House – Episode 9 (Season 2): “Deception”
This medical review of House contains many spoilers, so don’t say I didn’t warn you…
While House is at an Off-Track Betting parlor, a customer named Anica has a sudden seizure. House stops a passerby from starting CPR and notices that the patient has some discolored stretch marks on her abdomen. He advises the bystander to call for an ambulance and have her sent to the hospital.
Anica is admitted to the hospital and she is noted to have an anemia as well as a low platelet count. The labs also show an elevated blood alcohol level. House is suspicious that she has Cushing’s Disease. The other team members suspect lupus or Familial Telangectasia. Foreman believes that she is an alcoholic and has alcohol-related DIC (Disseminated Intravascular Coagulation).
House mentions Cushing’s Disease to Anica and she informs him that she had it last year because of a pituitary tumor that was secreting the hormone ACTH. She tells him that the tumor was removed surgically. An MRI shows no recurrence of the tumor. House thinks it may be a microadenoma (a microscopic hormone-secreting tumor) and performs a lumbar puncture. His poor technique, intentional or otherwise, ends up causing the patient’s blood pressure to rise dangerously high; House takes this as proof of the pituitary tumor but the others disagree. Chase mentions that there may be a tumor elsewhere causing the Cushing’s. A subsequent whole body scan shows a mass in the pancreas, but a biopsy shows it is not cancerous.
Cameron suspects Anica has Munchausen’s Syndrome, a psychiatric condition where patients fake being sick to gain attention. They do this by injuring themselves, faking lab tests, or taking medication to fake symptoms. To prove her diagnosis, Cameron “accidentally” leaves some medicine behind in the room. Anica believes this medicine will cause seizures so she takes it, but instead it turns her urine orange and proves that she has Munchausen’s.
House refuses to believe that Munchausen’s is the only diagnosis. He now deduces that Anica also has aplastic anemia, a disease where the bone marrow stops producing any kind of blood cell. Foreman won’t let him draw any more blood from the patient, so House tries to pretend someone else’s test results are Anica’s. Foreman catches on and she is discharged with a diagnosis of Munchausen’s.
House meets Anica outside, still convinced that she has aplastic anemia. With her consent, he injects her with insulin and colchicine. The insulin will cause a blood sugar low enough to cause a seizure, and the colchicine will cause a low white blood cell count. She is readmitted to the hospital because of the seizure, and the low WBC convinces Foreman that Anica does indeed have aplastic anemia. Dr. Wilson is consulted and he begins radiation therapy to kill off her bone marrow so that a bone marrow transplant can be performed. Meanwhile, House is reclining in Anica’s room and he notices a sickly-sweet smell. At the last minute he realizes that she doesn’t have aplastic anema but instead has a Clostridium perfringens infection. He stops the radiation and starts her on an antibiotic to cure her infection.
The medicine was dismal this time around. House is convinced Anica has Cushing’s — and the symptoms did support it — but never checked a cortisol or ACTH level: the tests that prove the condition, no matter the size of the tumor. Rifampin was a poor choice of drug for Cameron to fool the patient with as it has some nasty side effects. There are safer drugs to use to turn someone’s urine orange. Even more damning was the fact that Anica was started on radiation without a bone marrow biopsy to prove that she had aplastic anemia in the first place. In reality, the actual medicine was all just hand waving to set up the patient versus doctor Muchausen’s scenario and the Foreman versus House ego showdown.
The ethics and economics were poor as well. I hope I don’t have to tell anyone that helping a patient fake an illness is a bad thing. And the idea that House hasn’t dictated any notes in a year is frightening. At any reasonable hospital, he would have had his privileges revoked long ago and no insurance company would pay the hospital for billing that old (ninety days if you’re lucky).
The main theme of this episode was the conflict between Foreman and House, and I found it disappointingly tame. After last episode’s disciplinary committee, House has to serve under the supervision of another physician for a month — and Cuddy chose Foreman to be that physician. House tries all kinds of tricks to irk Foreman, and Foreman tells House that nothing he does will change Foreman’s mind. Repeat this about six times. Foreman was right at the end though: House came closer to killing the patient than saving her.
This episode earns a C for the mystery, another C for the solution, and a C- for the medicine overall. The soap opera earns only a C as well. This is an episode that could have been so much more, but ended up being disappointingly average.
December 14th, 2005 at 12:17 am
A lot of things seemed off tonight. I’m sad to see they still seem to be running with their misconceptions about the nature of House’s so-called addiction–have you seen any of the interviews with assorted show staff over that, by the way? One of the medical consultants pats himself on the back regularly over what a wonderful job Detox did presenting the drug addiction issue and its subtleties, and there’s an interview with one of the writers where he almost gives a textbook definition of physical dependency, but keeps insisting that’s just plain addiction, exactly the same as if House were, oh, scoring coke on the street he just happened to need to function.
