A cleverly set-up episode of House with some unfortunately very sloppy medicine.
House is rooting around in Cuddy’s desk when Jason, a patient, enters looking for Cuddy. House shoos him away, but a few minutes later he returns, armed with a pistol and dragging along a handful of clinic patients and staff he has taken hostage. He tells House that he’s sick and he wants the best doctor in the hospital or he will start killing patients. He explains that he has seen 16 doctors in past 2 years, had 3 CTs, 2 MRIs and 7 blood panels, but no one can figure out what his wrong with him. His symptoms consist of shortness of breath, fatigue, rashes, palpitations, and insomnia. House takes the case. He focuses on the lungs first and has Jason try, unsuccessfully, to blow out a lighter. From that, House deduces that he has low lung volume and tells him that he has pulmonary scleroderma. He recommends treatment with Propofol.
Now, scleroderma is a real disease and can certainly cause pulmonary symptoms, but it doesn’t generally cause the symptoms this patient is exhibiting. Nor is it treated with an “alkylating agent.” So is House trying to be clever and use an impressive sounding disease name to fool the patient, or is it sloppy writing? I like to think it is the former. Regardless, House was trying to be clever by using Propofol, which is not a treatment for scleroderma but instead a powerful intravenous anesthetic. Unfortunately, when Jason had him give it to a hostage first, House’s deception was revealed when that hostage collapsed. In retaliation, Jason shoots another hostage in the leg.
The SWAT team arrives on the scene as House has a conference call with all his young guns. Chase refuses to play along and leaves. The rest of the team comes up with a differential diagnosis of chronic lung infection, cancer which has spread to the lungs, a neurological condition affecting the diaphragm, or a heart defect. As House is ordering a variety of tests over the phone, Jason hears some SWAT personnel outside the office window. House is impressed because no one else in the room heard the police officers. He decides that Jason has hyperacusis (an extreme sensitivity to sounds) and this seems to point to a neurological cause. A slight left facial palsy (weakness of the muscles on the left side of the face) is also noted, and House now suspects that Jason has postherpetic neuralgia (chronic pain following a shingles outbreak). He orders some Capsaicin (the chemical that causes hot peppers to be hot) to test the nerve. This is an acutely painful test, but Jason makes Thirteen go through it first. She doubles over in pain. Jason is next, and he suffers the same amount of pain, ruling out postherpetic neuralgia. Meanwhile, the white blood count has come back normal, meaning that infection is not the cause (or at least less likely to be the cause), so that leaves a heart defect or cancer as the cause.
About this time, Thirteen notices that Jason has a distended jugular vein. His pulse is also racing along at 160 (a normal pulse should be no higher than 100). House tries carotid massage to bring the heart rate down but it doesn’t work. House doesn’t want to defibrillate Jason as the electrical shock could cause him to tighten his trigger finger and shoot someone. Instead, Thirteen suggests a chemical cardioversion (using medicine to return the heart rate and rhythm to normal). This is risky because it they don’t know for sure what the exact heart rhythm is. Regardless, House agrees to give it a try. She rushes out to the clinic and grabs some adenosine. Jason makes her take it first, and she blacks out from the low heart rate it causes. It works well for him though, returning his heart rate to normal.
Now House notices that Jason is just sweating on one side of his face. This makes him think that Jason has a Pancoast tumor, a lung cancer high in the lung pressing against some key nerves. Jason confirms that he has dry mouth and House finds a swollen lymph node in his neck, all of which seem to confirm the tumor theory. Jason trades two hostages for access to the CT scanner. The initial CT scan is inconclusive because the metal in the gun interfered with the scan. House talks him into giving up the gun and repeats the scan — it is normal. There is no tumor and House is stumped. To the dismay of Thirteen and the one remaining hostage, House returns the gun to Jason.
House talks to his team again, this time looking at the symptoms of dyspnea (difficult breathing), anemia, seventh nerve palsy, and tachycardia. Loa loa filariasis (an African parasite), Q fever (a bacterial infection caught from cattle or similar animals), histiocytosis X (an older name for langerhans cell histiocytosis), and Cushing’s Disease are all suggested. The latter seems the most likely, so House orders some Dexamethasone (a potent steroid) to test for the condition. Once again, Thirteen is forced to take the drug first. The patient is given the medication next, but it makes no difference in his breathing, so Cushing’s is ruled out. Unfortunately, all the medications have caused Thirteen to develop acute kidney failure and she becomes very sick. The team is puzzled that Jason didn’t have the same problem, and decides that he must have something protecting his kidneys. House finds Chvostek’s sign, which an indication of low calcium. Looking through his charts, the team decides that this is due to the proton pump inhibitor (PPI) he is taking (PPIs are stomach medications such as Prilosec, Prevacid, etc. By lowering the acidity of the stomach, they decrease calcium absorption and can lead to low calcium). The team decides the low calcium must be protecting his kidneys and whatever disease he has must have a long incubation (the leap of logic here seems a little abrupt). Leishmaniasis and melioidosis are suggested, but dismissed because they are tropical diseases. When the patient admits that he’s been to Florida, House tells him that’s tropical enough and melioidosis is the likely culprit. He orders 3 grams of ceftazidime (a potent antibiotic and the preferred treatment for melioidosis), but is forced to leave the room. Only Thirteen and Jason remain. She begs not to have to take the drug as she doesn’t want to die. Jason relents and takes the injection just as the SWAT storm the room. As he is led away in handcuffs, he indicates to House that he is already breathing better.
