House - episode 9

February 1st, 2005

Filed under: Medicine

On tonight’s episode of House, a famous jazz trumpeter who’s paralyzed from the waist down suffers sudden difficulty in breathing. He is rushed to the hospital where he is diagnosed with pneumonia in addition to his previous diagnosis of amyotrophic lateral sclerosis (better known as ALS or Lou Gehrig’s disease). House, of course, does not believe this is ALS. He settles on Wegener’s Granulomatosis (a disease primarily of the lungs and kidneys) as a culprit. When the musician develops an arm paralysis he believes it to be a stroke instead of a progression of the ALS (it’s his show, so he’s right, of course). Ultimately, the musician is found to have an arteriovenous malformation (AVM — an abnormal growth of blood vessels) pressing on the spine and causing his paralysis.

The show was a good character study and took a close look at Drs. House and Foreman, as well as Foreman’s previous physician supervisor. Foreman was offered a job in California and had to decide whether to stay with House or go west for higher pay and more perks (and less abuse).

While the character moments were good, the medicine was not particularly well done:

  • ALS seems a reasonable diagnosis, given what was known of the musician’s history and symptoms.
  • It would be quite a stretch for Wegener’s Granulomatosis to have affected both the lungs and spine without being detectable on an x-ray or CT scan.
  • The AVM should have been visible on any previous blood vessel study (such as an MRA) despite being hidden by inflammation.
  • There is only a very narrow window of time to give clot-busting drugs (such as tPA) after a stroke. The patient was well outside this window.
  • House violates his own favorite Occam’s Law by deciding that the upper arm and lower extremity paralysis are caused by two separate diagnoses.
  • Not only are the Young Gun doctors running labs and MRIs, but now they’re performing embolectomies by themselves — so apparently they’re trained interventional radiologists as well.

13 Responses to “ House - episode 9 ”

  1. Mazal
    December 5th, 2006 at 11:48 am

    I did wonder how the Young Guns were capable of such rigorous testing procedures! And to be so young and so knowledgeable! Besides that, there are some wonderful moments in the ‘opera’ aspects of the show. The particular scene when House points out the difference between Dr. Foreman’s friend and himself is quite poignant. House might be a ‘jerk’ but he is honest. This honesty is ultimately what attracts Cameron, who is, by the way, extraordinarily immature in the first season, to House. What is ironic, of course, is that House constantly berates Cameron for her ‘honesty’ when he says that he is a straight-forward kind of guy himself. This does not mean he is moral, of course. This simply means that he has a moral compass.

  2. Casey
    December 13th, 2006 at 3:04 am

    This episode brought some particular ethical questions to mind. However, not being an expert where the law is concerned, I find it difficult to reconcile these questions. While undergoing the initial portion of the treatments, the patient decides that he wants to have a DNR (Do-Not-Resuscitate order), which the doctors promptly provide to him. Then shortly thereafter, he goes into severe respiratory distress but maintains a good sinus rhythm. Now, the good doctors decide that they can do nothing for him because of the aforementioned DNR. As I understand it, a DNR is in place merely to prevent resuscitative efforts (i.e. CPR) and that clearing an airway with a good sinus rhythm does not fall under resuscitative efforts and can therefore be legally performed without violating the DNR. But now for the big question: can the doctor who signs the order in the first place either rescind that order or override it? I know that field personnel are not allowed to overrule that order, but can a doctor overrule it?

  3. rahul
    January 6th, 2007 at 11:43 pm

    Btw, House does not like Occam… He hates the Occam’s razor principle… just an error in your review. For clarification, see the Occam’s Razor episode 3, season 1.

  4. nocturnale
    January 31st, 2007 at 9:05 am

    Houses’ apprentice doctors are super-doctors… they do everything ‘in-house’!!!

  5. Brit
    March 3rd, 2007 at 6:27 pm

    As an independent film maker, I can understand reasons for why the “young guns” perform all the tests themselves. It’s more interesting to watch. Rather than have them send away for the tests and then sit around and wait for the results to come back, it allows the actors to be interactive and do things that look cool at the same time. Not medically relevent, for sure, but it’s a tv show and it’s main point is to be entertaining. I’ve just found your blog and I like reading it. Thanks for the insight. :)

  6. Senor
    March 8th, 2007 at 2:50 am

    ALS could have been immediately excluded because the patient had sensory symptoms… (or there are two different neurological disorders at the same time -very unlikely)

  7. Marge
    April 15th, 2007 at 1:34 pm

    Typically, ALS includes lesions of both upper and lower motor neurons - and in consequence there is a whole set of symptoms, e.g. spasticity (upper) as well as muscular atrophy and local twitching of parts of muscles (lower). By the time the patient came to House’s attention - hey, he even needed a wheelchair by then - these symptoms should all have been present. With the spinal AVM shown, on the other hand, there should have been no spasticity.