I find I’m finding this more disturbing than when the patient of the week medicine is bad, even profoundly bad. I mean, the individual cases are just that–individual cases, and we’re never going to see them again, so while I’m not thrilled when they get stuff so completely wrong even I can spot it, I can kind of understand. But somehow I keep expecting them to put some actual effort and research into getting accuracy for a problem that not only comes up recurringly on the show, but is experienced by the main character.
December 14th, 2005 at 8:03 am
Some insurance companies do have a 90 day timely filing limit but most have a 6 month to 1 year limit. But you’re right I doubt insurance will be paying any of Dr. House’s charges anytime soon.
December 14th, 2005 at 2:38 pm
Actually, I think it’s a little less dictation. Cuddy says, “For the first time in six years, I’m getting copies on all experimental testing procedures. Clinic hours have been logged and completed. You’ve given me four months of House’s dictation so I can finally bill insurance companies.”
But before that, when House gives Foreman the files, House’s line is “God! I can’t believe I got more than a year behind on my discharge summaries. Gotta get caught up. Oh no, wait: I’m not authorized to sign these anymore. Only you are.”
How does that compare? Is it still very unlikely?
I really love these recaps and explanations you do. They always make it sound good on the show, but I have no idea if it’s accurate or not. You explain it simply and clearly. I was once thinking about going pre-med, but didn’t. I have worked in medical records, though.
I wondered why House didn’t use an X-ray for the lumbar puncture so he could see where he was aiming. I thought that was pretty standard now. Wouldn’t another doctor have asked?
December 14th, 2005 at 6:15 pm
MB,
If you see this could you explain what you mean about House’s addiction. What are they presenting inaccurately? Anyone else, feel free to explain.
December 14th, 2005 at 9:27 pm
Official Comment
Jeff,
The show is confusing dependency with addiction; they’re related, but different. Dependency* means that a person’s body becomes so used to the drug in question that when it is not present, withdrawal effects occur. This can be seen in almost any drug, including narcotics, anxiety agents, Tylenol, Motrin, Afrin nasal spray, etc.
In addiction, there is not only a physical dependence but there is also a dangerous change in behavior in an attempt to obtain the drug (or gamble or drink, etc.). These are behaviors that the patient knows are wrong including lying, stealing, skipping work/school and so on.
I would consider House dependant, but not addicted. (I did a better job explaining this on the commentary to last year’s episode “Detox“)
*I’m talking about Physical Dependency. There’s also “Psychological Dependency,” but that’s a topic for another day.
December 15th, 2005 at 12:19 am
links for 2005-12-15
LIFE SCIENCES: Medical School’s New Doctoring Course (Inside Brown of November 2005) “Doctoring,” a new two-year required course at Brown Medical School sounds like the physical diagnosis class i remember taking at the VA (tags: Brown Medical Schoo…
December 16th, 2005 at 2:13 pm
So when the babe (I can never remember if her name is Cameron or not) jumps on the back of House’s bike and he puts her hands and arms around his waist and she smiles… that really really big smile… is it because of the motorcycle, or is it because of House himself?
and no I have not been watching all that much lately, and even if that crush-on-House/romance subplot was killed off last year or early this year that doesn’t bar bad writing….
December 26th, 2005 at 3:50 pm
Since when did Clostridium Perfringens smell like grapes? Pseudomonas Aeruginosa smells like grapes, but C Perfringens?
February 10th, 2006 at 4:56 pm
The whole ‘Detox’ issue involving House as an addict is one of the issues that really bothers me. There’s that sort of issue with people assuming that if you’re dependant you must be an addict. Furthermore, it was obvious that even though House is not an addict he is dependant and Wilson and Cuddy being a part of that when A) Wilson of all people should know the difference and B) Getting House to suddenly go off the Vicodin when the withdrawal symptoms will clearly affect his judgement and C) Taking that risk when going off gradually probably wouldn’t be an issue if not for tha fact that he’s obviously found a working solution to get through his day. I think society’s view of pain meds as regarding chronic pain is rather sad, actually, judging by my experiences with people. You would think someone like Wilson, the boy wonder Oncologist, would understand that the most. Bad writers!
