House - episode 21
Do I really have to say it? There are spoilers below for this week’s episode of House.
An intriguing and at times surreal episode of House that not only introduces the “love of his life” – now married to someone else – but also provides more information about his leg injury. This episode did not try to be as sensationalistic as the last two weeks, and the result was a much better show.
Dr. House is coerced into teaching a Medical Diagnosis to the medical students. He presents three cases, all starting with leg pain. The first case is a middle-aged farmer. Examination of his leg reveals an inflamed puncture wound consistent with a bite. At first, the bite is felt to be from a poisonous snake. The patient doesn’t respond to the antivenin, and in fact develops a life threatening allergic reaction. Different antivenin is tried with no success. After reminding the class that “every patient lies,” House discovers that the patient was bitten by his dog. The dog was a carrier for the strain of Group-A Strep known as “Flesh Eating Bacteria”, and the patient ends up having his leg amputated, but at least he survives.
The second patient is a sixteen year-old volleyball player who comes to the clinic with leg pain. Dr. Cameron examines her and diagnoses muscle strain. On a complete physical exam she notices a small thyroid nodule. The patient undergoes a fine-needle biopsy of the thyroid and thyroid testing, revealing that she was deficient in thyroid hormones. Later, she develops an unusually high calcium level and an MRI is obtained which shows an osteosarcoma of her leg. This was successfully operated upon and she returned to playing volleyball.
The third patient was another middle-aged male. This one developed severe leg pain while golfing. At his first presentation in the clinic, he appeared to be a drug addict. Later, when he returned to the office he was still having pain and had now developed discolored urine. He was misdiagnosed with muscle trauma when in reality he had a blocked artery in his leg. By the time the blockage was diagnosed, a great deal of muscle tissue had already died. An amputation was recommended, but the patient chose to have the blocked vessel surgically reopened instead. Due to worsening pain after the procedure, the patient opted to be placed in a medically induced coma until the worst of the pain was over. While he was in this coma, his significant other used the terms of his power of attorney to send him to surgery – not for the amputation, but for a removal of all the affected tissue. This left him with a limp and constant pain (and a serious beef with his girlfriend) – but at least he was alive. About two-thirds of the way through the episode, it became clear that this patient was House himself.
I really don’t have too much to say about the medicine this episode. For the most part it was decent; however I find it hard to believe that the doctors couldn’t tell a dog bite from a snake bite. Also, the idea of Drs. Foreman and Chase going into the farmer’s field, tackling the dog and swabbing its mouth is just ridiculous. The volleyball player’s diagnoses were more straightforward, though I will point out that thyroid testing and biopsies are generally done as an outpatient and don’t require admission to the hospital.
In terms of House himself, it sounds like his doctors screwed up if they just sat on an elevated creatine kinase without investigating further. A muscle infarction would be very low on my list of possibel diagnoses, but at least I’d look closer. Apropos of a previous post of mine, they were a little quick to shock a flatline this episode (and notice that they defibrillated the poor farmer through his shirt). I recommend a little more research on cardiac emergencies for next season. The medicolegal aspects of the episode I leave up to the lawyers, but it seems like an abuse of the concept of power of attorney to me.
Despite the introduction of Sela Ward as House’s ex, there was precious little soap opera inthis episode (it was basically a set up for next week’s season finale). The scenes where House was teaching the class were particularly clever and well done, especially those that featured Carmen Electra.
This episode deserves a B+ for the mysteries and an A- for their solutions. The medicine was mostly well done, and earns a B. The soap opera aspect also earned a B, but the classroom scenes earn an A+.
May 18th, 2005 at 2:21 am
One glaring error I noticed in this week’s episode is the confusion of an aneurysm with an infarction. If I’m not mistaken, it is mentioned in this episode that House’s muscle death was caused by an aneurysm. However, aneurysms themselves do not cause ischemia, additionally, it’s been previously mentioned in the series that House’s leg damage was the result of an infarction. Feel free to correct me if I’m wrong–I’m certainly not as qualified as you are.
May 18th, 2005 at 7:45 am
Official Comment
As I recall, they mentioned he had an aneurysm that had clotted off, which — if true — would lead to an infarction.
May 18th, 2005 at 9:40 am
House had a popliteal artery aneurysm that clotted off, causing acute ischemia to his calf muscles resulting in the infarction of some of the muscle tissue. This is a known potential complication of popliteal artery aneurysms and is (unfortunately) not too uncommonly the way these aneurysms present. In actuality, he probably would have been better off with a below-the-knee amputation.
May 18th, 2005 at 12:54 pm
What exactly is causing the pain five years after the incident, if all the affected tissue was removed?
