House - Episode 4 (Season 2)
This medical review of House contains spoilers, so don’t say I didn’t warn you…
Dr. Sebastian Charles is an American doctor who spends his time treating tuberculosis (TB) in the poor regions of Africa. While back in the United States on a fund raising trip, he collapses while talking to some pharmaceutical executives. Dr. House is assigned to the case when Dr. Charles is admitted to the hospital and the two of them butt heads almost immediately.
Charles wants to be involved in the discussion of his case, but House won’t allow it. Charles believes he has TB, but House suspects that there is another diagnosis. All of the initial tests are normal except the EKG which shows a subtle abnormality of the heart rhythm. House suspects that Charles may have Sick Sinus Syndrome (SSS). A follow-up echocardiogram and stress test are normal, but a tilt table test is positive. Charles is scheduled for a pacemaker.
On the way to surgery, Charles complains of a headache and numbness of the hands. He vomits and then passes out. As these symptoms are not consistent with SSS, the team looks for a new diagnosis. Foreman suspects an acoustic neuroma, but the MRI is normal. However, the PPD skin test that Cameron placed is positive, suggesting that Charles does indeed have TB.
House admits that Charles has TB but continues to insist that there must be a second diagnosis as well. Meanwhile, Charles refuses to take his antibiotics and seems determined to make a martyr of himself. House will have none of it and confronts Charles on several occasions, the last at a press conference that Charles has called. During the press conference, Charles suffers a cardiac arrest and is successfully resuscitated. Now he is the one who must admit that something more than TB is going on. Reluctantly he agrees to take his medication so that the team can determine which symptoms are due to the TB and which are caused by something else. Ultimately the team diagnoses Charles with a nesidioblastoma — a small insulin-secreting tumor. The insulin from this tumor led to dangerously low blood sugars which are the explanation for Dr. Charles’s symptoms.
A short surgery later, Dr. Charles is ready to head back to Africa, TB drugs in hand. After he holds a press conference, of course.
I’ve noticed that when House does a “character show,” the medicine suffers. This week was no exception. The drama came from Dr. House versus Dr. Charles and the medicine seemed like an afterthought.
Medical Concerns:
- As Julia points out, if the patient is suspected of having TB, why is no one treating him wearing a mask? Why he wandering around the hospital and not in isolation? Why is he not in a negative-pressure room?
- PPDs are not read by sight, but by feel. It doesn’t matter how red it looks, but instead how indurated it is.
- TB is slow growing. How did the team know almost immediately that it was resistant TB? How did the antibiotics kick in so fast?
- A nesidioblastoma would explain most of Dr. Charles’s symptoms, but *wow* that’s a convenient tumor. Small enough that it can’t be seen on x-rays or MRIs. Intermittent, so it only releases insulin periodically. And yet strong enough to lower the sugar level in his CSF. It’s more of a deus ex machina than a diagnosis.
- When Dr. Charles coded, why did no one in a room full of doctors start CPR while waiting for the paddles to charge?
- I’m certainly no surgeon, interventional radiologist or endocrinologist, but the scene where the team is trying to induce the tumor to release insulin seemed wrong. Injecting calcium directly into the pancreatic blood supply may be a legitimate procedure, but I doubt those four are qualified to perform it. Also, since they expected the blood sugar to drop to dangerous levels, they should have had the D50 ready to inject and not scramble for an IV setup.
This episode gets a C for the mystery and a lowly D for the medicine. The soap opera aspects earn an A-, mostly for the sparring between House and Charles.
November 2nd, 2005 at 2:34 pm
I enjoy your reviews of my favorite television show and was especially interested in reading this one, since even to this layperson’s eyes the medicine seemed slipshod (doubly so since apparently the episode was written by one of the consulting physicians for the show, David Foster). I’m the spouse of a healthy Type I diabetic who has decades of tight control to his credit, which means we’ve dealt successfully with a few lows here and there, and I’ve had the opportunity to educate myself to deal with the signs, symptoms and treatment of low blood sugar. I still can’t find see why Dr. Charles had the cardiac arrest. Can you explain it before my head explodes?
November 2nd, 2005 at 4:07 pm
Official Comment
I know of no connection (and couldn’t find anything in the literature) regarding hypoglycemia and cardiac arrest. In severe cases, a low blood sugar can lead to neurological manifestations such as seizures, coma, and death — but no mention is made of cardiac arrest(or sick sinus syndrome or prolonged PR interval, for that matter).