February 16th, 2006 at 3:33 am
I have Lupus and Sjogren’s Syndrome, and a lesion in a very painful place that is constantly irritated and unreachable for healing. In addition, as a result of an infection and thigh muscle death (like House, but not quite so severe), my leg is always in deep and intense pain. I am on Morphine now, after 17 years of serious chronic pain, and have neither the symptoms of dependency (except for increasing dosage needs over time and of course the need to leave Codeine behind for MS), nor addiction. It’s well documented that people with severe chronic pain do not become addicts, because we scream with pain, get relief, return to normal, and don’t experience any sort of “high.” The drug makes us normal, not altered. The pain alters us, alters our personalities, ruins our lives. Pain meds, when well-monitored and used with care and responsibility, make it possible to function. I don’t get sleepy on it, on days when there is no pain I don’t take any at all and have not one “withdrawal” symptom. I feel as though I’ve been let out of prison, with no desire for morphine. I’ve gone 5 days with no pain and no morphine, loving every second of my freedom, and was shocked and horrified when the lesion became inflamed and my leg started to hurt again, due to an increase in all-over Lupus inflammation. I agree that this aspect of the story is being poorly handled, but I’m sure there is fear of not showing serious “consequences” connected to House’s use of narcotics–this is America, after all. Most doctors still use the addiction model when medicating for pain, rather than risk their own careers by prescribing “addictive” drugs. I’m very lucky that my doctor believes in me, and I return his trust with responsibility. In hospital, on a PCA, my usage went from high post-surgery, then dropped to nearly nothing very quickly, as is common with “normal” people in extreme pain that is fading. But I did have a drug-seeking roomie, who was completely obvious. Good doctors can tell the difference.
I may be more unusual than most, as I’ve never been “addicted” to anything, not even coffee, chocolate, ice cream, and never did recreational drugs or drank more than the twice- or thrice-annual good glass of wine with dinner. Others may be more vulnerable before they get hit with pain, but I can say with 100% certainty that if tomorrow there was no more pain, there’d be no more drugs in my house. And I’d finally be able to have a lover again, after more than a decade without, so it shouldn’t be hard to believe I’d give it up if the lesion pain would just stop and let me have my life back. An addict is someone whose life is drugs. A “normal” patient with severe pain is someone who’d do anything to never, ever need them again for any reason at all. When we saw House go through his leg episode, we saw him as I’ve been–willing to stand any amount of pain rather than give up clarity and sensation and the joy that comes with being well. No drug can give one that.
May 3rd, 2006 at 3:44 am
I, too, am new to these reviews, and I’ve actually spent a few hours today reading them all and realizing how naive I am about the medicine they preach in House. For the layman like me, though (which, lets face it, probably comprises a substantial portion of the audience), the fact that they use accurate and official terminology sells it enough that we just take for granted they know what they’re doing and the medicine as about as accurate as Hollywood medicine can be.
That being said, they are going to need to get better from a medical perspective. The show has gotten ridiculously popular and is now slated for Season 3. There are somethings you just can’t do anything about, like the “Young Guns” doing everything themselves. It keeps the budget down and gives the writers time for dialog between the doctors and themselves or the doctors and the patients. Your reviews are really great at taking the mystery out of the medical magic they toss around, and I find that at least have the stuff you mention would not change the impact of the episodes at all if they got it right. If you haven’t considered actually consulting for the show, I think you should – the show would be that much better.
There is one question I had about this actual episode – was House right that diagnosing Anica with Munchausen’s would make it harder for her to get treatment if she were actually sick? Part of me finds it hard to believe, but part of me doesn’t.
Thanks for your great reviews and insights.
July 20th, 2006 at 8:43 am
Dustin
No, she’ll get care but the doctors won’t be wasting time with repeating expensive and irrelevent studies. Munchausen’s patients sometimes get complications of previous unnecessary surgery and frequently get complications from wierd things they do to themselves such as injecting pus or excrement so one can’t dismiss them. A doctor alerted to previous history will look for things like C.Perfringens (from injecting muck, no other reason she’d get it) if she looks ill. Obviously, not labelling her is highly unethical.
Anica is more credible as a patient than as a sex-kitten cum lawyer, don’t you think? And rather more credible than the medicine….. but then, one watches “House” for the one-liners. And the hilarious codes.
March 25th, 2007 at 5:32 pm
Scott-
I don’t think C. Perfringens smells like grapes….I think it is P. Aeruginosa. This would also make more sense given the pts Hx. of altering he body’s immunity levels and contracting P. Aeruginosa because of this tinkering.
April 19th, 2007 at 3:33 pm
One question: Why didn’t they get her a psych referral at the end? If she’s mentally ill, then either mental medicine can improve her condition (indicating a psych referral) or it can’t but she can visit a psychiatrist instead of injecting herself with colchicine (and a psych referral seems safer than risking what happened); is there something wrong with my disjunction, is a psychiatrist not a real doctor, or did they introduce her to the hospital’s Munchausen’s Anonymous group because a psych referral would be like offering an alcoholic a beer*?
