Polite Dissent

The final episode of House. I liked it and found it fitting, even if the medicine was spotty, but YMMV

House awakens on the second floor of a burning abandoned warehouse next to the body of a dead junkie. Through a serious of flashbacks told as question and answer sessions with House’s subconscious — played by various former characters, both alive and dead — we learn what brought House to his current predicament.

The junkie was a drug-seeking patient who showed up in the clinic, trying to connive House into writing him a prescription for narcotics. House wasn’t fooled, but decided to admit the patient after he noticed Cullen’s sign — bruising around belly button — a sign of pancreatitis (or, if the patient had been female, an ectopic pregnancy). House obtains an ultrasound of the patient’s abdomen which shows no pancreatitis, but does show blood and air within the peritoneum — neither of which should be there. The storytelling gets a little muddled at this point and House ultimately explains that the patient has a perforated ulcer (which would get both air and blood into the abdomen).

Later the patient suffers respiratory arrest and codes. While his team dithers about blaming it on a pulmonary embolus (“a clot in the lungs”), House calmly enters the room, searches through the code blue trolley, and injects the patient with naloxone. This immediately brings the patient, screaming, out of his arrest. It turns out the patient had overdosed on some heroin he had acquired. (Naloxone blocks the effects of narcotics on the opioid receptors. This will dramatically cure narcotic-related respiratory depression, but it also abruptly ends all the pain-killing benefits and euphoric effects of the medication, which explains why the patient woke up screaming.)

After the code, House sits and talks to the patient, who admits he will never give up heroin, because he likes the way it makes all his problems go away. This description of heroin intrigues House, even as he now diagnoses the patient with ALS (amyotrophic lateral sclerosis, i.e. Lou Gherig’s disease), based on nothing more than the twitching of the base of the thumb (the thenar eminence) and thinning of the muscle there (suggesting muscle atrophy). A short conversation later, he notices a bulge in the patient’s right supraclavicular notch and a handy ultrasound reveals a foreign body. It seems the patient had once inhaled some plant matter which caused an autoimmune reaction, which explains all his symptoms (the ALS ones, anyway. Kind of, if you pretend. Maybe the ulcer too, I’m not so sure. Not the drug addiction, though — can’t blame that one on an autoimmune disease.)

After that, House goes missing for two days and ends up in an abandoned warehouse, which just happens to be on fire, with his former patient dead next to him. It’s left to conjecture, but I think it’s fair to assume that House was intrigued by the patient’s description of heroin and decided to score some with the patient. House passed out, the patient OD’d, and…well, I don’t know how the warehouse caught on fire. It just did, OK?

Foreman and Wilson manage to track down House and arrive at the burning warehouse just in time to see him try to escape before being brought down by a collapsing rafter. Then to add insult to injury, the warehouse explodes.

A body is removed and identified as House through dental records. Everybody who is anybody is at the funeral – except Cuddy, but to be fair, he did try to kill her. In the middle of his shockingly appropriate (and classic Kubler-Ross) eulogy, Wilson receives a text on House’s cellphone –conveniently in his pocket — telling him to “shut up you idiot.” A short time later Wilson meets up with a clearly alive House who explains that he escaped out the back door of the warehouse and switched dental records. With him now officially “dead” he is free to spend the next five months with Wilson.

As the episode fades, we see the Chase is now head of the Princeton Plainsboro Diagnostics Department, with Adams and Park still working on the team. Taub is spending time with both of his daughters, and both of their mothers. Cameron heads out the door of her ER in Chicago to meet with her husband and child. Foreman discovers House’s conspicuously hidden hospital ID in his office. And Wilson and House head off into the sunset on their motorcycles.

The medicine was very random and entirely illogical this week. That being said, this episode was never going to be anything other than Greg House himself, and I’m going to respect that by not highlighting any errors or giving any letter grades this time. If you really want, you can probably divine my opinion on the medicine by my comments in the plot summary. Or there’s always the comments.

I thought this was a fitting end for the series. House himself was such a complex character and had such a rich history over eight years that there was no way they were going to be able to keep everybody happy, or even satisfied, with any ending. This ending hit most, if not all, of the key points: friends, family, pain, loneliness, and mystery.

It wasn’t a perfect episode, or probably even a great one – too many coincidences for my taste – but it was at least a very good episode.

