House - episode 10
This was the first episode of House with an unhappy ending. The medical mystery was fairly involved and several personal mysteries were thrown in as well. Why is the homeless patient seizing and photophobic? Why does Dr. Foreman detest the homeless? Why does Dr. Wilson go out of his way to help them? All the mysteries were answered — except for the one about Dr. Foreman, which was dropped halfway through the show and never picked up again (even though it was the driving force of the first half-hour).
The ultimate solution to the medical mystery was good and bad with the one-two punch of an abdominal tuberculoma and rabies. Abdominal tuberculomas are uncommon, but there have been several well documented cases. It was a bizarre presentation for rabies, both in the patient and Dr. Foreman, so I’m suspicious of the diagnosis with the information presented.
There some other mistakes (medical and otherwise) that caught my eye on tonight’s show:
- The show was right that Iron Dextran is infamous for causing allergic reactions. However, contrary to what the script said, the “banana bag” was still infusing in the patient and not the iron dextran when she had the allergic reaction. In case you’re wondering, a banana bag is an intravenous multivitamin formulation that is nearly neon yellow in color.
- Why was the epinephrine injected intramuscularly when there was a perfectly good IV site? IV administration gives faster and more reliable results — very important in a code situation. Foreman remembered the IV site when he had to give the patient Haldol several scenes later.
- CA-125 is a tumor marker that is useful for following a patient diagnosed with ovarian cancer; it is not useful as a screening tool. It’s very expensive too, so I find it hard to believe that any physician would use it as a first-line general screening test.
It wasn’t all bad. There was some good medicine in the episode too. Serotonin syndrome and paraneoplastic syndrome were likely diagnoses and adenosine is an appropriate drug for a supraventricular tachycardia.
Once again, the Young Gun doctors were performing every test themselves. Dr. Chase performed the abdominal ultrasound and Dr. Foreman performed the biopsy on the ovarian mass. He’s a neurologist so I’m surprised he even know here the ovary is.
I give this episode a B+ for the mystery (the score would have been a great deal higher if they hadn’t forgotten the plot point involving Foreman), a C for the eventual solution, and a C- for the medicine (the episode lost lots of points for perpetuating the CA-125 screening myth).
February 16th, 2005 at 10:17 am
Hey–great reviews! I’m starting to think that one of the writers for the show is also running our curriculum; every week seems to cover exactly what we’re just learning. (Two weeks ago we learned about rabies, and just last night I start our heme block and was learning about anemias. Even came across naptholene very briefly.)
I noticed the IM epi as well. Even though I’m still completely pre-clinical, I can still figure out the most basic stuff.
February 17th, 2005 at 10:48 am
What I found itneresting about this one is how the medical team that specialized in breaking into houses handled a homeless case: They found her tarped-covered box in an alleyway and poked through it, then they found her former address and broke into that.
I hope in a future episode they have a patients who’s a hobo so they can go searching through a week’s worth of old rail cars to find a clue.
August 24th, 2005 at 8:32 am
I didn’t know much about the medicine this week (I’m interested in medical matters, but I’ve never been professionally trained, so my knowledge is strange and patchy), but even if it had been 100% wrong I would have got off on the dialogue this week. There was some great stuff in this episode.
October 9th, 2006 at 6:41 pm
I was surprised that they didn’t clue into rabies much sooner. Bats are one of the primary carriers, and when somebody finds a live bat in their bedroom they should check with their doctor, because bats can bite you or lick you in your sleep without you knowing it. This lady had about half a dozen bats flying out of her “bedroom”, and none of these doctors even thought about rabies?
October 26th, 2006 at 12:53 pm
Hallucinations, BATS, fear of light, fear of water…dude, how could you say this is NOT rabies? it’s definately plausible!
December 5th, 2006 at 11:54 am
From what I understand, medical students dissect cadavers–that would explain how Foreman knew where the ovaries were. Besides that fact, the most important aspect of the show was the inclusion of COMPASSION. For Foreman, who initially detested homeless people ( which is due to his detestation of his homeless and druggie brother) learns to have compassion for them. As a doctor, this attribute is commendable. What I liked so much was that it came from Foreman, and not any other character. He allowed a dying woman to die in relative ‘peace’.
December 19th, 2006 at 11:36 pm
Foreman has a homeless and druggie brother? I didn’t notice any reference to that in the episode. Either you are referencing later episodes or you are confusing Foreman with Wilson.
December 20th, 2006 at 3:20 pm
Official Comment
A season three episode mentions Foreman’s brother.
March 6th, 2007 at 4:25 pm
I finally just started watching House and today I found your lovely blog. I’m a neuropsychologist so I’m in it for the neuro cases primarily, although it’s all interesting…This episode had me shouting at my screen more than most! As soon as the pt bit Foreman, I was yelling, “check her for rabies!” And then once the bats erupted out of the box, well, COME ON! The show takes an awful lot of dramatic license. It’s fun, though. And a nice review…
March 29th, 2007 at 8:48 am
I would just like to point out that the word “friend” in Swedish does not mean what dr. Wilson claims it to be. As far as I know anyways. Great show btw and I always enjoy reading this blogg.
March 31st, 2007 at 10:10 pm
Y’know I think this is the reason I like this show so far … In medical mystery shows like this I like to try to guess the diagnosis … with this one it’s funny because I’m operating on the exact same information as the characters are which is my first 2 years of med school combined with NOTHING! I’ve never heard of anyone practicing SWAG medicine (that’s Simple Wild Ass Guess). But at least it’s interesting.
