Despite Joel Grey in a guest starring role, this was another sub-standard episode of House. Frankly, some of the worst medicine in the series yet. Medical explanations and spoilers follow.
Ezra Powell, a famous researcher, is in his lab dissecting some rats. A subtle tremor of his right hand can be seen and he is coughing as he is examining the rats. His breathing becomes worse and he starts gasping for breath before falling unconscious to the floor.
Powell is admitted to the hospital and House and his team take over the case. They are unsure if the breathing problems are due to the heart or to the lungs. They mention such diagnoses as amyloidosis (a condition where an abnormal proten builds up in certain organs leading) and long term exposure to toxic chemicals, but both the EKG and chest x-ray are reportedly normal (which is strange as they repeatedly refer to fluid in the lungs — pulmonary edema — which does show up on x-ray).
House orders an exercise stress EKG. This is the first big mistake of the night because that’s entirely the wrong test. The team is concerned with heart failure — that the heart is not beating as strong as it should and fluid is backing up in the lungs. An exercise stress test doesn’t evaluate this; instead it shows how the electrical system of the heart reacts to stress. While it is a valuable tool for picking up ischemic heart disease (narrowed arteries) or irregular rhythms, it tells nothing about how strong the heart is beating. They need an echocardiogram for that — like the one they ordered in last week’s episode.
Anyway, Powell is too frail to walk on the treadmill, so the test is stopped. Cameron tells House that there’s too much fluid in Powell’s lungs, so House tells her to get rid of it. Chase performs a thoracentesis and drains some fluid. And this is the second big mistake. Thoracentesis drains fluid from the area around the lungs (pulmonary effusion), not from within the lungs themselves (pulmonary edema). It simply wouldn’t have worked (according to my notes, this isn’t the first time the writers have confused pulmonary effusion and edema. They also did it in the first season). Regardless, they stress Powell again, this time having him use his arms. When this doesn’t raise the heart rate enough, House injects some epinephrine (adrenalin) into Powell’s IV. This gets the heart racing enough for the test, which unsurpsingly is normal (because it’s the wrong test!). Powell takes this opportunity to inform the team that he knows he is dying and would like them to help him die.
House is now more suspicious that the cause of the shortness of breath has to do with the lungs. He considers Strep pneumoniae (a common bacterial cause of pneumonia) and mycoplasma (a less common cause of pneumonia). Powell refuses any more tests. He informs House plainly that he wants to die and would like House’s assistance. House strikes a bargain: if he can’t make the diagnosis in twenty-four hours, he will help Powell die.
The team needs to make the most of the twenty-four hours. They run a variety of tests including amylase (looks for pancreatitis and some lung cancers), d-dimer (looks for clotting disorders), C Reactive Protein (measure the amount of inflammation), urine tests, and a bone marrow biopsy. He has Cameron search Powell’s lab for clues. The blood tests are all normal and Foreman reports that no bacteria grew in the blood cultures (but this can take up to 48 hours, even if you “spin them down.” Bacteria can only grow so fast). The bone marrow biopsy showed abnormally few cells, but showed no obvious source of the problem. An MRI of the brain is ordered when House suspects Powell might be having memory problems, but it too is normal.
With the twenty-four hours up, the team returns to Powell’s room. House tries to bluff and tell Powell that he has multiple myeloma (a cancer of the blood forming cells in the bone marrow), but Powell quickly realizes House is lying and tells House that he expects him to keep his word and help him die. Later, House returns to the patient’s room with a syringe of morphine. Cameron and Foreman protest and then leave the room, but Chase just shuts the door and closes the blinds. House injects the morphine into the patient who quickly goes into pulmonary arrest and codes. As soon as this happens, House grabs the rescue gear and intubates the patient, placing him on a ventilator. Now House can continue his tests without Powell’s “whining.”