Medically, as much as I complained, let me make it clear once last time that the medicine on House was still miles ahead of every other medical show. Even the bad medicine on House was better than what passed for good medicine on other shows.

Thanks for stopping by and reading — and commenting, or at least lurking — for the past eight years. Next year, I’ll continue to review Fringe, and any new medical show that catches my eye. In the meantime, I’ll continue to focus on the depiction of medicine in pop culture, particularly comics. (For those of you playing, the House Challenge scores should be updated and completed by the end of holiday weekend.)

One last thought: a bit of advice for all current and aspiring writers who want to write good medical scenes. It’s simple — Primary Care. Specialists are great, they are the big names and bring in the big bucks, but they only look at one small part of the problem (which is fine, we need them to do that in the real world). But if you want someone who knows how everything fits together, who sees the forest for the trees, then talk to your primary care doctor. Have them take a quick look over the script (or story or novel or comic) to make sure it hold together medically as a whole. Most of my complaints about medical writing could be solved with this one little step.

The review of the previous episode of House
A list of all prior House reviews

While the soap opera aspect of this penultimate episode of House was outstanding, the actual medicine left much to be desired

Derrick is a 19 year-old cheerleader who was admitted after suffering from dizziness and a massive nosebleed (and dropping his partner). A head CT was normal. Taub suggests a “mini-stroke” (though you’d think a doctor would use the correct term TIA, especially when talking to other physicians), but House tells them it is a midline granuloma and has them check a PET scan. The scan is negative for any cancer, but it does show activity in the auditory area, suggesting that Derrick is hearing to something, though no sounds are present. He denies hearing voices, but the team suspects otherwise. They suggest schizophrenia or drug use. His dorm room is searched, and though his roommate is an active participant in the drug culture, he insists Derrick is clean. A thorough exam of the room finds a picture of a young boy hidden in the back of a drawer. Confronted with this evidence, Derrick explains that the picture is of his long dead brother, and reluctantly admits to hearing his voice for the past ten years.

The differential diagnosis now consists of viral encephalitis (though, as pointed out on the show, an infection of the brain wouldn’t persist for ten years) or temporal lobe epilepsy. The team runs tests on Derrick trying to trigger a seizure, but nothing happens — except that he suffers a sudden blindness in his right eye which Adams diagnoses as a “clot in the artery behind the eye” (i.e. a retinal artery occlusion, and massage is one of the treatments supported by anecdotal evidence) and rubs out of existence. The team debates how many of Derrick’s symptoms are physical, and how many are psychological. Park is a firm believer that years of purposefully avoiding grief over the death of his brother has left Derrick with an anxiety disorder that appears as physical symptoms (though this wouldn’t explain the clot). Taub is more prosaic and believes in a physical cause. He suggests polycythemia vera (blood that is thicker than normal), Hodgkin’s lymphoma, or DIC (disseminated intravascular occlusion) due to some trauma suffered in cheerleading (I can believe this: I see more injuries due to cheerleading than any other high school activity. Basketball is second, and football a distant third.). A spinal tap is obtained. It shows no evidence of bleeding (and therefore, no trauma), but an abnormally high opening pressure (reflecting the intracranial pressure) tells them something else is going on. The suspect a “extreme” migraine as the cause. An MRI is obtained, but shows no evidence of migraine – and then the ceiling collapses due to a prank House pulled on Foreman. Before the collapse, Park noticed that he misidentified her as Adams, and that is enough for House to deduce that Derrick has a persistent stapedial artery. This is a small artery in the fetus that should fade away before birth, but sometimes it remains. In Derrick’s case, this artery has been pressing against his temporal lobe causing dizziness and hallucinations. After surgery to remove the artery, his symptoms should resolve.

Neither House nor Wilson is doing well now that they’ve learned that the chemotherapy didn’t work and the tumor remains. Wilson decides to go without any more chemo, figuring he has five months left to live. House refuses to accept this. He wants Wilson to take the chemotherapy and extend his life another couple of years. He tries a number of tricks on Wilson to get him to agree: he doses him with Propofol (a potent IV general anesthetic – what killed Michael Jackson) to mimic death, he fills a room with former patients, he has a quiet nostalgic dinner with him – but nothing he does convinces Wilson to try chemotherapy. Instead, it drives a wedge between them.