November 2nd, 2005 at 5:15 pm
Thanks for answering so quickly. Alas, it was just as I’d suspected, but it’s always wise to get a professional opinion. Until the low blood sugars became the focus, I was hoping for the noble Sebastian to have something really nasty, like a hantavirus.
November 2nd, 2005 at 7:24 pm
I watched house last night and at least I can say that it’s better than Grey’s Anatomy:
There were definitely some problems with the show last night. for one, they should, as you point out, have been wearing masks. He should have been in isolation. Also, just the fact that the PPD was positive point sto exposure…which we already knew he had since he works with these patients. it does now however mean definitive infection. This should not have even been a twist as it would be something i would expect.
Overall, not too bad. i didn’t get why house was holding off on giving the d50, of course there were a few things thrown in for drama but it’s hollywood, so who can blame them.
otherwise, good review
November 3rd, 2005 at 1:20 am
links for 2005-11-03
Blogging for health - Countdown with Keith Olbermann - MSNBC.com : Doctors encourage patients to blog (tags: patient blogging medblogger) The Computer Will See You Now (Feel Better?) - New York Times (tags: EMR) Pandemic Flu : US Government response &…
November 6th, 2005 at 11:15 pm
I love your House reviews. Would you care to do the review of Grey’s Anatomy as well. I want to see someone blast a hole in the “heart catches fire during surgery” spiel.
November 8th, 2005 at 10:30 pm
What kind of TB does he have exactly? I did not get that part of the show, I think. The only contagious kind is Bronchopulmonary. Was he coughing? Did they do a sputum AFB? Has he lost weight and his appetite? The PPD will be positive in almost everyone who has lived for any time in a country with epidemic TB. I should know, I am from India.
December 12th, 2005 at 12:18 pm
My wife loves “House.” I’m so-so. She’s a group leader in a virology lab for one of the largest clinical labs in the company and used to work at a major hospital. I used to work at that
hospital as well, but now I’m a full-time freelance writer specializing in health and medicine and biotechnology. Both of us laugh a great deal at the
idea of these doctors actually performing lab work, running the MRI, or any of the other things they do on the show. Typical TV problems–can’t afford to
bring on more actors or sets. Want to make the doctors look like they do more than they do. Great character, though he’d probably last about a week before
a typical hospital let him go because of insurance risk and patient complaints Think of it as a medical Sherlock Holmes and you’re okay. Otherwise the
show probably is like most CSI shows–about as close to reality as Star Trek.
February 10th, 2006 at 4:35 pm
“Think of it as a medical Sherlock Holmes and you’re okay.”
Well, that’s a major point, isn’t it? That House is a medical Sherlock Holmes. Although some glaring errors bother me *cough* Detox *cough* for the most part me and the rest of my family (Brother-in-Law - Doctor/Mother - Nurse/Sister - P.A.) seems not to be fazed by it. Despite this I love your reviews of the shows because I am interested in such things and I love hearing about the nitpicky stuff. More to the point it’s never ‘ruined’ the show for me. So it’s all good. I guess it depends on your reasons for watching the show, and for most people that I know, even the medically inclined ones, it is not a part of it. I do feel however that as a show that is becoming increasingly more popular it is important for the average person who has no one to tell them otherwise to see medicine that is at least partially accurate (the ducklings running around doing all the tests is one thing that bugs me, but I can live with it. Hey, CSI got away with that sort of stuff too. Doesn’t mean it’s not important that people have the right idea though.) Plus my brother-in-law seems to enjoy watching it, despite the fact that he repeatedly reminds us all that in real life House would be booted before anyone could even blink, because House gets away with a lot of the things he wishes he could get away with.
February 16th, 2006 at 3:06 am
Of course everyone is correct about the superdocs doing everything themselves–it’s patently absurd, but if they didn’t, we’d see them for about 5 minutes a show–about how long a patient gets to see his doctor if it’s House. This is the same problem that CSI has always had. If the CSI’s really only did their jobs, we’d be bored stiff watching the main actors doing lab tests (alone and in near silence), while Brass and his detectives would have all the screen time. In fact, the show would be called “NYPD Blue.” I guess it’s an problem inherent with such shows, and they get away with it on House I think, because we’re supposed to believe that the kids are having to learn how to do everything for themselves. That’s the conclusion I came to in order to explain this serious plot-point problem for myself and just get over it so I could have fun watching Hugh, whom I’ve enjoyed since the mid-80’s on British comedies and in films. Without him in the role, there’d be very little reason to watch.
