House – Episode 14 (season 2): “Sex Kills”
Sex and marriage and sex after marriage, and maybe some extra-marital sex. Yes, it’s another episode of House. But be warned, there are spoilers below!!
Before I began I just want to make sure that everyone realizes that the part of the patient Henry was played by none other than Dr. Johnny Fever (Howard Hesseman) of WKRP in Cincinnati fame.
Anyway, it was an interesting episode that dealt more with ethics than medicine.
While talking to his daughter during a game of bridge, Henry suffers an absence seizure (basically a prolonged non-responsive staring spell). While at the hospital to evaluate this seizure, Henry tells Dr. Foreman that he also has a swollen right testicle. An MRI of the brain shows a tiny smudge — it might be a micro-abscess, or it might be nothing. The team’s initial differential diagnosis is testicular cancer, lymphoma, or a sexually treated transmitted disease (STD) such as syphilis. A needle biopsy of the testicle reveals no cancer and House decides to start the patient on antibiotics for a suspected STD.
As House is injecting him with medication, Henry starts to cough up frothy bloody sputum. This is consistent with Flash pulmonary edema, othe sudden build up of fluid in the lungs An echocardiogram reveals infected growths along his mitral valve. These growths are known as vegetations and are caused by some kind of infection in the bloodstream. The team considers psittacosis and Strep viridans as possibilities, but neither completely fits the situation. House remembers Henry mentioning attending a wine and cheese party and deduces that Henry has caught brucellosis from unpasteurized sheep cheese. This infection led to the growths on his mitral valve which caused a small embolic stroke, causing the seizure. Unfortunately, Henry suffers a massive heart attack when one of these growths breaks off and plugs an artery supplying blood to the heart. His heart suffers so much damage that he is only days to live.
House goes to the transplant committee, but they turn him down because Henry is too old. So House decides to procure a heart for Henry himself. A female school teacher has been killed in a car accident and House decides that she would make a perfect candidate. She is turned down as an official donor because of concerns about possible Hepatitis C because she had a recent fever and elevated liver enzymes. After convincing her husband to donate her heart to Henry (a painful and extremely ethically questionable situation), House elects to treat the cause of the woman’s liver problems so that her heart can be given to Henry. An MRI of her gallbladder and liver shows no gallstones, but does show a cyst in the liver. A presumptive diagnosis of amebiasis (infection by amebas) is made and she is started on high dose antiparasitic medications. Unfortunately, these medicines have a nasty effect on her heart so they have to be stopped. House considers other causes of liver disease, particularly toxins or infections. No toxins are found in her house or school room, but he becomes suspicious that she might have had an affair. She tests positive for gonorrhea and House begins treating her with ceftriaxone.
Not a moment too soon! Henry’s heart gives out completely and both patients are rushed into surgery. The transplant goes well, and Henry soon regains consciousness, daughter and ex-wife at his bedside.
Not as much medical mystery in this one as usual — basically two mini-mysteries — but as I mentioned earlier this episode was mostly about ethics and marriages (and, apparently, cows).
Just a few significant medical concerns:
- Henry is well outside the normal age range for testicular cancer (it’s primarily a disease of younger men), so that wouldn’t be as high on my list of possible diagnoses. If it were on my list, I certainly wouldn’t do a needle biopsy. There are certain cancers where needle biopsies are not performed for fear that the cancer will track — spread up the needle’s path. Testicular cancer is one of these cancers. If it is suspected and confirmed by scrotal ultrasound, then the testes is removed. No biopsy except in rare cases, and then a special surgical biopsy is performed. Never a needle biopsy.
- I realize that heart transplants do not require as careful a match between donor and recipient as other transplants, but tissue compatibility is still important. Was this even mentioned? How about blood type compatibility?
- An ultrasound or CT is a better choice in looking for gallstones than an MRI.
- I’m not a transplant surgeon, but the cavalier way the heart was transported between patients seemed a little sloppy to me.