Foreman buys House season tickets to the New Jersey Devils, with seats next to his, in a bid to help House get over Wilson, but House decides to stuff the tickets down the hospital bathroom drain. This leads to a massive water overflow, ultimately collapsing the ceiling over the MRI and requiring the city emergency crew to be brought it (apparently, there is no way to shut the water off at Princeton Plainsboro).

In the end, Wilson decides to go through with the chemo for House’s sake, but House tells him not to, and they’ll just enjoy the time left. They are making plans for the next few months, when the Foreman and the hospital lawyer walk in (but why is the hospital lawyer acting as an accusing officer hear? He should be protecting his doctors, not acting like a DA), telling House his plumbing stunt was severe enough to draw police attention and his parole is being revoked and he must server the remainder – six months – of his sentence.

As usual, with a soap opera heavy show (not that I’m necessarily complaining, just noting), the patient and medicine are given short shrift. Major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

The main issue with this week’s diagnosis is what I call the “have your cake and eat it too” problem — commonly seen on House — but not usually this blatantly. In this case, Derrick has a persistent stapedial artery significant enough to cause a rise in intracranial pressure (leading to clots and bloody noses) and large enough to press against the temporal lobe causing hallucinations – yet, this large artery is not seen on CT or MRI, and the patient has none of the common symptoms such as hearing loss or tinnitus (ringing in the ears). The writers want to have it both ways — bad enough to cause extreme symptoms, but yet small enough to be missed by every exam until the last minute.

TA midline granuloma would have been seen on CT.

I see little evidence (really noevidence) in the literature of a migraine, even an extreme migraine, causing an elevated intracranial pressure. Now, an elevated ICP can cause a headache, sometimes even a migraine, but that’s the opposite of what’s suggested here.

I notice they make no effort to actually lower the elevated ICP – other than the initial spinal tap.

How did misidentifying Park as Adams lead House to the final diagnosis?

Here’s one I have no answer to, and so I’m not really calling it an error; I’m just wondering. Would an auditory hallucination light up the same areas of the brain as actually hearing something would, or would it light up different areas?

The medical mystery would be boring for any medical show, but was particularly pedestrian for House. It earns a meager D. The final solution made a little sense, but not much when you consider the so big to cause major symptoms, yet too small to be noticed paradox. I give it another D. The medicine overall was just OK. Not horrible, but not particularly brilliant. I give it a C. Once again, the soap opera was quite good. Both Laurie and Leonard deserve kudos for their scenes. I give it an A.

The review of the previous episode of House
A list of all prior House reviews

The final episode of the penultimate season of Fringe. The universes are safe (again).

The Plot: Peter and Olivia head back to Walter’s lab only to find Walter and Astrid missing. Soon after they arrive, Olivia receives a phone call from one of the victims she saved last week from the nanite attack. She tells Olivia she thinks she is being watched. Olivia agrees to head right over. It turns out that she is being watched, by September the Observer, but he falls prey to a second level cleric spell and is trapped.

Olivia and Peter arrive to find an empty house and a strange hole in the floor. Broyles calls and tells them Astrid is in the hospital, recovering from a gunshot wound. They rush to the hospital and learn about the warehouse where Walter was last seen. Peter and Olivia head to the warehouse and find September, still trapped. The woman Olivia helped last episode steps out of the shadows, holding a pistol. She makes it clear that is working for William Bell and her job is to get Olivia riled up. She shoots September, but due to his “super Observer speed,” he is able to catch the bullets. She then pulls out a special pistol, designed by Bell, which can shoot so fast the Observer can’t catch the bullets. She fires a shot, and sure enough, September is hit in the chest. She fires three more shots but Olivia catches them and throws them back at her, killing her. Of course, in the Fringe universe, no one stays dead forever, especially when they hold the clue to Walter’s location, so she is brought back to the Harvard lab, hooked up to a machine, and dragged back to life, temporarily at least.

The Fringe team learns that William and Walter Bell are on barge, presumably heading for the safe zone where the two universes will collide. They find the boat, but only Peter (and the satellites, apparently) can actually see it, because it is out of sync with our universe. Peter and Olivia (acting on their own, again), jump to the barge and confront William Bell. He tells them that Olivia’s powers are energizing the collision of the universes, and once begun, there is no way to stop it. Walter disagrees, then pulls out a pistol and shoots Olivia right in the brain, killing her. Without the required power, the universes immediately return to normal. Bell disappears (literally).

