House - episode 19
There is a big spoiler below, so condsider yourself warned.
At first, this seemed like it would be an excellent episode of House, but by the end it had degenerated into a “Look at us, we’re so clever” hour of television.
At a swim meet, one of the judges drops dead of bacterial meningitis. The hundreds of participants and bystanders are rushed to the local hospitals for evaluation. While examining a precocious twelve year-old highdiver, Dr. House is alarmed by her symptoms. She has a fever, neck pain (with side-to-side movement, not the flexion/extension pain normally seen with meningitis) and a rash on her abdomen. Due to the fact that these symptoms have been present for several days, House is convinced that she does not have meningitis, but is still concerned enough to admit her to the hospital. A spinal tap is normal. Drs. Foreman and Chase notice that she has blood in her mouth, though an endoscopy (apparently performed with a nasopharyngoscope) is fairly normal. The patient has an absence seizure while conveniently hooked up to an EEG. Due to the overcrowding in the hospital, a CT scan cannot be obtained so they have to ultrasound her brain. The ultrasound shows bleeding around the brain so she is taken to surgery. Ultimately the team discovers that the patient has Thrombotic Thrombocytopenic Purpura (TTP) due to being pregnant. House informs her that she needs plasmapheresis and must terminate the pregnancy.
There are two main problems with the medical care presented. First, while it is possible to ultrasound the brain, ultrasound waves cannot penetrate the skull. The procedure must be performed either before the skull bones have fused or on a surgically opened skull. Neither was the case here. Second and more important, termination of the pregnancy is not required in cases of TTP. The goal is to succesfully treat both the mother and the fetus; terminating the pregnancy does not affect the course of the disease.
A few medical nit-picks: Those weren’t absence seizure waveforms on the EEG. There are many more causes of TTP than the ones mentioned, though pregnancy is a major cause. Did they ever get around to explaining why the patient had neck pain?
The soap opera in this episode involved House trying to convince Cameron to come back to work for him. She agrees, but only if he goes on a date with her. This has conflict of interest written all over it.
This episode earns a B+ for the mystery but a pitiful C- for the solution. The medicine receives a barely passing D. The soap opera aspects earn a B.
May 4th, 2005 at 6:27 am
I’m not 100% sure, but I think when the neck pain first came up, the girl said she hurt it during the dive, or some such, which House (true to form) didn’t believe.
And Cameron’s ultimatum was just…creepy.
May 4th, 2005 at 10:10 am
I was surprised that the parents could be kept in the dark about the abortion. But I checked, and the New Jersey courts threw out their parental consent/notice law.
What also surprised me as that House and the others could miss that she was pregnant for that long. The ultrasound made it look like she was two or three months along. Shouldn’t she be in the midst of morning sickness? It seems like House has usually been better at spotting pregnancies than this.
May 4th, 2005 at 10:16 am
Official Comment
Yeah, the ultrasound showed a fetus that was at least 3 months. I’m surprised they took her to surgery without checking a pregnancy test or at the very least getting a good history.
May 4th, 2005 at 11:53 am
Personally, I think that the date request was a good way to show Dr. House how other people feel around him. It’s an area he probably has no expertise in. That might be why she asked him, imho.
May 4th, 2005 at 3:10 pm
Early into the episode, I knew the problem would be sexually-related. I thought for sure that the coach was having a relationship with the girl. This is t.v.,after all, so the problem must have a predictably “shocking” solution. While I really like “House,” this episode was disappointing.
May 4th, 2005 at 9:41 pm
When she had blood in her mouth, did it make sense to check for bleeding in the intestines? Stomach, maybe, but could blood from the intestines make it up to the mouth?
Also, how come she was already hooked up to the EEG monitor before she’d had a seizure? Or would that be routine?
May 4th, 2005 at 9:54 pm
Official Comment
If she had been vomiting heavily, blood from the small intestine might make it up to the mouth (but she wasn’t).
You echo my point about the seizure and EEG — sure was mighty convenient she was already hooked up when the seizure happened out of the blue.