    So it’s either or: Either spasticity and muscular atrophy; then the initial diagnosis of ALS would have been plausible, but the AVM diagnosis wouldn’t have worked (and the patient wouldn’t have been able to walk at the end of the episode). Or no spasticity/atrophy - fine with the AVM, but no one should have diagnosed ALS to start with.

  8. Geoff
    May 7th, 2007 at 9:37 pm

    Okay, so the medical application of Occam’s Razor states the odds of patients suddenly developing two unrelated conditions at the same time are next to zero.. but remember this is House’s Universe: where the improbable is guaranteed. Occam’s Razor still applies, but we have to go back to the original definition.

    “entia non sunt multiplicanda praeter necessitatem,” is what Occam originally said. It’s often paraphrased as “all things being equal, the simplest solution tends to be the best one,” but Einstein improved it as “make everything as simple as possible, but not simpler.”

    What I’m getting at is: two unrelated conditions may be the simplest (more likely) diagnosis than a single, rarer condition. In fact, I believe House makes this point in an episode.

    Okay, I’m done ranting now..

    Geoff

  9. Peter
    May 9th, 2007 at 2:24 am

    Very basic error in the writing: his code status was only specified as DNR, not DNI (do not intubate). Resuscitation would involve stuff like CPR and defibrillation, whereas a DNI order specifically addresses intubation. Patients can and sometimes only choose one of the two. Strictly by the letter, there should have been no conflict at all about intubating this patient in respiratory distress. This show is not very good in general with medical realism, but I would have hoped that the advisors would have at least caught that error.

  10. Demosthenes
    July 8th, 2007 at 4:47 pm

    The patient in this case is shown only saying to a doctor, “I want one of them papers that say I don’t want nothing done if something go bad.” It’s the doctor (Foreman, aka Omar Epps) that calls it a DNR. Given the patient’s statement, it seems logical to conclude that he chose both a DNR and a DNI. It could be that doctors just used the term DNR for short, or that the writers used it to simplify things.

  11. Stephen Greenwald
    October 29th, 2007 at 3:56 pm

    Also, I might be wrong as I’m a chemist and not a doctor, but my focus is NMR, which is equivalent to MRI.

    How could the AVM “hide behind” inflammation? MRI is not an X-ray. Things do not cast shadows over other things. That is the the whole point of using MRI! The AVM and inflammation would have to be in the same place, and I think even House agrees that two things can’t be in the same place at the same time. Am I missing something here?

  12. Bryan
    May 22nd, 2008 at 7:54 pm

    I’ve had a nagging feeling about this episode for a long time now, and hopefully someone can shed some light on it for me. I *think* it’s an error in the writing, but tell me I’m not the only one who picked up on this…

    ————–
    So Dr. Hamilton (John Henry’s doctor) is called in “to pull the plug” and allow John Henry to die.

    At this point, House thinks 100% that JH has Wegener’s, but Dr. Hamilton says that Wegener’s is one of the first things he tested for, and the results were negative.

    So then we move to the scene where Dr. Hamilton is about to pull the plug, and House and Wilson are standing out in the hall talking, and here’s the dialogue word-for-word:

    House: If it’s Wegener’s, his lungs won’t be able to handle it. As soon as they pull that plug, he’ll die.

    Wilson: That’s why they call it…”pulling the plug.”
    ———–

    So here’s my beef - Dr. Hamilton already tested for Wegener’s and it was negative. BUT the only way that they can “pull the plug” is if John Henry actually HAS Wegener’s….

    So either Dr. Hamilton didn’t think this through very well (why would he pull the plug if he knows his patient doesn’t have Wegener’s), or the writers really messed up somewhere….

    Did anyone else notice this seemingly huge contradiction besides me?

    Thanks for any input!

  13. Igor
    July 12th, 2008 at 1:14 pm

    @ Bryan

    Well, I guess, Marty Hamilton is just “letting” John Henry die. Dr. Cuddy says that Marty, as a friend of Henrys, will be coming to pull the plug. And, since he’s pretty much convinced that John Henry has ALS and therefore will die slowly and painfully, he reckons letting John Henry suffocate is a better way to end his torment.

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