Walter rushes to Olivia, reminding Peter of what we only learned last episode, that Cortexiphan has healing powers. Using improvised surgical tools, he pushes the bullet out of Olivia’s brain, and miraculously, her wound heals.

As the episode ends, Congress increases Fringe’s funding, allowing them to add their own science department – a department which the now “General” Broyles asks Nina Sharp to head. Olivia is released from the hospital, but not before telling Peter that she’s pregnant. Meanwhile, September appears to Walter, telling him to warn the others about what is coming.

1. I’ve Heard Of Soft Spots, But This Is Ridiculous
Skulls must be softer in the Fringe universe, because there’s no way a syringe, let along a letter opener, would be able to break through the skull that easily – if at all.

2. Just Ask Penn & Teller
The trick to catching a bullet is not just being fast enough to intercept it, but somehow arresting all its momentum without taking any damage. Super speed may solve problem number one, but not number two.

3. In A Case, Just In Case
That was one of the more blatant examples of Chekov’s Gun I’ve seen in recent memory.

4. Khaaaan!
I couldn’t help flashing back to Start Trek II and the Genesis device in the beginning of this episode, when William Bell was talking about how God created the universe in seven days but it took him [Bell] considerably longer. There is a similar quote in Star Trek II (only it takes them seven hours, not seven days).

5. ParadoxodaraP
A nice time paradox. When September told Olivia that in every universe she has to die, where did he learn this? From Olivia.

Another good episode, but I have the feeling it could have been better. This two-part finale would have worked better a three-episode arc, so some of the key points wouldn’t feel quite so shoe-horned. Still, a good season overall, even if Charlie is still AWOL. The Fringe Doomsday Clock creeps back to 11:55.

This week’s Fringe cipher was: PURGE.
A list of all previous Fringe reviews is available here.
Karl, as always, has more to add.

Better late than never. The Fringe team has their final confrontation with David Robert Jones and learns the identity of the real mastermind in an entertaining, albeit fairly cluttered, episode.

The Plot: The Fringe Team is called in to evaluate a cluster of cases of spontaneous combustion at a nearby convention center. Walter initially suspects a viral infection, but when he realizes the infection was caught from the handrail on the escalator and locates the source, he determines the victims have actually been infected with nanites. Video surveillance shows that David Robert Jones planted the nanites in the escalator, but after looking over the nanites, Walter recognizes them as the work of William Bell.

In this universe, William Bell died in a car crash seven years before, but Walter is insistent that Bell must still be alive and tells the rest of the team that William visited him at St. Claire’s Hospital after he was supposed to be dead. A visit to the hospital shows no evidence of Bell visiting, but Walter keeps the sign-in log for good measure.

The viewers quickly realize that Walter is right and William Bell is still alive, and the Jones is working for him. After some clumsy metaphors about chess, Bell tells Jones that it is time to take out the Bishop. Soon, a bright powerful beam of light comes down from the sky, burning everything in its path. Walter and Peter realize that it is caused by satellites reflecting the sun’s rays and Walter is able to track down the source of the transmission controlling the satellite. Peter and Olivia head off to the transmission sight – antennas on two nearby buildings. They each climb to the roof of one building and shut down the transmitters, but Peter is jumped by Jones. Olivia is able to use her Cortexiphan abilities to take control of Peter’s body and beat Jones senseless. Jones then disintegrates into powder, remarking that he was the Bishop being taken off the board.

Back in his lab, Walter, with help from Astrid, cow’s brains, and an EZ Bake oven, determine that Bell did visit the asylum, leaving behind a trace of his favorite snack – almonds – on the sign-in log. Walter and Astrid head off to the almond warehouse in an attempt to track down Bell. They succeed too well – finding both Bell and some armed goons – and Astrid receives a gut shot as the episode ends.

1. Flame On!
Not quite classic spontaneous combustion. In this case, only their cheeks and respiratory system (or maybe GI system) burnt up – they didn’t all spontaneously burst in to flame.

2. Forget Minute Rice, Try Our Minute Cultures!
That’s way too short an amount of time to declare an area free of airborne germs. Well, unless you’re using a tricorder. Mabey Nimoy brought one with him.