May 4th, 2005 at 10:21 pm
links for 2005-05-05
Xtreme TB320DKO 320-Disc CD/DVD Case Price After Rebates: $9.99 (tags: CD DVD case) Dr. Henochowicz of Medviews: Scan Me an allergist who’s ticked off that folks will go clamoring for CTs of their cardiac vessels even if they’re low risk, increasing…
May 4th, 2005 at 10:50 pm
Have you seen this week’s TV Guide? There’s a two-page article where three doctors were consulted about medical plot points from various “House” episodes. Their reactions seem to range from tepid to very negative.
May 4th, 2005 at 11:11 pm
Official Comment
Loren,
My wife pointed that out to me. I can’t believe they stole my schtick! Honestly, there has never been anything near a 100% accurate medical TV show, and House is far better than most. Still, I feel I have to correct its more blatant errors…
May 5th, 2005 at 11:17 pm
As for the abortion, that could just be House doing what he feels is best for her. That is the kind of guy he is, after all.
May 12th, 2005 at 9:11 am
House’s statement to the swimmer was that she would either have to have plasmapherisis OR terminate the pregnancy. The closed captioning reads “plasmapherisis or else terminate.” This may be no more medically correct, but at least House isn’t making the decision himself.
August 23rd, 2005 at 8:47 pm
According to my father while watching a re-run of this episode, the blood in the brain should have already shown up in the spinal tap, since a spinal tap is the conformation of a CAT scan. Is he right?
August 23rd, 2005 at 9:42 pm
Official Comment
If blood is seen on a CT, it generally shows up in the spinal tap. The main reason for doing a CAT before a spinal tap is to prevent a herniation of the brainstem.
August 25th, 2005 at 9:12 pm
What he is saying is that since they did the spinal tap first and saw no blood there was not a need to do the CT after the negative spinal tap. Is that right is the question.
August 26th, 2005 at 3:14 pm
Official Comment
He’s right - there was no need to do a CT scan to look for bleeding if the tap was negative. If they’re looking for masses, tumors and such they may still want to du a CT though.
December 2nd, 2006 at 7:05 am
Bad medicine is practiced in this episode of House. TTP is diagnosed by a low platelet count, anemia and neurological disorders. There is no relationship between TTP and pregnancy, however there is a relationship between HUS (haemolytic uremic syndrome) and pregnancy. HUS and TTP do have some resemblance, renal failure is more predominant in HUS and neurological disorders in TTP. A spinal tap and brain surgery is to my opinion contra-indicated in this case. Plasmaferesis is the treatment of choice. A remark on the videocapsule, the result of this test will be avalable after one week. In this episode it’s suggested that the result is known after several hours. Final remark: this episode shows again that on base of medical history taking, physical examination and basic laboratory examination the diagnosis would be made without the need of more sophisticated test.The TTP diagnosis in this case is wrong.
December 9th, 2006 at 6:40 pm
I would comment that House is one of the worst medical shows as far as medical accuracy is concerned. Even comedy shows like Scrubs tend to have fewer blatant errors. As a physician, I can overlook minor errors in tvland, but House routinely trots out blatant errors even medical students would recognize. It seems to me that the medical aspects of the show are researched on the internet by laypeople and that doctors are not involved.
December 9th, 2006 at 6:58 pm
And one more comment.
The comment by the above person Karpov is incorrect.
There is an association between TTP and pregnancy. Pregnancy is one possible precipitating factor among many, and account for 10-25% of all cases of TTP.
There is no relationship between HUS and pregnancy. In fact, HUS most commonly presents in children after bacterial infections.
And while the TTP diagnosis in this show was silly, calling it wrong implies that there was a “right” diagnosis given the way the patient was presented. And that is a bit ridiculous.
I do agree that doing a LP without a CT is stupid.
December 16th, 2006 at 11:36 pm
So who was the father?
December 23rd, 2006 at 5:55 am
Mayby I’m not totally correct in the relationship between TTP and pregnancy, however there is certain a relationship between HUS and pregnancy. However we can say there is some debate about HELPP, HUS, TTP etc. The main comment of John and me is that the diagnosis in this case of House doesn’t make any sense.