April 9th, 2007 at 2:34 pm
I was disappointed to see how the script handled her sinus tach. Adenosine administration should have been a fairly simple procedure to research and emulate: I was disappointed to see it pushed without a saline flush and at 1 mg (?!) dosing. Even more surprising was how the team belied the possibility that the fever could have been causing the tachycardia. 150 is too slow for a reentry circuit; it seems totally plausible that a high fever (>104) could vasodilate her enough to demand a compensatory tachycardia. I love the show, but was just a little surprised to see them drop the ball in this scene.
April 26th, 2007 at 5:55 am
Aw, House cheated a bit with the 17-year-old with the eating disorder and caused me to miss the call even after I was sure I’d finally “gotten” one. Korsakoff’s syndrome doesn’t start with a c….but *confabulations* does :)
June 20th, 2007 at 6:59 am
IV epinephrine is indeed faster. It can also precipitate ventricular arrythmias. Hence is is given IM (0.5mg) for anaphylaxis. Where you have a cardiac arrest, and you really need to drive the blood centrally to prevent the vital organs failing, use IV. Don’t do this for anaphylaxis.
A recent study of New Zealand doctors found ~80% did not know the correct dose of adrenaline to give in anaphylaxis!
June 30th, 2007 at 4:28 pm
I thought that the sidestory about Foreman and how he views homeless people was nicely resolved. At the start of the episode, he was prejudicial and bigoted towards them, but after learning about Victoria’s history, he empathised with her and told her that it wasn’t her fault. So he learnt that not all homeless people were alike, not all of them run scams, and not all of them (in fact very few) become homeless because they want to.
July 18th, 2007 at 8:31 pm
Wow, I actually was thinking rabies. I am so awesome…
August 26th, 2007 at 8:42 pm
Yeah, I thought “rabies” as soon as I saw the bat.
October 3rd, 2007 at 6:40 pm
Hey doctors, I thought rabies shots were no longer given in the abdomen. Am I wrong?
November 3rd, 2007 at 8:46 pm
I was reading about Jeanna Giese and I remembered this episode. I’m surprised they didn’t even try that treatment.
November 18th, 2007 at 3:15 pm
Don’t forget that the patient becomes aquaphobic in this episode, because the writers got confused between that and hydrophobia, the obsolete name for rabies.
November 21st, 2007 at 10:40 am
I agree with the person who questioned the fact that Foreman was vaccinated in the abdomen.
Rabies vaccines are given in the deltoid muscle and rabies immunoglobulin (RIg) is administered to the bite wound.
December 5th, 2007 at 1:40 am
AC- Epinepherine 1:1000 is given for Anaphylactic reactions, it is not given IM(intramuscularly) though. Epi 1:1000 is given at .3 - .5 mg SQ(subcutaneously). epi 1:10000 is given in cardiac arrest situations at 1mg pushes with intervals of 3-5 minutes depending on your protocols. Adenosine is given in a rapid IV bolus, with a saline flush following right behind it(not in the show) due to its short half life(under 10 seconds but varies on manufacturer) and should be given in a vein proximal to the heart. i.e. left AC is our usual vein of choice down here. Also, the Adenosine is given in three dose intervals unless broken in between those doses. 6mg, 12mg, 12mg and the IV bolus syringes are usually prepackaged in those amounts. for example, adenocard has a red top box for their 6mg bolus and yellow top box for their 12 mg bolus. But I still like the show :)
March 24th, 2008 at 12:54 am
Winston Jen, she actually did admit to self administering an overdose of insulin to get her a bed for the night but I know what you mean.
I’m glad I don’t have a doctor like house for my clinical attachment, like those two medical students (the 1 time during pre clinical years when we get to visit ‘the real world’ and meet real patients). This semester I’ve got a General Practitioner who is friendly and the patients are asked to come visit to have histories taken by us. If I’d a doctor like House (and I think some who are in hospitals have people similar to this, because I’ve heard stories about it) then I’d probably hate what is the best part of the week, and worth the hassle of trying to get to the surgery (which is also closer than all except one of the hospitals, and most of the other general surgeries, so I got lucky).
April 27th, 2008 at 10:47 pm
UpToDate says Epi i.v.
April 27th, 2008 at 10:47 pm
i.m. I mean, sorry
May 6th, 2008 at 7:55 am
I had a look at the dates and I’m not sure if they would have heard of Jeanna Giese by the time the episode was written.
I had given it some thought and I think it would be pretty inappropriate to suggest they could cure rabies even after Giese’s survival, since doctors all over the world are trying and failing to save real people from the virus.
I think would have been the same if the patient they cure in season 4 did actually have polio.
May 21st, 2008 at 1:55 pm
Giving adrenalin SQ is stupid and dangerous. The peak adrenalin concentration is reached after 30 minutes vs. 8 minutes for IM.
The British guidelines recommend the IM route unless you are an anesthetist, emergency physician or intensive care physician. And, of course, “patients who are given IV adrenaline must be monitored – continuous ECG and pulse oximetry and frequent non-invasive blood pressure measurements as a minimum.”
So the IM route is the recommended way to treat anaphylaxis
http://www.resus.org.uk/pages/reaction.pdf
Leave a Reply
Contact Me
Subscribe:
The Best Of...
Special Topics
Archives
Categories
Arbitrarily Interesting Medical Condition
Twitter
Comic Blogs
Medical Blogs
Currently Reading
The Net:
Contents may have settled during shipping. Past results are no guarantee of future performance. No animals were harmed during the production of this product. Void where prohibited by law. All rights reserved. Not valid with other offers or specials. Professional driver on a closed track. Your financial institution may impose other fees. All models are over 18 years of age. Employees must wash hands before returning to work. Results not typical. Many suitcases look alike. 18% gratuity added to tables of six or more.
Do not taunt Happy Fun Ball.
© 2004-2008 Polite Dissent. Powered by WordPress