3. Must Be Empty, And Very Understaffed
St. Claire’s hasn’t reassigned the room, or at least cleaned the desk, in the four years since Walter left?

4. And Lets Not Forget the Foreshadowing: Almonds = Cyanide
If William didn’t sign the page of the ledger, then why is his almond-residue on it? And why is only his snack on there? Surely someone else had eaten before touching the ledger.

5. My Get Rich Quick Plan Continues
Tonight’s episode is just more proof that the best way to make money in the Fringe universe is to own empty warehouses.

6. Don’t Try This At Home Kids
It’s not that easy to relocate a shoulder — in fact, I doubt Peter would have the strength to do it the way shown — especially with a posterior dislocation like Peter suffered. (Now if Peter has suffered multiple posterior dislocations before, his shoulder could pop in and out of socket easier than normal, though with all the fights he’s been in, you’d think we’d have seen that before.)

7. Have A Bigger Party, There’s More Than Enough XP To Go Around
It never occurs to Peter and Olivia they might need back up? They have access to an entire FBI division, after all.

8. Loaves and Fishes Lemon Cake and Pigs Brains
Cortexiphan now has regenerative properties? Hasn’t seemed to do much for Olivia in the past, though it does completely restore that tissue lemon cake really easily. Forget telekinesis, Walter has solved the world’s hunger problem.

A good episode, but there was enough here to spread it out over another episode. The Fringe Doomsday Clock remains at 11:54.

This week’s Fringe cipher was: POWERS.
A list of all previous Fringe reviews is available here.
Karl, as always, has more to add.

What seems at first to be a rather dry “history lecture” public service ad is actually a subtly pointed affirmation of the Freedom of Religion — a lesson that could bear repeating today.

The PSA presents a fairly abridged version of the Flushing Remonstrance, but then it is only a five panel PSA intended for 8 to 12 year old boys.
Wikipedia has a nice summation of the Remonstrance.
The full text of the Flushing Remonstrance

Since this PSA was published just the one time, and because it is more political than most, I wonder what was going on in the country in 1957 that prompted Schiff to write it?

Remonstrance is a fun word to say; flushing is too.

This PSA can be found in DC comics from February, 1958. The script was by Jack Schiff, with the art by Bob Brown.

More PSAs

Tags: comics psa religion cbob brown jack schiff

Another episode with the team being mostly on their own while House and Wilson do their own thing. Not a bad episode, overall.

Dr. Treiber is the hospital’s outspoken pathologist. In the middle of an autopsy, he suddenly decides to cut his own scalp open with a scalpel and complains of being cold. He is admitted to House’s service — but House quickly runs off on a buddy trip with Wilson, so the team is left to solve the case on their own. Before he leaves, House suggests Treiber may be suffering from the Cotard delusion (a mental disorder where people believe they are dead — therefore House thinks Treiber was trying to perform an autopsy on himself), but the history doesn’t fit well. Other suggestions include liver failure due to hepatitis C, toxin exposure in the morgue (in particular, dimethyl sulfate), or blood clots. An ultrasound is obtained but shows no clots, and an examination of the lab turns up no toxins, but does reveal that Dr. Treiber is a big fan of energy drinks, the team now suspects he is suffering from stimulant psychosis, due to all the caffeine he consumes.

Treiber soon develops abdominal pain and distention, meaning that something else besides stimulant psychosis is going on. Adams still suspects the caffeine is behind most of his symptoms, except the abdominal ones, which she believes are caused by a bowel obstruction. Other thoughts are diabetes or ulcerative colitis (a type of inflammatory bowel disease). Chase finally suspects an intussusception (a collapsing of the bowel in on itself) due to cancer. They obtain an x-ray which is normal, but Treiber wants Chase to go ahead and check the small bowel surgically for the intussusception. Chase agrees to perform the surgery, but no abnormalities are found.