* http://www.positiveatheism.org has a series of pages which depict the basis view for AA as being that alcoholism is a mental illness** (ingrained into our mindset: We say “You need to get help” rather than “Why don’t you just stop drinking?”) and Munchausen’s and Alcoholism both seem to me to be addictions or psychological dependancy.
** Although it not being a mental illness (in combination with implications within earshot that if you don’t follow the program you’ll start drinking again) would explain the high failure rate of AA (described by both Pos Ath and House in 2-22)
April 19th, 2007 at 3:39 pm
P S: Dr Scott, could you please replace the hyperlink in my above message with http://www.positiveatheism.org/tocaprrwp.htm (It’s 6:40 AM and I don’t think straight this time in the morning)?
May 3rd, 2007 at 9:10 pm
[...] Munchausen Syndrome,, say what?? Diterbitkan Mei 4th, 2007 the Ma thing.. , Medical stuff.. Ma nonton salah satu film fave Ma beberapa minggu kemaren, House, episode ke 9,, (sebelom Ma jatoh dari tangga,,) dan baca reviewnya hari ini, abis ada yang Ma lupa,, ada nama penyakit aneh yang disebut di sana,, ternyata namanya Munchausen Syndrome, yang intinya kondisi psikiatri yang pura pura sakit supaya orang merhatiin dia,, bikin gejala dan keluhan bohong, ampe bikin dia sendiri sakit, mau minta tes yang sakit sakit, mau dioperasi,, aneh banggeett!!!!! katanya sih mungkin gara gara pernah jadi korban kekerasan waktu kecil dan terlantar,, bawa ke psikolog atau psikiater gih,, [...]
July 20th, 2007 at 10:33 pm
Anica’s ACTH level was tested, House mentioned it in the meeting room just before House and Cameron went to search her apartment.
June 13th, 2008 at 1:02 pm
House has hiding places for his medicine, and, also, in the third season he commits fraud in order to get some painkillers. Does that qualify for addiction?
June 13th, 2008 at 1:27 pm
Actually, now that I think about it, in the very first episode he steals Vicodin: he gets them for a patient, then switches them out for placebos. But he puts the vicodin in his pocket.
October 2nd, 2008 at 8:10 pm
(spoilers) Nimby–
In the third season, yes, House is definitely addicted. However, as of right now (2nd season), he is just dependent. This was proven in season 1: Detox.
Although it’s hard to say for sure and I haven’t seen every episode (I own the first 3 seasons, but I’m not done watching them yet), I would say the pivotal point where he becomes addicted would be when he starts writing prescriptions for ‘patients’ to get Vicodin. He does something else at approximately the same time, but I don’t recall exactly what…I think he takes something from Wilson, but I can’t remember what exactly.
At that point, House is definitely addicted.
November 3rd, 2008 at 1:17 am
Aurora- he takes Wilson’s prescription pad and writes himself prescriptions in Wilson’s name.
January 25th, 2009 at 5:39 pm
Quinn -
But Wilson later finds out and points out that House could have easily gotten Cameron (or anyone else) to write the prescription, which he didn’t try to do. Wilson concludes that House did it more to push the limits of their friendship than to score more narcotics (his jacket pockets were all full of them, he could have waited until the next day).
February 11th, 2009 at 8:15 am
The girl that got on Houses Bike was either that 17 year old that wanted to “do” house but he knew she was to yound and she said she was almost 17 and cuddy was trying to push her away and so on…. or it was cameron. And if it isnt that 17 year old…then i need someone to tell me what episode shes on. xD
February 26th, 2009 at 12:08 pm
The thing the bothered me most in this episode: the way everyone pronounced ‘Munchausen’. Ouch.
June 2nd, 2009 at 1:03 pm
For House to be addicted requires that he do things he knows are wrong and would not otherwise do.
What on earth would he not otherwise do?
His actions may prove addiction for you or I, but House is much more lax in his law abiding or complete lack thereof.
July 9th, 2009 at 11:50 am
The thing the bothered me most in this episode: the way everyone pronounced ‘Munchausen’. Ouch.
Not a proper German pronunciation, no, but that does tend to be the way people pronounce it in English. But I’m not sure about medical contexts (though my dictionary gives me the same pronunciation they used), and House has a lot of pronunciation issues in general. They’ve made me cringe with “whirr-nicks” and “whirr-nickys” for “Wernicke’s” (in two separate episodes), and “ta-kay-yay-zoos” for “Takayasu’s arteritis” in the episode right before this one.
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