House - Episode 3 (Season 2)
House spoilers and review below.
A good episode of House this week. One of the better episodes of the series, actually.
Alfredo, a young handyman working on Dr. Cuddy’s house suddenly falls off the roof. In the ambulance on the way to the hospital Cuddy notices that several fingers on his right hand are turning dark and dusky. When prompted, Alfredo mentions decreased sensation in these fingers. These are new symptoms; he’s never had them before. The medical team’s first thought is that the patient has Disseminated Intravascular Coagulation (DIC), a condition where the clotting system in the body goes haywire. Cuddy decides to start him on Activated Protein C (brand name Xigris), a new drug with some serious side effects. Sure enough, the drug causes Alfredo to develop a bleed in the brain that needs surgery to correct.
The chest x-ray come back and show that Alfredo has some sort of pneumonia. The basic tests and blood cultures are all negative. Drs. Cuddy and Cameron search Alfredo’s house. They find a dead rat and decide that Alfredo must be suffering from rat bite fever. Meanwhile, Drs. House, Chase and Foreman search Cuddy’s house and find some mold growing in the bathroom that House suspects is the cause of Alfredo’s pneumonia. Cuddy starts him on Amphotericin B believing that he has Aspergillosis. Amphotericin also has some potent side effects and Alfredo starts to develop kidney damage.
Since the pneumonia did not respond to the Amphotericin, House decides that it must not be Aspergillosis. The gang goes over a variety of causes of atypical pneumonia, but none of them fit the case. House checks on Alfredo’s temperature and notices that his left right hand is turning gangrenous. The hand is amputated before the infection can spread, but then Chase notices that the fingers on the other hand are starting to look a little dusky as well. Belatedly, House realizes that Alfredo has developed Psittacosis from his Saturday night job — working with the roosters at the neighborhood cock fights. Doxycycline is started and the Psittacosis clears up (and presumably the DIC along with it).
My major medical complaint was Dr. Cuddy’s use of Xigris. This drug is only designed for use in patients in sepsis (an overwhelming infection of the body), and Alfredo was not septic. It is a risky drug and her incorrect use of it is both medically and legally indefensible.
Nit-picks? I have a few: Psittacosis isn’t that far-fetched a diagnosis and the team should have figured it out sooner. The surgery team wasn’t wearing proper eye protection. Finally, I would have liked to see more attention paid to the DIC diagnosis, particularly since that was a large part of Alfredo’s problem.
I was glad to see the return of some of the soap opera. There was more interaction between the main characters this episode than the previous two combined. The scene between Foreman and House about the treatment of black patients was particularly well done. On the flip side, I thought the touchy-feely scene at the end with House and Cuddy didn’t fit well with House’s character at all.
The mystery earns an A with the ultimate solution getting a A- (they should have pegged the Psittacosis sooner). The medicine earns a B+. The soap opera earns an A-.
The absolutely worst thing about House? We have to wait a month to see another new episode.
UPDATE (25 Sept 05):
FYI, according to the CDC and this week’s MMWR, there have been 15 cases of Psittacosis reported so far in 2005. However, it should be noted that not every state requires that Psittacosis be reported.
September 28th, 2005 at 8:22 am
Random Amphotericin antecdote. The mother of a man that I used to go to church with discovered Amphotericin. I’m surprised that you didn’t mention its nickname, “Amphoterrible.”
September 28th, 2005 at 4:27 pm
How does Foreman’s reaction to his patient seeking a second (and threatening to find a third) opinion differ from Cameron’s attachment to the cancer patient in the first episode this season? In both cases it seems like you’ve got a doctor going out of their way to help someone when a diagnosis has been given, is there difference I’m missing?
September 28th, 2005 at 4:42 pm
Official Comment
I think the main difference is that Cameron’s attachment was inhibiting her from practicing good medicine — she could not tell the patient the unpleasant truth. Foreman, on the other hand, wanted his patient to have the best medicine and wanted him to have the truth (though the medicine in question is really not any better than much cheaper alternatives).
Patients seek second opinions all the time. It can be a blow to the ego sometimes, but it’s something you learn to live with.
September 28th, 2005 at 4:52 pm
If they had figured out that it was Psittacosis shortly after he was admitted, could they have save the hand?
Also, it does seem to me that Chase should have recognized the claw marks on his hand and known that they weren’t construction related.
September 28th, 2005 at 5:11 pm
Official Comment
If they had recognized the Psittacosis sooner, the docs would have had a better chance of saving the hand, though it would still be touch and go. The blockage leading to the hand dying was from the DIC which was from the Psittacosis. The best treatment for DIC is to correct the underlying problem, though it’s not an instantaneous fix. Blood thinners have some effect in DIC too, and they did intially started Alfredo on Heparin (a blood thinner)– though that had to be stopped when he had the bleed around his brain.
I think Chase should have recognized they weren’t construction injuries too, but maybe Alfredo was building chicken coops. Chase probably should have asked what he was constructing.