And it was nice to see a “hero” so thoroughly skewered. The real heroes are the ones who do such work quietly, not for glory but because they need to for many reasons; as a former disaster relief worker, I can say without fear that I did it because I was good at it, was satisfied by it, and needed to be useful in the world–there is always an element of “selfishness” involved, in that one must need to do it. Altruism is an effect, not a cause. I didn’t care if anyone knew my name–just that I was in my rightful place. And if you get sick, you get well quickly, then get back to work without making oneself the center of attention. He was insufferable, and it’s easy to picture him posing for photos with his “poor patients” at every opportunity. Cameron’s naivete was a bit disturbing.
June 14th, 2006 at 1:05 pm
Any hospital inpatient as sick as this man would get daily serum chemistry panels. They would have seen his low blood sugar very quickly. no mystery there. The diagnosis to jump to wouldn’t be an insulin secreting tumor or glucagonoma. First, they would think maybe adrenal insufficiency…low cortisol leading to hypoglycemia in times of stress.
House truely sucks as a diagnostician. He should be sued for malpractice almost every episode and most interns should figure out most of the diagnoses. Any experienced doctor should make a list of possible diseases that could cause the symptoms or a differential diagnosis when their treatment isn’t working. Rule them out one by one until you find the one that fits.
good dramatic show though :)
December 24th, 2006 at 12:18 pm
I’m slowly working my way through the series from the first episode and follow each one by reading your review. As a non-medical person I have little idea what anyone is talking about much of the time, but I understand the irritation - I feel the same way whenever my area of expertise is portrayed in the media in a way that is complete fantasy.
Given that, you have to accept the artificial limits imposed by budget, time, etc. Otherwise there’s no point watching. The only thing that stretches my credibility is House’s success rate. Doesn’t he ever (no spoilers for later episodes, please)lose a patient ? I’m beginning to think Scrubs has more accurate medicine.
January 6th, 2007 at 1:30 am
A persistent (and persistently annoying) theme of the show is “House is Right”. Once House arrives at his final diagnosis, you can be sure it’s right and the pateint will live, providing everyone listens to House. Of course, if the diagnosis comes at 30 minutes into the hour, it’s certain to be wrong, but ultimately House will correct it in time.
My major beef is with that part the show, much more so than the spotty medical details. House knowingly takes all sorts of risks in every episode and *always* beats the odds. After a while you just can’t accept that he’s “just that good”. I would love to see an episode where House’s risk taking blows up in his face. Not that it would be his fault, but it’s important to acknowledge that sometimes the correct decision is not always the right decision (a point House himself made in one episode). I think it would really humanize the character and show.
April 21st, 2007 at 7:57 am
best+mlm+lead++P
April 27th, 2007 at 4:32 am
One thing GLARING in this episode that I really hate is the fact they keep saying AFRICA. How unspecific can they get? If Dr. Charles was an actual person, I’d bet money that he thinks Africa is a country instead of a continent.
May 13th, 2007 at 1:07 am
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May 19th, 2007 at 7:55 am
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May 22nd, 2007 at 2:31 pm
The character of House, and the dynamics between the six main characters, are always entertaining and often thought-provoking. My wife and I enjoy the show a lot :).
The points about wearing masks to treat TB and about the interns performing all sorts of specialized tests seem valid to me, but correcting either of those issues would cause serious dramatic problems on the show. The problem about the tests/procedures was already covered well in this thread. Forcing everyone to wear masks would have really limited the exchanges of the characters — especially House and Cameron — with Dr. Charles.
Although … having everyone wear masks and then having House tear off his mask when he lays into Dr. Charles for Charles’ supposed hypocrisy could have been very effective. Or perhaps House could refuse to wear a mask altogether, while everyone else wore one, because he is so convinced there is no infectious TB, and willing to risk his health on it…
In any case, I’ll give the writers and medical advisors enough credit to have thought of these issues, but to have chosen to use “dramatic license” to ignore them.
But what does bug me is that they should make sure that the final diagnosis explains the symptoms! If it’s true that the small tumor and the resulting low blood sugar could not actually have caused the non-TB symptoms, then the fun of guessing along with House and the interns is really undercut at the end.
June 3rd, 2007 at 1:48 pm
Still slowly workin’ my way through the episodes (and med school), but Scott, in ACLS class we learned that hypoglycemia can be one of the causes of pulseless arrest … the H’s and T’s or “MD PATCHHHHH” if you prefer that mnemonic.