January 10th, 2007 at 8:50 pm
The decision to abort was one completely separate from the need for plasmapheresis. From a medical perspective, it was NOT an “either or.” TTP is caused by a mutation in the enzyme ADAMTS13 (Moake, NEJM 2002), and requires plasmapheresis to replace that defective enzyme - irrespective of pregnancy. In fact, pregnant mothers with TTP are treated with - plasmapheresis. She can keep the pregnancy with plasmapheresis, and if she aborts she still needs plasmapheresis.
It really felt like that bit was just thrown in at the end to find some way to close the episode with something that an uninformed lay person might understand as a life or death dilemma.
Or! do you think Dr. House already knew the girl had made up her mind on the matter, and given that he has no legal authority, decided to give her more justification for choosing what she already wanted to do? hmm . . .
February 6th, 2007 at 10:27 pm
It was interesting that the girl was 12. That is the same age that my daughter ended up being diagnosed with this rare and often fatal blood disease. He id not say that this disease does not want to leave one’s system after treatment, and comes back again and again with that patient.
Many of the girls who end up with this disease are high-risk and end up dying from TTP, the disease that he pretty much laughed at.
Brittany lost her battle with this rare disease at age 12. She had over 45 treatments of plasmpheresis, and then chemotherapy to try and stop TTP.
This is a rare and often dangerous disease.
May 15th, 2007 at 9:57 pm
Hi%21
May 18th, 2007 at 10:53 pm
Hi%21
July 4th, 2007 at 7:01 am
I am a patient suffering from the effects that TTP left on my body. It destroyed my kidneys and now am on dialysis,waiting for a transplant. Been on dialysis 4 years.I usually like House, but this episode, because it was so close to home (an episode of House being close to home LOL)I was pretty disappointed in it.
September 7th, 2007 at 5:42 am
I have to add that it is actually possible to do an ultrasound of the brain in adults without surgery. At my university (and some others in Germany), they try to diagnoze Parkinson’s disease early through a “bone window” in the temple area. I admit that this is still controversal (ultrasounding the substantia nigra seems not an easy thing to do), but you should be able to see blood that way.
September 7th, 2007 at 5:42 am
http://jnnp.bmj.com/cgi/content/abstract/76/3/423
October 11th, 2007 at 5:51 pm
you may think that he could not terminate the pregnancy but i think the girl was too young to have the kid if something more goes wrong in that kind of pregnancy she dies too because of her age so in that case was the right choice even if she’d wanted to have a baby
October 20th, 2007 at 12:52 am
this was the worst i mean the rash was bleeding into the skin (did u mention that???)
lol me being serious!
:)
October 20th, 2007 at 9:40 pm
scott plz answer 2 my message plz plz plz
ily and ur reviews, i never would have guessed some of the more obvius things u point out.
bye 4 now
January 22nd, 2008 at 11:45 pm
I just watched this on DVD, and was surprised to see, listed on the whiteboard, the words “intercranial bleeding.” The next time we see the whiteboard, it says “intracranial bleeding.” I was glad she hadn’t grown another head.
January 23rd, 2008 at 5:31 pm
In this episode, the girl ingests a camera which shows the doctors her digestive tract. Both the LP and this test, called a capsule endoscopy, take a total of three hours. However, when I had a capsule endoscopy, I had to wait for the camera to finish passing, which in me was slightly faster than average- about 6 hours total. Thus, the team’s timing was off. And, who are Chase, Foreman, and House to look at and interpret this? They certainly are not gastrointestinal doctors! The writers MUST stop making House and his lackeys perform tests that they are obviously unqualified to do, and they need to stop producing results from tests that take days and/or hours to complete in a lot less time. It makes me feel slightly stupid that they do not always stick to the natural rules of medicine because they feel like people won’t pick up on it! So anyway, I thought you’d like to know another mistake that I picked up on in this episode =]
June 9th, 2008 at 9:04 am
My biggest problem was actually with the way House is inspired to guess TTP: the idea that the other boys on her team are “avoiding” her. This is a false clue, given that it turns out to have little to no explained relevance–was it the sixteen-year-old kid on the team? If so, why would the other guys avoid her? Sixteen-year-old males don’t have sex with twelve-year-old girls and then let their friends know–they would immediately be ostracized along with the girl. So they’d shut up about it. This is a logical “bridge” that just doesn’t connect from clue to conclusion.
I’m not sure I explained that very well.
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