September 29th, 2005 at 5:59 pm
Wasn’t it his right hand that was amputated due to gangrene?
My real reason for posting, though, is to say thank you for these write-ups. I started watching the show over the summer because of them.
September 29th, 2005 at 10:43 pm
Official Comment
Johanna, glad you like the show (and my write-ups). And you’re right, I did have the hands backwards.
October 24th, 2005 at 1:05 pm
Another nitpick, from a friend of mine who’s an EMT: the neck brace that they had him in during the ambulance ride was installed all wrong.
Question: I was under the impression that doctors would give antibiotics when they don’t completely understand. House is a diagnostician, but had they just randomly given the guy an antibiotic on the off chance it was a bacterial infection, how much harm would it have been done? Had they done it on day 1, they might even have saved the guy’s hand. I know there are downsides to antibiotics, but can you elaborate?
I am, BTW, immensely grateful for your reviews.
April 23rd, 2006 at 7:34 pm
it is wierd to me that there wasn´t anything to see in the Ecocardio in the clamidia pshitashi endocarditis episode..(humpty dumpty i guess ). they should performence a trans esofagial Echo to rule out a vegetation or a clot in this heart.. anyway . . the show is the best..
December 15th, 2006 at 12:34 am
As a EMT myself…. along with the neck brace not being the right size and being off center, and ummm NO head blocks… or no staps that go with the spinal board that he is strapped to… right? LOL My husband and I are vivid fans, but like anyone else we nit pick things. I know its not a medical show but come on some things are just plain COMMON SENSE. If your going to use the every day things like an ambulance and the equipment we are properly trained on… do a lil research and show the viewers that you are a lil up to date with the workings of the emergency end that gets your patients to you….
December 15th, 2006 at 12:47 am
Generally, as an EMT, when I show up on scene (especially to a trauma scene) I am not going to just take a bystander’s word that they are a doctor and then take backseat to them. If a person can properly convince me that they are indeed a doctor, then I may allow them to give me advice, where appropriate. But, doctors for the the most part are not trained in field medicine and do not have the proper qualifications to stabalize and transport a patient to the ED. Case-in-point is how Cuddy starts doing a spinal exam in the back of a moving ambulance after the patient has already been given full spinal precautions (well, sorta… see above). Any field personnel can tell you that all of that would have been thoroughly performed on an otherwise stable patient long before, during, and after the back boarding evolution and definately not in the back of a moving ambulance!
Whew! I feel better now! Finally something that a lowly EMT can nit-pik with all the doctors around! He he…
July 29th, 2007 at 5:14 pm
I’m not a doctor or even a medical student, but I understood that, according to the show, DIC actually didn’t cause his fingers to drop off. It was endocarditis which was concealed somehow by psittacosis. Whether this endocarditis was actually from psittacosis or some other bacterium remained unclear.
December 11th, 2007 at 3:15 pm
The infection causing the endocarditis caused the DIC.
Also, there is one other major GLARING error. Chlamydia pssitaci grows extremely readily in culture (contrary to House’s clue for Chase), so readily as a matter fact, that it’s a safety hazard to culture it in a normal lab, as it might be inhaled by someone and further spread.
Also, I’m going out on a limb on this one…but I feel like his asthma medication would have made him more susceptible to the infection…not the actual asthma.
February 2nd, 2008 at 12:40 am
Just curious, but with this episode playing now on USA, I’m revisiting some questions I had…
Would EMT’s/Paramedics have actually allowed Cuddy on the ambulance? I thought that was extremely limited. Unless the ambulance was for her hospital only and she was their superior?
When she checks for a broken rib, why not just wait for an x-ray instead of risking puncturing a lung or his heart?
It also really pisses me off how quickly they prescribe a medicine. Why risk it before you’ve even seen all the tests? Like assuming DIC and starting him on Activated Protein C. I hope an actual diagnostician doesn’t do the same.
April 18th, 2008 at 10:54 pm
I just wonder how did dr.house think that it is psittacosis,???I mean there are other bugs that can cause same lesion(culture-negative endocarditis+pneumonia) such as bartonella and coxiella …..he just went for psittacosis ,ignoring other bugs,although when he diagnosed it like that he did no nothing about the guy’s job with birds….
June 11th, 2008 at 8:11 pm
@Aaron:
“I’m surprised that you didn’t mention its nickname, ‘Amphoterrible.’ ”
House himself did in the episode.
June 11th, 2008 at 8:43 pm
@MBS: I’m pretty sure that bartonella, which varies widely according to strain, also presents with more than those two symptoms.
And coxiella, if what I read about it a few months ago was correct, also presents with headaches, respiratory symptoms, and chills.
But I’m not a doctor, so I could be wrong.
July 5th, 2008 at 11:17 pm
how does Psittacosis cause gangrene..these 2 dont seem to go together
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