May 18th, 2005 at 8:16 pm
Something that I have been curious about since I started watching House, MD–It seems to me that a lot of the show’s tension is derived from forcing the three residents into making differential diagnoses almost within minutes of the patient’s initial examination. Even during the lecture on leg pain, House almost immediately demands differential diagnoses from the medical students. “What is causing the leg pain?”
My reply to him would have been a flat, “I don’t know, and I won’t speculate until I examine the patients myself and see some test results.”
Now, I do realize that sometimes, you have to act fast and go with your instincts in hopes of saving a patient who might be dying now, rather than waiting a couple of hours for lab results to come in. But how valid is this emphasis on guesswork? Is it part of the Hollywood medical show formula? It seems far too haphazard a way to proceed with real patients.
Chantal Whittington
May 19th, 2005 at 12:24 am
The guesswork is House’s “thing,” we are by no means meant to believe it’s common. That’s what House establishes in the first episode, that he makes his decisions quickly because he knows what a delayed decision can do, as evidenced by his constant leg pain. With normal, clinic cases he uses his Sherlock Holmes style deductive ability to diagnos them within minutes, and the episodes are taken up by larger cases that, the show wants us to believe, other doctors couldn’t handle in time.
I don’t mean to be rude, but that was in the official show description, and I assumed everybody either knew that going in or had drawn the conclusion themselves.
May 19th, 2005 at 1:22 am
links for 2005-05-19
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May 19th, 2005 at 8:31 pm
Actually, based on the presentation, symptoms, and outcomes, House suffered a clot in the lateral circumflex
femoral artery. The infarction was in his thigh (quad compartment and adductors, to a lesser extent), and not the calf muscles.
May 29th, 2005 at 4:34 pm
I am so in love with this ep. (And thus was somewhat disappointed by the finale, if only because it seemed so anticlimactic after this hour of brilliance).
I had the same reaction at first wrt Foreman and Chase’s going to the farm to find the snake themselves. However, given the surreal storytelling and shifting use of familiar and unfamiliar characters/actors to represent other characters, I started thinking [fanwanked?] that we weren’t REALLY supposed to believe that F&C had ACTUALLY gone to the farm in the “real” story; rather, this was just for storytelling purposes, because, just as it was more fun to see Carmen Electra than a middle-aged farmer, or a basketball player, or a generic golfer, or House, it made for a better story to put Foreman and Chase into the roles “really” played by random animal capture people (no clue what you call them). At least, I hope this is the case. ‘Cause, otherwise? Yeah, dumb.
June 1st, 2005 at 3:11 pm
Yeah, them going to the farm reminded me of CSI or Crossing Jordan. Esp. with Crossing Jordan I catch myself saying “why is a coroner doing investigative work” about 3 times a show :)
November 10th, 2006 at 9:13 pm
I loved this episode too but am left completely puzzled as to what House hoped to gain from being allowed to “ride out” the pain.
As I understood it, he wanted to let his body take care of the dead muscle in the hope that he would recover much of the use of his leg. He wanted to do this despite the knowledge that it could kill him and that he could be left with permanent “chronic pain”.
As we know his wife ignored his wishes and had the dead muscle removed surgically. This resulted in House regaining much of the use of his leg, and, yes, left him in chronic pain.
So… what’s the difference? What did he hope to gain if his wife HAD respected his wishes? How might it have been a better result for him? It seems to me like it turned out the same in any event. Clearly I am missing something. Would anyone like to explain?
I guess this also overlaps with question 4, above - why does he even have such tremendous pain years later? People who have amputations don’t feel chronic pain years later. Or do they? I can’t say I know anyone so perhaps I’m just really ignorant.
Please help!
Cheers.
November 15th, 2006 at 3:32 am
People who have amputations DO feel chronic pain years later. Not everyone, obviously. It’s called “phantom member syndrome”. They keep feeling pain in their members even when they have been removed. This is because the nervous terminations are still there, they are chronically damaged and they keep hurting. The brain keeps thinking this painfull signals come from the member itself, not from the nerves.
Anyway House’s pain has a lot to do with muscle atrophy surrounding the lesion.
December 5th, 2006 at 9:19 pm
Re: why House still feels leg pain so many years later, it has been debated in later episodes that the pain is actually in his head and that his leg is fine. For example, there was one episode where Cuddy gave him a placebo instead of his medicine, and he thought his leg had gottne better. Also, in the recent storyline involving the cop, House has been on a restricted Vicadin regime, and has been in extreme pain; Cameron suggested at one point to the rest of the team that he was going through withdrawal, not real pain.
On the other hand, House’s extreme reaction to the cutback in his Vicadin could indicate that the pain is real. Further evidence of this is in the episode where he gets shot; at the end, he asks to have a procedure done that will end his pain and give him back the use of his leg. At the beginning of the next episode (beginning of season 3), House has the use of his leg back and is even running. Slowly the pain returns until he needs the Vicadin again.