The team now decides that Treiber must have intermittent porphyria (an inherited metabolic disorder) and starts him on hemin (a treatment for acute intermittent porphyria). Despite the treatment, Treiber continues to decline and develops bilateral pleural effusions (fluid build up around the lungs). At this point, Treiber finally learns that House is nowhere to be found, and Foreman is brought on to the case. He immediately suspects a cardiac cause (not unreasonable, given the pleural effusions) and obtains a cardiac MRI which shows an enlarged left ventricle. Foreman takes this to mean that Treiber has an infiltrative disease of the heart (an accumulation of some substance in the heart muscle that is not supposed to be there), probably sarcoidosis, and wants a heart biopsy. Chase suspects a prion disease (a neurological disease spread by infected proteins) and wants a brain biopsy; he also wants to start him on amphotericin to treat the suspected prion disease. Unfortunately, only one biopsy can be performed and Foreman elects to go with the heart biopsy. Chase heads down to the morgue to find the source of his suspected prion disease The cardiac biopsy shows fibrosis, not infiltration, meaning Foreman was wrong about sarcoid, but Chase was also wrong about a prion cause (because no prion disease causes fibrosis in the heart). Foreman now suspects a viral infection (like a viral cardiomyopathy) and obtains cultures and starts antivirals, but Chase remains in the morgue, convinced the answer is down there. Overnight, Treiber falls into a coma, making Foreman and the rest of the team rethink their diagnosis. They come to the morgue to talk to Chase who has reluctantly decided that Treiber is too fastidious to have caught a disease in the morgue – but then he realizes it is that fastidiousness – or more specifically, the antibacterial soap he repeatedly uses – that is the source of the problem. The repeated exposure to Triclosan (an antibacterial in soap), plus a high dose of caffeine from the energy drinks, caused Treiber’s thyroid to shut down and Treiber ended up in a myxedema coma (a severe form of hypothyroidism).

As always, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

While triclosan has been implicated in thyroid problems in bullfrogs and mice, human studies haven’t shown this effect (admittedly it was a limited study looking at triclosan in toothpaste).
Similarly, there haven’t been any studies linking high caffeine intake and hypothyroidism in humans (there is a study showing caffeine can interfere with absorption of thyroid medication, but that’s a different situation).

No one thought to check thyroid studies for an unexplained coma?

Studies have suggested that amphotericin may play a role in treating certain prion dieases, but it’s never been tested in humans.

They can’t perform both biopsies because of the amphotericin Chase wants to use because it might theoretically limit the possible prion disease the patient might have. Problem easily solved. Hold the ampho (it’s never been tested in humans for this anyway) then you can perform both biopsies.

That was simply a horrible code, but then, I think it was supposed to be one because it was supposed to be a bad doctor. Just for starters: only two people involved (not counting the patient), and one is just idly looking at IV bags. Shocking a flatline. No airway.

A small amount DMSO applied to the knees got converted to a toxic amount of dimethyl sulfate via several brief shocks to the chest?

Did no one think to ask Treiber why he was cutting his own scalp? The answer would likely have been revealing.
Despite the hypothyroidism/myxedema coma worsening, his mental status was fine in his hospital stay, despite it being his presenting complaint.

Here’s what I could get off of Chase’s whiteboard (or whiteboards) — hopefully someone got a better screenshot. In no particular order: Neimann-Pick disease, Japanese encephalitis, Creutzfeldt-Jakob disease, Q fever, impetigo (really?), typhoid, schistosomiasis, leptospirosis, gastroenteritis, neurofibromatosis, fatal familial insomnia, Tay-Sachs disease, cronobacter, syphilis, kuru, lyme, aortic aneurysm, shigelloisis, malaria, HIV, Klinefelter syndrome, yellow fever, cryptosporidiosis, dengue, German-Straussler-Scheinker syndrome, hypoglycemia.

The medical mystery was interesting, if less so once the patient was admitted. I give it a B+. The final solution made a modest amount of sense, if you accept the fact that the condition has never been seen in humans — that’s a few point off, in my book. I give it a C-. The medicine overall was thorough — on Chase’s end, at least — but missed some obvious possibilities, with myxedema coma topping that list, and easily testable. I give it a weak B. I thought the soap opera was good. The House/Wilson last fling was somewhat cliché, but Chase’s dilemma was well done. I give it an A-.

The review of the previous episode of House
A list of all prior House reviews

As usual, in a soap opera heavy House episode, the medicine suffers — though the writers tries to distract us by adding an unlikable character into the mix.