August 14th, 2007 at 5:43 pm
An interesting point made by my dad, a GP.
The patient is given a streptomyocin tablet at one point.
Streptomyocin can not be given orally, only by injection.
November 21st, 2007 at 7:21 pm
Sorry to jump in so late, but I’ve just started watching the show and although the medical errors don’t usually bother me, I have to say that I had TB, and I’d've loved to get my hands on the meds they used in this ep- A couple of days you’re healthy enough to be discharged and immediately zoom off to a continent with no real medical infrastructure!? I realise they have to do the show within 40 minutes, but really…
December 10th, 2007 at 10:01 pm
One of the things that bothered me in this episode was the clinic patient that Foreman saw. If I remember correctly, she thought that she felt a lump in her breast & she’d had a close family member (sister) who had died of breast cancer. Foreman gives her a breast exam WITH NO FEMALE MEDICAL STAFF IN THE ROOM WITH HIM!!! Maybe it’s just the hospital I work at, but at no time does any of the male staff handle a female patient’s breasts or sex organs without having another medical person (preferrably female) in the room. This is to make sure that the patient doesn’t come back later saying “He gave me a breast exam, but it felt like he was groping me.” He also didn’t give her any sort of x-ray or anything of her breasts to ensure that there wasn’t anything going on. She’s got a good enough family history & I’ve seen people go into scans for less than that. Unless she had a history of being a hypochondriac, which I didn’t think they mentioned, it is something that should be checked.
Again, I go back to the thing about no one else being in the room with Foreman when he gives the breast exam. She could have just as easily said that he didn’t give a satisfactory exam or was just groping her since she didn’t get the diagnosis she was expecting. You always have to CYA by having another person in the room with you.
December 10th, 2007 at 10:17 pm
One correction: I looked up some more info on the episode & it seems that there was a biopsy done to see if the woman had cancer & it came up negative, so it seems that there were actions taken. Still, I stand by the whole thing where he should have had someone else in the room with him.
December 25th, 2007 at 7:33 pm
This is probably two years too late to actually be read, but whatever :)
Isn’t there a vaccine for TB? ( http://www.cdc.gov/tb/faqs/qa_glossary.htm#BCG )
I mean, if he was treating TB in an area where TB was endemic, you’d think he’d make damn sure to be vaccinated first. Not to mention that if he *had* been vaccinated, I’m pretty sure he’d ALWAYS test positive for TB afterwards, whether or not he had it - that is, the skin test checks for an immunological reaction against the same antigen that’s in the vaccine. I can’t believe House didn’t simply sneer at the positive skin test by assuming that the guy had been vaccinated. And I certainly can’t believe a TB *specialist* would let this escape him.
January 9th, 2008 at 5:57 am
That’s a good point Ari & I can’t believe that I didn’t pick up on that. As a person who would be spending 100% of his time around people who are either infected with or are carriers of TB he’d have to get a vaccination. I imagine he’d have to get one just to make sure that he wasn’t already a carrier, thus making sure that HE wouldn’t pass TB onto the people he’s treating.
January 15th, 2008 at 9:16 am
I have no idea about medicine, so I’m just talking from what I *think*, which obviously doesn’t worth much:P
Anyway, there’s been mentions of how the doctors do all the tests themselves and they are unrealistically
“superdoctors”.But I don’t think they do everything themselves. They mention this or that test being needed,
and then they run off to an unseen place. I have never thought they go to do the tests personally, but to tell
the lab people,whatever they are called, to do so. I’m probably just babbling though:)
March 18th, 2008 at 2:52 am
“Isn’t there a vaccine for TB? ( http://www.cdc.gov/tb/faqs/qa_glossary.htm#BCG )”
From Wikipedia:
The most controversial aspect of BCG is the variable efficacy found in different clinical trials that appears to depend on geography. Clinical trials conducted in the UK have consistently shown a protective effect of 60 to 80%, but trials conducted elsewhere have shown no protective effect, and efficacy appears to fall the closer one gets to the equator
April 3rd, 2008 at 12:27 am
Surely as mentioned above he’d be vaccinated. As a medical student in N.Ireland I have had to have a Heaf test to see if I was TB resistant. It was positive (very strong result apparently, they even got the other nurses in to see what to look for - but not strong enough to be positive for TB itself). Surely a doctor, especially one treating TB would have at least had the BCG (or similar - not sure of names in USA) and that would have shown up the Heaf )or similar) as positive.