The soap opera dealt with marriages and sex: Henry and his ex-wife, the organ donor and her husband, and Dr. Wilson and his wife…and maybe an affair.
This episode earns a B for the mystery, another B for the solution, and a B+ for the medicine overall (extra points for including Johnny Fever). The soap opera also earns a B+.
March 7th, 2006 at 11:25 pm
First, I had no idea that was Howard Hesseman, and I spent many hours watching WKRP as a kid. I’m not used to guys like that getting old, I guess.
Second, I have mitral valve prolapse, and I hope to Jesus, Elvis, and Buddha I never get PLANTS growing up in there.
Thirdly, I wondered about the compatibility issue, too, and I’m just some guy in his underwear. Of course, for all I know you could be, too, but you’d be a doctor in your underwear.
March 7th, 2006 at 11:51 pm
I don’t do too much with transplants — okay, not at all – in my mid-size Naval
intensive care unit. If a particular donor is excluded based on a risk – not
an actual problem but a risk – how can they ethically decline a transplant which would
PROBABLY save a life and might POSSIBLY cause a problem? Isn’t there room for a second
tier of donor qualification?
Well, just waxing philosophic… Diane R
March 8th, 2006 at 12:01 am
I have to wonder the realism of transplanting a heart with gonorrhea into a patient who needs a heart. I mean, it makes sense, but I imagine the legal risk is far too great for it to actually happen.
March 8th, 2006 at 1:39 am
Speaking as someone who did recently go through a transplant (kidney-pancreas) I’ve been really frustrated in general by the way the show handles the various sorts of transplants.
Keep in mind that I’m (obviously) NOT a doctor, and also, my experience is with a type of transplant which is considered a treatment rather than a life-saving measure.
My first problem here: the whole issue of high-risk donors. If I’m not mistaken, it was a big, huge deal when transplant surgeons began to offer patients organs from donors who were IV drug users or risky for some other reason.
Not to mention, my impression of transplant surgeons (and surgeons in general) is that they’re prima donnas and very, VERY picky about many aspects of a transplant, including the quality of donor organ(s), potential recipient health, and basically anything else that will affect the success of the procedure (considering that a negative outcome could affect their record/reputation, this makes sense). *House* telling a *transplant surgeon* what to do about any of this stretches my credibility past its breaking point.
And the way in which the donor’s husband was informed of his wife’s death and status as an organ donor — this is something I’ve only heard about, but if my impression is at all correct, this process is pretty scripted and not bungled the way this episode suggests could be the case.
Also, I recall waking up with two tubes down my throat (one hanging out my mouth, one protruding from my nose) and quite groggy from the anesthetic as well as the Fentanyl they were giving me for pain. Isn’t any sort of heart surgery an even bigger deal than the procedure I had done? Shouldn’t the patient have been out of it and unable to speak? (My dad had a valve replacement, and recalls the whole throat tube-and-morphine deal… dimly). Not to mention, shouldn’t the patient have been in the CICU for the first few days after surgery?
I, too, cringed to see the heart removed and transported so quickly and clumsily. Again, I;m not sure what this *would* look like, but I believe that three hours of the approximately nine I was on the table were spent preparing the pancreas while it was disconnected from the donors’s body and not yet placed in mine. Delicate work! Granted, a heart is a simpler piece of hardware (as I understand it) but just treating it like a car part seemed… wrong.
AND, maybe the recipient was blood type AB+ (therefore automatic compatibility of blood type) — and it’s true that modern transplant meds allow for a lot more tissue incompatibility than was allowable at one point (my donor and I had only one HLA factor in common, for instance, and my transplant has been wildly successful so far), but a nod really should have been given to this issue.
There were so many other nits to pick, sigh, but more than anything, the organ transplant stuff (in this episode, and in general on the show) just feels plain WRONG.