Personally, I think the viewer is meant to keep wondering whether the pain is real or not.
January 22nd, 2007 at 11:35 pm
House has been a doctor for over 20 years. He didn’t get brilliant just after his leg injury. He revealed that his doctors did not diagnose him for three days. Couldn’t he diagnose himself? It would be easier to determine what the problem was because he was experiencing it himself. House is supposed to the the doctor of last resort. They say, “Doctor, heal thyself.” I loved the way the episode was done, however, I could not suspend reality to believe that he couldn’t figure out what was wrong with his own leg.
January 26th, 2007 at 10:32 am
But no-one’s answered jamesie’s question, which has bothered me ever since I saw this episode. How is the actual outcome after STACEY’s intervention (ie no amputation but chronic pain) any different from what would have happened if she’d respected his wishes to leave it alone (ie no amputation but chronic pain)?
February 20th, 2007 at 3:02 pm
In the volleyball player’s case, they diagnose hypercalcemia by noticing her hypersensitivity to pain. Did this seem odd to anybody else? I had understood that hypercalcemia decreased nerve firing, leading to weakness rather than hypersensitivity.
Thanks for this site - I find it very useful for my classes!
April 16th, 2007 at 4:10 am
this is a good site u have up here. didn’t have time to figure if u really are a medical proffesional.. but to clarify one of ur commentators questions… what is causing the leg pain that House is suffering from ..lower limb ischemia as a result of a clot that might have migrated into his more tiny blood vessels further down his leg (from his aneurysm..) ischemia goes thru some clinical stages, they being claudication pain and the worse being rest pain. rest pain however does not decrease with any known medication, may be a sympathectomy can work. House takes an analgesic… probably a trade name…but to finally answer your question… my limited knowledge knows no ther chronic post operative predictable pain. some one mentioned “phantom pain”… that does not last for more than 2 to 3 months… n can happen only after a amputation. maybe they should have an episode describing exactly what the pain is due to…
April 19th, 2007 at 4:38 am
Hi there, it’s been two years for you, but I’ve just seen this episode with the explanation for House’s leg, and there were several things I was wondering. Like said before, couldn’t House diagnose himself ?? I mean, by the end he was suffering quite a lot, but when he felt pain at first, could’nt he do his differential dignose ??
Then, several times during this season, and by the beginnig of the 2nd, we see House sitting normally (in the 2nd episode of the 2nd season, he seats on a stool and brings up his two legs on a metal bar an then, he can ride his motorbike. ) I mean, if he can’t flex his leg to walk, how come can does so to sit or ride ?? Anyone can tell me if it’s an error, or really possible plz ?? thanks a lot ! And thanks for this site, it’s a great idea !
May 16th, 2007 at 9:38 pm
Cecile:
Speaking as someone who has a few family members with various leg afflictions, it’s a very different thing to constantly bend and unbend the leg to walk (repetitive motion), then to simply keep it bent on a motorcycle (or mostly bent, on a bicycle — my dad has two awful knees, and while he sometimes cannot walk, the exercise bike is still not very painful).
Now, I don’t know anything about leg infarctions, but it seems reasonable to me.
May 21st, 2007 at 10:35 pm
I discovered this site a few days ago and I’m already hooked. I’m really enjoying the civilized discussion of House medicine. :)
I have a history of migraines, sciatica, and osteoarthritis(thankfully not all at once), and when the pain was bad enough, I couldn’t think of anything but the pain. Severe pain can be incapacitating, both physically and mentally. I’ll bet House was in so much pain from the infarction, he couldn’t think straight.
And what happens to dead muscle tissue in the body, anyway? Would it have been medically advisable to leave the dead thigh muscle in situ?
Aside to Scott: I tried to subscribe to your site, but I kept getting bounced to a different page. I’d be much obliged if you’d sign me up.
July 23rd, 2007 at 6:05 pm
Hi, a big thank you to who ever is running this site! You’ve got me hooked. Anyhow, I’m 18 with big plans of one day becomeing a doctor one day. This is realy intresting to read!
August 31st, 2007 at 8:58 am
Just a little typo: “list of ‘possibel’ diagnoses”
On finding your site (via wikipedia), I chose this episode first because I’m interesting in screenwriting and think that episode is one of the best hours of TV of the last few years.
