Despite the use of a magician, the medical mystery on this week’s House was only a little better than average. The final solution though was unexpected and much awaited. It’s a shame the medicine was so wrong.
Cole (i.e Big Love) and Kutner (i.e. Kumar) are at a magician’s show when Flynn, the magician, performs his version of Houdini’s famous Chinese Water Torture trick. In it, the magician has his arms and legs shackled and is suspended upside down in a large glass box of water. Flynn struggles for a minute, then stops moving entirely. Cole quickly realizes something has gone wrong when blood starts oozing from Flynn’s mouth. Kutner has Flynn admitted to the hospital, telling the team that his heart stopped and he lost consciousness as soon as he hit the water. House is unimpressed and believes that Flynn just screwed up the trick, but Kutner truly believes that something is wrong. House tells him to go ahead and work up the patient, but if he’s wrong and it is nothing interesting, then he’s fired.
Kutner performs standard and transesophageal echocardiograms (ultrasounds of the heart), but both are completely normal. In the meantime, Dr. 13 is questioning Flynn about his past medical history, but he has no cardiac history or symptoms at all. Kutner turns to Foreman for help, and he suggests taking a look at the lungs because low oxygen in the blood could have led to heart failure. He suggests an MRI. As Kutner starts the MRI, Flynn starts complaining of severe abdominal pain. On exam, Kutner and Dr. 13 note bruising on his flanks (Grey Turner’s sign) and deduce that Flynn is bleeding internally. He receives a transfusion of 3 units AB blood and is rushed to surgery to find the source of bleeding. The team’s list of diagnoses now consists of liver disease, Vitamin K deficiency (Vitamin K is important in blood clotting, so low K results in easier bleeding), and an intestinal infarction (a blockage in the blood supply to the intestines). House disagrees and he marches into the surgical suite; in addition to lacerations in the digestive tract and a shredded spleen, he finds a small metal handcuff key. Flynn had this key hidden (in either his mouth or esophagus) and was going to use it to escape the shackles, but he forgot about it and the strong magnetic field in the MRI pulled it through his intestines. House fires Kutner.
Later, House goes to talk to Flynn himself. Flynn insists that he is an excellent magician and did not screw up the trick. He thinks something else must be wrong. He performs a card trick that stumps House and then suddenly develops an uncontrollable nose bleed. This intrigues House (both the card trick and the bleeding). Kutner is rehired and the differential diagnosis now includes cocaine use and polyarteritis nodosa (an autoimmune disease of the arteries). House sends Kutner and Taub to search Flynn’s house while Amber and Cole biopsy the blood vessels around his heart. The biopsy is negative, but Taub finds rabbits at the magician’s home and suspects that Flynn has Tularemia. Antibiotics are started to treat the tularemia.
A short time later, we are told that Flynn has passed out, and an ultrasound “revealed bleeding around the heart” which was subsequently drained (sound like cardiac tamponade). Tularemia is the wrong diagnosis. Cole and Amber might have botched the biopsy, or Flynn could have a clotting disorder, DIC (disseminated intravascular coagulation — a life threatening condition where both uncontrolled clotting and bleeding are occurring), or cancer. An MRI is ordered. As Flynn enters the MRI, hetells Cole that he knows he will be dead by this time tomorrow. The MRI shows fluid in the lungs, no masses, and some damage from where the key ripped through his intestines. It also reveals bleeding in the kidney and thigh. Cole reports Flynn’s suspicion that he is going to die and tells House that he believes his “sense of impending doom” could be a symptom. Amber suggests adrenal disease, blood disease, or anaphylaxis. Kutner suspects it might be tainted blood from a bad transfusion. Foreman, looking at the labs, notices a high low level of immunoglobulins (antibody proteins) and suggests Amyloidosis. About this time, Flynn suffers a gran mal seizure. The team notices leg edema (swelling of the lower legs), and then he has another seizure and “flank pain” (but how could they tell since he said nothing about pain and never even grabbed his side?) Cole and Kutner report back that Flynn has developed kidney failure which led to low sodium and seizures. House continues to suspect amyloidosis, but Kutner is firm in his belief that it was a bad transfusion. House gives Kutner and 13 two hours to proved it was transfusion related — meanwhile the rest of the team will be obtaining a subcutaneous fat biopsy to look for amyloidosis. Kutner and 13 can find nothing, and the fat biopsy in inconclusive, but House decides to treat Flynn for amylodidosis anyway with a bone marrow transfusion. First though, he will need radiation therapy to kill all his current bone marrow. Foreman — using his speaking-for-Cuddy fiat powers won;t let House go through with the radiation treatment without more evidence. House, since he has blood type AB as well, suggests the team transfuse blood from the same 3 donors Flynn had into him and see if he develops any symptoms. The transfusion is performed and House develops a fever. He blows it off as a common reaction is someone like him who has had multiple transfusions, but the team is suspicious. They suggest a Pneumococcus or Pseudomonas infection. House disagrees and stands up but begins to feel faint and realizes that they’ve spiked his coffee with narcotics. He wakes up a short time later, strapped to a chair, as Dr. 13 is performing a liver biopsy. That biopsy, along with the kidney and lung biopsy they already obtained, were all negative. Amyloidosis seems to be the cause and Flynn is scheduled for radiation. In the middle of a conversation with Wilson, House has his Eureka! moment and realizes that Kutner was right. He asks Flynn what blood type he is and Flynn tells him “A.” That means that he received the wrong type of blood. House tells the team that the laboratory doesn’t actually test the patient’s cells for blood type, but instead they test for antibodies against other blood types. Flynn has an antibody he shouldn’t have, which made the lab think he was AB when he was really A. The reason for this extra antibody? Lupus, which along with the transfusion reaction explains all his symptoms.