Major complaints are in red, minor in blue, nit-picking in green:
Post herpetic neuralgia affects one particular nerve on one side of the body. If Jason has problems with his left facial nerve, giving him an injection in his back/buttocks will do nothing or prove nothing as it is nowhere near the only affected nerve.
Postherpetic neuralgia is a painful condition that sometimes has numbness associated with it. This does not match the patient’s symptoms at all.
Topical capsaicin is used to treat postherpetic neuralgia, and there has been a study of an injectable form for other causes of neurological pain, but I can find no record of it being used to test for postherpetic neuralgia.
I’m not sure what the writers were trying to show with the dexamethasone. It can be given in low doses over several days to diagnose Cushing’s Disease or Syndrome. A higher dose can be given to differentiate the causes of the condition, but it’s not used to treat Cushing’s. Remember, in Cushing’s, the patient has too much steroid in their system, so giving them more (like Dexamethasone) doesn’t correct their symptoms (why would it?), but it may temporarily cause the body to slow down the amount it makes — but this takes several hours, or days, to have an effect. It is a lab test; it has nothing to do with symptoms.
Hyperacusis means that patient has an increased sensitivity to everyday sounds. It does not mean that their hearing is any better.
The time course of this episode was extremely off. Medications simply do not work that fast. The writers had the dexamethasone working too fast (takes a day or two), the ceftazidime kicking in too fast (a few weeks not a few minutes), and Thirteen’s kidney failure hit within minutes.
Adenosine is an extremely short acting drug that only lasts a few seconds. It would have been out of Thirteen’s system quickly. While it can cause a brief heart block, it doesn’t cause people with normal hearts to collapse like that.
Previously unmentioned symptoms kept appearing for no reason. First, House mentioned that the patient had “abdominal pain,” though Jason had never mentioned it. Later on, “anemia” showed up as well though it had not been mentioned previously.
If a tumor were large enough to cause all those symptoms, you would think that it would show up on at least one of the CT scans in the pat two years.
There has not been a case of melioidosis in the US in over sixty years.
Ceftazidime is the drug of choice, but the maxiumum dose is 2 grams per dose, not 3.
You don’t give a high dose antibiotic shot in the cubital fossa. It needs to go in a big muscle, or an IV line.
There are much better method’s, though none so dramatic, of inducing Chvostek’s sign. I don’t think House’s technique would even work.
Propofol is an intravenous drug, not intramuscular.
Don’t talk during the CT.
The medical mystery was interesting, and the setting clever, so the show started out with a strong A-. The final solution was quite a stretch (for instance, it just happened to be the last tropical disease mentioned, rather than the two previously discussed) and earns a C. The medicine, even given the conditions, was sloppy and deserves a D at best. The soap opera was well done and almost made me sympathetic to Thirteen; I give it a B+.
Last week’s House review
A list of all prior House reviews
Agent Dunham receives a mysterious e-mail from the late Agent Scott, her former partner and lover. It directs her to a basement room in an abandoned building filled with boxes of toads. Bishop recognizes the toads Bufo alvarius, which are known for secreting a hallucinogen. He identifies a concentrated form of this toxin in Young’s body and deduces that he essentially died of fright (well, that and a thirty-story fall) and the cuts were all psychophysiological (i.e. psychosomatic — caused by his own mind).
It seems that whenever I visit a comic book convention, I always manage to stumble across a few public service comics I haven’t seen before. Wizard World Texas was no exception and I managed to find a few good ones. For starters, here is Supergirl (or American Honda Presents DC Comics’ Supergirl, In Cooperation with the U.S. Department of Transportation’s National Safety Belt Campaign). While not horrible, it’s not a particular good PSA — the fact that four writers are listed is always a dead giveaway. There’s about six pages of story stretched out to 28 pages. The message is somewhat muddled too, as the person who is supposed to be “learning a lesson” seems to be having a better time than everyone else.
Hearing the news, Linda rushes to the hospital and is dismayed when she realizes how badly Steve has been hurt. Doing what any normal person would do when she finds a loved one injured, she runs off to Superman’s Fortress of Solitude and uses some of the alien machinery there to access Steve’s mind in an attempt to bring him out of the coma.
the parasite, and its DNA sequence suggests it is tied to an organization known as ZFT. This leads Agent Dunham to Germany to quiz a prisoner by the name of David Jones about the parasite. Jones will cooperate, but only if he can talk with his compatriot Joseph Smith back in the U.S. Unfortunately, Mr. Smith was just shot and killed in an FBI raid. This doesn’t deter Dr. Bishop, who hooks the recently deceased Mr. Smith up to one of his machines so that Peter can act as an intermediary and read his brain (with a little help from high voltages of electricity). The plan works and they are able to convince Mr. Jones that he is in contact with Mr. Smith, and he gives the cure for the parasite. Loeb is saved, but surprising no one, except the supposedly very smart characters on the show, seems to be involved in “The Pattern” himself.