October 20th, 2007 at 8:53 am
I have long had an interest in the effects of snakebites, and noticed even more inaccuracies than described here. Firstly, the venom of coral snakes (one type of snake Dr. House thought might have bitten the farmer) is a neurotoxin, which causes muscle weakness, slurred speech and blurry vision eventually leading to paralysis, not necrosis. A bite from a coral snake would present with minimal swelling and pain, with noticeable symptoms of the venom becoming apparent about eight hours after the initial bite. Additionally, a coral snake’s fangs are far too small to penetrate jeans AND rubber boots like the farmer was shown wearing. Though the symptoms would match those of a cytoxin (causes muscle necrosis), which is produced by timber rattlesnakes, House’s first guess. A rattlesnake would also be capable of penetrating the clothing, and is significantly more aggressive than coral snakes.
Also, it would be COMPLETELY impossible for trained doctors to confuse a snakebite wound with a dogbite. The two look nothing alike! At that position on the limb a dog would need to wrap its jaws around the leg in order to have necessary angle to produce significant puncture wounds, which means that there would be bite marks on both sides of the leg. There would also be more shearing and tearing on a dogbite.
Loving this site, by the way. As you may be able to tell, I love picking apart the medical inaccuracies of shows like this.
October 20th, 2007 at 9:46 pm
i luv this ep.
January 16th, 2008 at 6:48 pm
jamesie, you’re right there was about a 50/50 chance he would be in chronic pain either way but the writers wanted him crippled physically and mentally (he is). Good idea too, makes the show way more interesting
March 13th, 2008 at 11:58 am
Quoting Emily: “At that position on the limb a dog would need to wrap its jaws around the leg in order to have necessary angle to produce significant puncture wounds, which means that there would be bite marks on both sides of the leg. There would also be more shearing and tearing on a dogbite.”
I was bitten by a dog in nearly the same place on my leg and I received *three* deep punctures from the top teeth and not so much as a mark from the bottom teeth. There was no tearing in the punctures. Guess it just depends on how the dog gets you and how quickly they release.
March 27th, 2008 at 9:38 pm
House’s pain might be neuropathic eg due to false pain signals possibly coming from cut off nerves sprouting trying to find their lost continuations.
April 8th, 2008 at 8:16 am
I want to thank you from the bottom of my heart for your excellent reviews of my favorite show. Being able to have a doctor explain the medicine makes this the best
hour on television ever. The producers should hire you to do a few minutes after each show. The results would be a blockbuster, like when you get expert commentary
during a professional sporting event. Kudos and thanks again!
Your Fan,
Gent
June 4th, 2008 at 3:32 am
Hi. I’m new to this site, but I’m extremely hooked already. Now I don’t know next to jack about medicine, but I have something to contribute to the “phantom pain” discussion. I seen this one program on Discovery Chanel years ago about an Indian neurosurgeon figuring out these various medical mysteries that are related to the brain (such as only recalling half an image from memory). One patient, with an amputated arm, complained to the doctor that there’s a lot of pain on his amputated side (it’s important to note that I don’t recall how long his arm has been amputated until he appeared in the program). The temporary treatment was very simple: the neurosurgeon placed a mirror perpendicular to the patient, and have him wave his remaining arm in front of the mirror. The patient immediately reported feeling relief on his amputated side, in which the neurosurgeon deduced that the patient’s brain was thinking that the amputated arm was still there.
July 7th, 2008 at 12:36 am
Surya: I’m familiar with a case which was treated similarly to the one you describe, except that the pain was described as feeling like the amputated hand was clenched far too tightly and couldn’t be unclenched (because the hand is not there). The doctor was able to give him the illusion of being able to unclench his hand by having him open the other hand, with the mirror making it appear as though it were the amputated hand, and this was enough to fix the illusion of excessive clenching.
Is that the incident you’re referring to? It seems odd to have generic phantom pain fixed by waving at mirrors.
As to people wondering what the difference would have been between House’s solution and Stacy’s, the impression I got was that after the clot was removed, chemicals which had built up in the dying muscle were being released throughout the body and were doing all kinds of unpleasant things, hence the pain that caused House to ask them to up his morphine and later to put him in a coma. House hoped that, given time, all of these chemicals would be released and pass out of his system, leaving the muscle clear to heal. The upside to this is that, theoretically, he might regain full use of his leg and completely recover. The downside is all the damage and pain being done by the chemicals rampaging through his system in the meantime, potentially fatally.
Stacy’s solution avoids the fatal chemicals by cutting out their source; she had them completely cut out the muscle which was releasing the chemicals. This stopped it flushing nasties through his system, but also stopped it being able to contribute anything to walking. I’m unclear on the exact cause of the ongoing pain that leads to the vicodin (ab?)use, but having an entire muscle cut out of your thigh after it throws nasty chemicals at everything around it has to suck.
July 13th, 2008 at 12:53 pm
Snake bite can be confused with a dog bite specially if the patients says its a snake, plus when you got a tissue witha lot of swelliing its difficult to determine the type of bite. the practice of meds isnt absolute even in simple things are exceptions and odds.
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