April 5th, 2008 at 3:56 pm
The poor grade for the medicine in this one strikes me as ironic — this is the only diagnosis I’ve called before House did. I’m a veterinary technician, and we see analogous insulin-producing pancreatic tumors in (US-bred) pet ferrets all the time.
April 25th, 2008 at 5:46 am
One other problem with it is that a PPD does not necessarily have a TB infection. He may have been exposed to it in the past and had a sufficient immune reaction. Also some individuals who have had the BCG will respond positive to the PPD test. Although I’ll admit I’m not familiar with the uptake of the BCG in the US. I think it’s not widespread. Do doctors have to take it?
April 25th, 2008 at 8:59 am
Official Comment
There are no required or commonly used BCG-linked vaccines in the US.
The medical school I attended had a vaccine program where you could earn some money by being an experimental volunteer (usually final dose testing of vaccines). I did it for the Hepatitis A vaccine, but not for any others because they all used BCG and I didn’t want to test PPD positive for the rest of my life and have to get repeated chest x-rays.
May 8th, 2008 at 5:36 pm
Fun website. Can’t tell though if it just ate my post.
May 8th, 2008 at 5:43 pm
I have to assume posts with urls are either blocked or previewed. So at the risk of posting the same thing 3 times, here is my post again sans the url.
A couple comments on the infection control and BCG vaccine points.
First re infection control, not every active case of TB is contagious. ~25% of active TB infection sites are outside of the lung or airway and as such are not in a contagious state even if active. A patient could have active TB and not need isolation. A chest X-ray is all you’d need to take a patient out of isolation.
Re Scott’s comment about BCG vaccine in the US, while it is rarely used, we do have it.
The following source can be found at the CDC web site under ACIP guidelines in the MMWR section:
The Role of BCG Vaccine in the Prevention and Control of Tuberculosis in the United States A Joint Statement by the Advisory Council for the Elimination of Tuberculosis and the Advisory Committee on Immunization Practices
“In the United States, the use of BCG vaccination as a TB prevention strategy is reserved for selected persons who meet specific criteria. BCG vaccination should be considered for infants and children who reside in settings in which the likelihood of M. tuberculosis transmission and subsequent infection is high, provided no other measures can be implemented (e.g., removing the child from the source of infection). In addition, BCG vaccination may be considered for health-care workers (HCWs) who are employed in settings in which the likelihood of transmission and subsequent infection with M. tuberculosis strains resistant to isoniazid and rifampin is high, provided comprehensive TB infection-control precautions have been implemented in the workplace and have not been successful. BCG vaccination is not recommended for children and adults who are infected with human immunodeficiency virus because of the potential adverse reactions associated with the use of the vaccine in these persons.
In the United States, the use of BCG vaccination is rarely indicated. BCG vaccination is not recommended for inclusion in immunization or TB control programs, and it is not recommended for most HCWs. Physicians considering the use of BCG vaccine for their patients are encouraged to consult the TB control programs in their area. ”
BCG has some benefit. It can limit meningeal and miliary TB in children, both forms of rapid TB disease progression. It does not appear to prevent TB infection. So it is not useful to vaccinate people including health care workers in areas with low TB prevalence except in special circumstances. Any more you’d like to know about BCG vaccine, the ACIP recommendation above will likely have the answer.
About House in general, notice the almost complete absence of nurses! Talk about errors…
June 11th, 2008 at 10:26 pm
@G_Switzer:
Nurses are not absent! They rush into rooms, stand behind desks, etc. The reason they are absent from everything else is because House doesn’t trust them, so his team frequently does things for themselves.
Scott, in your review, you said this:
A nesidioblastoma would explain most of Dr. Charles’s symptoms, but *wow* that’s a convenient tumor. Small enough that it can’t be seen on x-rays or MRIs. Intermittent, so it only releases insulin periodically. And yet strong enough to lower the sugar level in his CSF. It’s more of a deus ex machina than a diagnosis.
I don’t think you’re being quite fair to the show. You seem to be saying the tumor’s convenient because it’s hard to discover medically and it fits all the symptoms… but isn’t that the point?
I wouldn’t say that the criminal in a murder mystery is too “convenient” a solution to give it credit since all the clues ended up pointing to him/her upon close, thoughtful examination, would you?
Hardly a deus ex machina.
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