Thanks for your reviews… I’ve been reading them for a few months now and find them enjoyable.
March 8th, 2006 at 7:08 am
Just want to say I’ve always liked your reviews and so on, but the real reason I decided to post a comment was to nitpick:
“The soap opera was more restrained this week, focusing mainly on House and Stacy trying to salvage their professional relationship. I expect more fireworks in the next episode when Foreman is in charge.”
That doesn’t seem to belong in this review. Thought I’d bring that to your attention.
March 8th, 2006 at 8:35 am
Official Comment
Thanks Björn,
I was cutting-and-pasting my tag template and got a little carried away. It’s all fixed now.
March 8th, 2006 at 10:16 am
Wouldn’t the immune suppressants required for the transplant make the gonorreah extremely life-threatening? Or can it be controled with antibiotics even in the absence of a working immune system?
March 8th, 2006 at 10:34 am
Johnny Fever cannot be 65, dammit.
Any time there’s a transplant on HOUSE, I always ask She Who Must Be Obeyed if she remembers that one Chicago Hope where they dropped the heart. Compared to that, ANY handling of an organ looks good to our non-doctor eyes…
March 8th, 2006 at 10:37 am
Official Comment
The immune suppresion would make the gonorrhea tougher to kill, but high dose antibiotics should still be able to kill it off, particularly if the antibiotics are bactericidal instead of bacteriostatic (and ceftriaxone is against gonorrhea).
March 8th, 2006 at 11:53 am
Just an aside on the cow patient–I don’t think you would detect BCG in the blood after it’s been thoroughly digested. Maybe it’s one of House’s therapeutic lies about testing something that isn’t there to convince the patient to stop lying.
March 8th, 2006 at 11:58 am
I wish that they’d quit having the perfect donor right down the hall, it’s a long tough wait. Transplant surgeons are thinking about the patient and their stats {and I don’t fault them for that at all} and wouldn’t just go ahead and do something because the all-mighty House told them to.
But what do I know, my husband waited 7 months before he got his call for the heart transplant…
March 8th, 2006 at 1:27 pm
Just wanted to point out a rather droll typo–you refer to “sexually treated diseases”, which of course calls to mind a little Marvin Gaye.
March 8th, 2006 at 1:52 pm
This episode made me think that if I ever needed a transplant, please oh please, don’t let House make the case to the transplant committee.
And it’s awfully convenient that the dead woman’s husband reveals he’s the source of gonorrhea after all the agravation of diagnosing her infection, I think I’d remember to mention something like that. It is life or death, after all.
March 8th, 2006 at 3:48 pm
“or a sexually treated disease (STD) such as syphilis.”
Heh. I could be wrong, but aren’t STDs *transmitted* sexually, not *treated* with more sex?
March 24th, 2006 at 6:04 pm
Scott, I’d asked you a couple of eps back whether or not anyone from the show has ever contacted you about your corrections? I don’t know if you missed it, or just don’t want to answer, but I’m still curious. After reading through the last couple of ep reviews, I want to tell you how grateful I am for your time and energy; I’m a Midwife and worked for a “big” Immunologist at Yale Med School, and know a bunch of stuff about a bunch of Medical stuff and certainly have had, just on my own, that “that can’t be right” feeling, but your clarity and and thorough knowledge, as well as that of the other Medicos on this board, really help us to understand what’s real and what isn’t. I appreciate this more than I can say, wanting to learn more all the time as I do. And I now have Lupus, so stuff is very personal in a whole new way. I go nuts every time they shout out “Lupus” when dealing with some very seriously ill patient: I’ve not quite been “House” bad enough, yet, but come close enough to cringe!