Emily is a six year girl with a variant form of AT (ataxia telangiectasia, an inherited neurodegenerative disease) who is admitted to House’s team after she develops a nosebleed and breathing difficulties while riding on a merry-go-round. Her mother Elizabeth, a geneticist and expert on AT, also joins the team, whether they like it or not. The initial diagnostic possibilities include a worsening of the AT or head trauma, but her mother rules them both out. Park suggests Wegener’s granulomatosis and Elizabeth agrees that is a possibility, so an MRI is arranged (AT patients have a decreased ability to repair broken DNA strands, so ionizing radiation such as x-rays are avoided whenever possible as they run the risk of damaging DNA). The study shows no signs of Wegener’s, but while undergoing the MRI, Emily develops cold and blue hands and feet. Emily’s circulation is restored and the new differential diagnosis includes primary Raynaud’s disease or Raynaud’s secondary to lupus. Emily’s mother doesn’t like any of these and instead blames heavy metal poisoning from her estranged husband’s new apartment. While she goes to search his apartment, Chase and Adams decide to search hers. They find evidence that Elizabeth has been giving Emily Lex-2, an experimental antibiotic thought to help patients with AT. Unfortunately, the antibiotic has also been tied to renal failure, and now there’s concern that may be what is ailing Emily.

Luckily, an ultrasound of the kidneys is fine, but then Emily develops chest pain and starts to cough up blood. Pneumonia is discussed, as is a pulmonary embolus (a blood clot that blocks part of the lungs(. An MRI of the lungs shows no evidence of any clot. However, Chase notices scleral icterus – yellow eyes – a sign of jaundice and deduces that Emily is now in liver failure. Further studies show she has a blocked hepatic vein (large veins in the liver). Diagnostic possibilities include polycythemia vera (the blood is thickened with too many red blood cells), a connective tissue disease (another name for an autoimmune disease), or advanced Lyme disease. The team decides that the Lyme is the most likely cause — it had been held in check by the experimental antibiotic Elizabeth was giving her, but flared up when the antibiotic was stopped. A lumbar puncture is obtained to confirm the diagnosis, but Emily suffers a stroke after the procedure. The differential diagnosis now includes a fungal infection or a hematological malignancy (cancer of the blood forming cells, like leukemia or lyphoma). Then Chase realizes Emily has an atrial myxoma, a tumor of the heart. Little pieces of this tumor are breaking off and have been causing all her symptoms (Raynauds, obstructed hepatic vein, stroke, pulmonary blockage). Surgery removes the tumor, and Emily is back to normal (her normal, that is).

As always, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

The chest MRI may not have shown a clot, but it should still have shown a blockage, or at least evidence of a recent blockage, especially given the severe symptoms Emily was having.

A normal renal ultrasound does not rule out renal failure. Blood tests and urine tests tell you a lot more about what’s going on in the kidneys.

I can see a shedding right atrial tumor causing blockages in the pulmonary circulation, but how is it going to get all its little clotty pieces into the systemic circulation when they have to travel through the lungs capillary beds first, which act as a filter. An ASD or VSD wouldn’t explain it, because that would cause a left-to-right shunt.

Emily doesn’t seem to be showing many signs of AT – which of course they explained away as “Atypical AT” but she wasn’t showing any signs of the condition at all.

I know it was a pathos thing, but I would be leery of an oncologist with as poor a grasp of statistics as Wilson. Trade a 25% chance of death for a 33% chance of death? Sure! Sign me up!

I like how Wilson’s blood counts miraculously improved overnight. (And how House doesn’t seem to believe in isolation or neutropenic precautions).

Foreman should never have allowed Emily’s mother onto the case. Her objectivity was compromised — demonstrably so with the discovery she was dosing her daughter with Lex-2 — and her alleged expertise added nothing; seriously, she said “no” a lot and never contributed anything constructive.

The medical mystery was fairly interesting, though the AT aspect only contributed slightly to the medical aspect of the show (the “no x-ray” part; the AT did contribute majorly to the pathos aspect of the show). I give it a B+. The final solution was modestly succesful; it explained most of her symptoms — though a murmur probably should have been found on a good physical exam. I give it a C+. The medicine overall was average and earns a C (which still makes it better than most soap opera heavy episodes). The soap opera was good and heartbreaking. Both the Wilson/House aspect and the knows-she’s-dying-before-her-time little girl aspect. I give it an A.

The review of the previous episode of House
A list of all prior House reviews