Taking another look at the MRI, House notices that it went low enough to reveal that the top of the lungs show scarring. An autoimmune disease — it could be lupus — is suspected and Powell is started on immunoglobulin and a colonoscopy is ordered. The colonoscopy is normal and the immunoglobulin makes things worse. A diagnosis of Idiopathic Pulmonary Fibrosis is now considered and a lung biopsy is performed — which is also normal (but while pulmonary fibrosis would cause shortness of breath, it wouldn’t cause fluid to build up in the lungs). Powell now develops a right pneumothorax (a collapsed or “dropped” lung) and a chest tube is placed to reinflate the lung. As he is stitching the chest tube into place, House notices that Powell has no sensation on his right hand. The team wakes Powell up, who is understandably angry, and he refuses any more tests. Through some sleight of hand, House is able to confirm a lack of sensation to the left leg, right arm, and abdomen. The differential diagnosis now consists of Kawasaki’s Disease (”Which would explain the kidney failure,” Chase says. What kidney failure? When was this mentioned?), lymphoma, and sarcoidosis. A skin biopsy is obtained by Cameron and tests negative for all three (but of those three, only sarcoidosis shows up in the skin, and not in random biopsies). However, when exposed to a Congo Red (a special red dye), it fluoresces, showing that the patient has amyloidosis (and that Chase was right all along, for once). Unfortunately Powell has the most severe form of amyloidosis and it is terminal (though it is not quite as immediately fatal as suggested — but then, it’s not clear how long Poweel has had the disease). He dies later that night under what can be called suspicious circumstances.
Clearly I had some concerns with the medicine in the show tonight. They often run unnecessary labs and tests, but rarely do they spend fifteen minutes obsessing on a test that is the wrong test in the first place. Furthermore, expecting a frail elderly man to be able to perform an exercise stress test is a little ridiculous. That’s why there are several chemical stress tests — where the heart is stressed chemically instead of by exercise — and none of them use epinephrine. It was just sloppy medicine. Wrong test, wrong procedures, and symptoms that were suddenly mentioned (kidney failure) or forgotten about (the tremor).
The soap opera aspect was better this week. The issues raised are intriguing, and we spent several hours discussing them in medical school. Under what circumstance, if any, is physician assisted suicide acceptable? How can you make sure that depression, common in severely ill patients, is not influencing the patient’s desire to die? Is there an ethical difference between withdrawing support and letting the patient die, and taking a more active role? All good questions, and all addressed to some extent during this show. No firm answers were provided — which is as it should be — but the show did an excellent idea raising the correct questions.
This episode earns a B for the mystery, but only a C for the solution because the final answer seemed too random (a red thong!) and really should have been found sooner — but the medicine overall earns an even-worse-than-last-week D-. The soap opera/non-medical aspect were very good and deserve an A.
The previous House review
A list of all prior House reviews
Tags: television medicine house amyloidosis.
The Amazing Spider-Man: Double Trouble is the second in a series of Canadian anti-drug PSA comics that were later published in the U.S. for $1.50 each. This issue is once again written by Dwayne McDuffie, but penciled this time by Herb Trimpe.
The Chameleon breaks into Beth’s room but can’t find her notes. He then disguises himself as a teenage boy and befriends Beth and Charlie. The Chameleon discovers Charlie has a drug problem and offers him more drugs if he can get Beth’s notes. Beth walks in on Charlie tearing apart her room and discovers his drug problem. She throws him out. Later, Spider-Man shows up at her window and tells her that he needs her notes for a “dire emergency.” She gives him her notes, but as you’ve probably already guessed, this isn’t the authentic Spider-Man — but instead the Chameleon disguised as Spider-Man. The real Spider-Man chases the fake Spider-Man and manages to recover Beth’s notes, but the Chameleon escapes. Spider-Man returns Beth’s notes, but not before giving both her and Charlie a lecture about drugs.
There’s a small press comic coming out next month that I think everyone will enjoy (well, at least everyone who reads this site). The name alone should tell you why I like the comic: Dr. Id, Psychologist of the Supernatural.