Huntington’s Disease is a particularly nasty inherited neurological disease. Symptoms are progressive and include an abnormal gait, uncontrollable body movements, severe dementia, and emotional changes. It is especially heartbreaking because most people don’t realize they have it until they’ve already had kids, and by then half of those kids will have inherited the disease. Having a parent with Huntington’s means that you have a 50% chance of inheriting it and there’s nothing you can do about it. Huntington’s is incurable.
Lung MRIs are rarely obtained, and is not an appropriate choice here. A much better study would be a lung CT scan or a even a ventialation/perfusion scan (
VQ scan) if looking for a pulmonary embolus. Of course, those tests don’t use powerful magnets and wouldn’t fit what the writers needed to happen.
When people are transfused in the hospital, they receive a “type and cross“. Their blood type is obtained and their blood is tested against the donor’s blood in the laboratory to make sure there aren’t any unexpected reactions (like Flynn had). This takes time — about 30 minutes — so in emergencies Type O- blood (the universal donor) is used while the crossmatch is obtained. Flynn would have received 3 units type O, not type AB.
Furthermore, House’s explanation of how Flynn got mis-typed as AB is horrendously wrong Blood typing is done on blood cells, not antibodies. Anti-A antibodies are added to one sample of a patient’s blood, and Anti-B antibodies to a second. If the patient has A or B proteins on his blood cells, one or both of samples should clot as the antibodies react with the proteins on the blood cells. If neither tube clots, then the patient has blood type O (neither A nor B proteins on the blood cells). If only the A tube clots, then the patient has type A; and if only the B tube, type B. If both tubes clot, the patient has type AB. (This page has a nice explanation of the tests, with pictures!)
Antibody tests on the plasma can be performed as well, but this is never the primary means of blood typing. Anyway, House has this backwards. People with Type AB blood have no antibodies against A or B (that’s what makes them the universal recipient). If Flynn had an extra antibody, then he would be misread as type O, not type AB.
Does this hospital not test for the Rh factor (the positive/negative aspect of blood type) on its patients? It hard to hear doctors doctors talking about ABO blood types without mention the Rh factor as well. In fact, Rh mismatches cause worse transfusion reactions than ABO mismatches.
Why would you slip a narcotic mickey to someone on chronic narcotics? How could you even begin to guess what dose to give him without killing him. Benzodiazepines (the Valium class of drugs) or a major tranquilizer like Haldol would be a better choice.
It was nice to see the tables turned on House and seeing him on the receiving end of unethical experiments, but 1) those biopsies carry substantial risks, 2) it was really to soon for “tainted blood” to affect the organs enough to see on biopsy, and 3) House’s liver with his chronic acetaminophen overdosing (i.e. Tylenol, one component of Vicodin, and a known irreversible cause of liver damage) is going to already screwed up on the biopsy, transfusion reaction or not.
I give the medical mystery a C+; it started out slow and built up speed, but still barely finished above average. The final solution was so close to fitting exactly, and dose explain most of his symptoms, so I’ll give it a B. The medicine was was artificial (the MRI and key) and wrong (the blood typing) and earns a D-. The soap opera was strong, probably my favorite of the year so far. I was cringing when House first suggested stealing Cuddy’s thong, but the way it led to collusion between unexpected parties was inspired. I give the soap opera a strong A.
The previous House review
A list of all prior House reviews
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Tags: television medicine house cardiac arrest tularemia amyloidosis transfusion scleroderma lupus huntington’s disease
I’m not a big fan of water births. I know that they are somehow supposed to be more natural, but I don’t buy it. They may be more relaxing for the mother (and there’s nothing wrong with that per se), but they can be downright dangerous to the baby. The tubs also weigh a tremendous amount — all that water is quite heavy. For them to be placed on an upper story, the floor needs special reinforcement (and the clinic may have this reinforced floor for all we know).
In Ultimate Fantastic Four #46, Reed Richards is forced to absorb the memories and emotions of the entire planet. The rest of the team step in to help and — as seen here — it’s Johnny Storm who seems to take the brunt of the psychic trauma. 
X-Men #203 “Blinded by the Light, part 4 of 4”
Worlds Collide was a crossover event between the Milestone universe and the regular DC Universe (primarily the Superman books). In this scene, Blood Syndicate gang member Kwai reacts to the collision of the two universes.