation in the belly), or any of the other signs of end-stage liver disease.
Woman mysteriously develops a blood clot even though her blood is thin.
ER decides to send this woman home. (Malpractice)
House and company are completely surprised when she starts throwing up blood. Somehow the treatment of the blood clot and the blood clot itself completely disappears from the script.
After they diagnose her finally, they somehow reverse years of cirrhosis and brain damage overnight.
January 4th, 2007 at 10:09 pm
“While it’s true the condition is very rare, it is mentioned over and over and over again in medical school, so it’s unlikely to be missed as long as it was.”
I was just watching “Medical Mysteries” on the Discover channel. One of the real-life cases on it was a Wilson’s diagnosis, which went undiagnosed (despite the involvement of many doctors over many years) for two decades. FWIW
January 12th, 2007 at 11:54 am
While it’s annoying to have the Cottages (Cameron, Foreman, and Chase, or “The Little Houses”) running all their own tests, hiring actors to play the various techs would add up pretty quick, and we’d lose the character beats that happen in the labs and stuff. It’s just One Of Those Things you have to sort of handwave away.
February 25th, 2007 at 9:52 pm
Thank you redhairedgirl. I was going to say the same exact thing. It’s a television thing, not a medical thing. Let’s remember that while this show is a *medical* show, it is also a *television* show. If this show were 100% true to life, I honestly don’t think so many people would watch it. But that’s just my opinion.
By the way, I *love* this blog. Just wanted to put in my 2 cents.
March 18th, 2007 at 12:12 am
I thought it was an okay episode. But the solution at the end wasn’t totally satisfying. And you could not be more right, they should have realized pretty quickly that it was not schizophrenia.
April 3rd, 2007 at 10:20 am
Redhaired girl and Jamie–I beg to differ. A non-speaking part like an
ultrasound technician gets paid standard union wages. This is no different
than the nurse at the nurse’s station. Hey, the pharmacist has been used
in something like 11 different episodes. They can hire a small handful
(say 3-4) non-speaking actors to play technicians and just rotate them.
Since they tend to use the same test over and over, it shouldn’t be a huge
expense. One radiology tech to run the CT’s, the MRI’s, the X-rays. One
lab tech to be random assistant around the hospital. One or two techs to
run any room-based tests (like US). In the grand scheme of things, this is
a very minor expense. I bet they spent more on acquiring House’s motorcycle
than they would on the union wages for non-speaking bits like this.
April 18th, 2007 at 12:18 am
The intent of the test scenes is not to showcase “the cottages’” medical prowess or responsibility, but mainly as a plot-driving segment. It doesn’t matter how easy it would be to add that realistic detail, because they need those scenes to flesh out the actual story arc.
May 9th, 2007 at 12:32 pm
I’m a 31 year old that was just 2 weeks ago diagnosed with Wilson’s. I’ve fought for over 10 years to figure out what the hell was going on. I didn’t really have overtly hepatitis-like symptoms, nor any schizophrenic activity. I’ve not developed jaundice or really a lot of the outer-showing symptoms. I’m also not infertile - in fact, I have overactive ovaries. There’s 2 reasons that doctors miss a diagnosis that should be cut and dry. 1. They’re not paying attention (quite rare) 2. The patient doesn’t tell the whole truth. (most common). Mine was several doctors over the course of several years with complete and total honesty. I had prescriptions written for every symptom I ever had - but no diagnosis.
Wilson’s can present at any time throughout the lifetime. Its rare by itself, and even more rare to present after the mid 20’s. You do have to take into account the amount of copper a person is exposed to in the span of time up to their onset of symptoms that would prompt a diagnosis as well.
As for why the doctors are running every test themselves - this is a teaching hospital. There are a lot of teaching hospitals that do require the doctors to run their own tests for many reasons - accountability and to learn what they’re asking people to do for them.
Let’s also remember, this is a TV show - and its only an hour long :)
July 6th, 2007 at 7:32 am
Oh, come on you idiots! Stop the freakin’ chitchat and understand why I am much better than you in many uncountable ways. You got any doubts about my way of doing things? Well, that’s your problem ’cause I am pretty sure about what I do and no other freakin’ doctor like the moron who writes this stupid forum is going to tell me what I am supposed to do. You got any problem with that? Stop watching the show, but oh no! You’ll never do that ’cause you love me so much, so just stop the stupid critic and have some guts to be quiet. THANK YOU.
July 16th, 2007 at 1:37 pm
Well, in my opinion, the lab scenes are important to the plot because they are kind of used as a reflection time for them to talk about what happened. Also, a lot of conflict occurs there when they question each other and House. Also, it’s a time for them to complain about House when he’s not there, which is always satisfying…
August 13th, 2007 at 8:00 pm
I just wanted to comment, I love your reviews, and I love the show :). In the beginning the ER Doc, says to the son “We put her on blood thinners, you can probably take her home tomorrow.” So they are in fact keeping the mom overnight :)
October 8th, 2007 at 4:07 pm
I find it strange that a diagnosis of antiphospholipid antibody syndrome as part of systemic lupus erythematosus was not even considered. This would readily explain the psychosis, pulmonary embolism and pulmonary hemorrhage. As a matter of fact I was expecting this to be the initial, apparently obvious diagnosis which would turn out to be wrong eventually…
December 27th, 2007 at 9:35 am
I know it has been forever since this episode aired, but I just got the first season on DVD and was watching some episodes, so I decided to check out the reviews. A few people have mentioned how improbable it is that she would have recovered “overnight”. To me it seemed like they used that “swirly” camera trick towards the end to indicate that time was passing. House is only an hour long, and they wanted to show the conclusion to the episode.
January 13th, 2008 at 6:04 pm
I’m pleased I found this forum. I enjoy your reviews, Scott, and I’m glad for the real medicine explanations. Almost everyone who posts leaves interesting insights as well.
I too am watching the first season again. Even in these early episodes, the show has the elements of what will give it three great seasons: great actors, great ensembles, great writing, great directing, great characters. IMO, House demonstrates how good TV can be.
Aloha!
January 23rd, 2008 at 10:48 pm
I agree with Anonymous - the episode never implied the mother got better ‘overnight’, she was probably in the hospital for quite a significant length of time between the diagnosis and when she was finally discharged.
Also in rare cases people with Wilson’s sometimes don’t present symptoms until they’re 30 or even 40 years old.
March 22nd, 2008 at 11:32 pm
I’d say that the swirly camera was to show more than a day passing, even as much as every 360 rotation being a day or longer.
This episode I may have partly glazed over, with just being happy that within the first 5 minutes I correctly predicted a DVT and pulmonary embolism. I’m a first year med student so its nice to every get the basics right, especially at times when this early on you feel like you knew more before you became a med student than you currently do.
April 11th, 2008 at 5:36 pm
The doctors keep running the tests themselves because it keeps us (viewers) interested in them as characters. The more screen time they get, the more we identify with them. Remember it’s fiction. Fiction trumps the facts, at least for them.
April 18th, 2008 at 11:16 am
As a radiologist, I can tell you that the “liver tumor” diagnosis was wrong if you look at the ultrasound image. The first time you can see the right kidney with a small piece of liver above. When they try to inject ethanole to the tumor, again the U/S screen shows the right kidney and a needle moving toward and into it.
The “liver tumor” diagnosis is much more serious than the Wilson’s disease because it is fatal to the majority of the cases, with or without surgery and chemotherapy.
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