I’ve been over on the “Bones” message board at Fox.com, and found that no one there cares about the accuracy of either Forensic Anthropology or FBI stuff, and have actually been hate-emailed by someone who argued with me when I pointed out the small but unlikely fact of 15+ yr. old chart-sized x-rays from the Army (an overseas war unit) being in a brand-new ER chart; x-rays unconnected to the current problem, while everyone who’s ever been a patient continues to argue, that I’m wrong. That “whole body” x-rays are done commonly, is one defense! So this site is such a relief! And I like it that here everyone gets accepted for knowing what they know. I haven’t seen anyone accuse anyone else of “trying to kill the show” because of inaccuracies. All shows are inaccurate, due to the fact that it’s the general public they’re being made for, not its highest educated members. So we enjoy ourselves despite the problems, and then go pick up a book.
I also wanted to say, in addition to thanking all of you, that I think it’s really a testament to Hugh Laurie’s talent (and to lesser degrees, his co-stars–Edelstein, especially) that this show has made it. He’s so interesting a character–it’s rare for a show to let someone be unlikeable yet endearing in his own odd-ball way, and I’m grateful for that. And that Laurie, beloved in England since the 80’s, has finally got a larger fan base. But the medicine!! Maybe you can supplement your income by becoming an advisor??
I hope you’ll keep writing–I’m glad you have the time. If the producers of “House” haven’t contacted you, they should. To thank you, at least. In the meantime, I think we all thank you.
P.S. If only STD’s could be treated with more sex! How much more fun (fortunately I’ve never had that problem, but wouldn’t be so nervous about it if that were the cure)!
March 24th, 2006 at 6:13 pm
P.P.S. The transplant stuff was off-the-charts bad. I would have run a mile from someone coming on to me the way House did to that poor wife–it’s one of the worst moments in her life and she’s being badgered like this? And why does he never have to even discuss anything with a supervisor? The last time I was in for surgery, my daily doc talked every day with my surgeon about stuff–and that wasn’t even in the same category as pulling organs out of one person from another. Doesn’t that decision have to be made with the transplant team in on it? They’re not robots, to be called and dictated to, are they? Especially by a non-cardiologist? Unless, maybe, the patient is the oh-so-precious and beloved Dr. Johnny Fever! That must be it!
(Private to you: can you edit my previous comment to correct my sentence to “the small error of the unlikely fact…” I can’t get back to it to edit it. Thank you; I don’t want to sound illiterate. I’d been interrupted by the phone and suffered a syntax breakdown.)
April 16th, 2007 at 10:07 am
The way transplants are discussed in this show is awfull. None of the respect shown in daily practice when asking a spouse for donation is taken into consideration. The poor woman was pronounced dead in the ER, however some minutes later she was lying on a bed with the respiratory unit connected to her. This makes no sense at all. In my whole life as a docter (in internal medicine, just like House :-)) the moments I could tell a surgeon what to do are easy to remember, however a transplant surgeon ordering to perform surgery is something on mine ” to do ” list.
June 1st, 2007 at 3:14 am
I watch the House episodes in Bulgaria, so there may be a “lost in translation” -or rather, improved in translation moment. Some bloopers in English are filtered out by the consultant (a pediatric surgeon).
July 9th, 2007 at 2:21 am
House suggested to Cuddy that the transplant be listed as experimental to avoid messing with the transplant team’s stats. I don’t know how accurate that is, but that combined with Cuddy’s seal of approval might make the transplant surgeon a bit more cooperative.
July 18th, 2007 at 4:01 pm
House really does own the hospital doesn’t he? One call from him and they immediately whisk up two operating rooms and a whole army of doctors and nurses willing to perform the transplant.
October 8th, 2007 at 7:02 am
As far as the patient’s state when being woken up (adressed by Stephanie Wukovitz) I got the impression that this scene didn’t take place immediately after the surgery. The surgical wound wasn’t covered by anything, which suggests that it’s been a few days.
What stuck out the most to me in this episode is that House dismisses Laura as being hep C positive because “hep C doesn’t present itself with fever and a stomach ache”. I know somebody who has chronical hep c, and she gets fevers and stomach problems just like the rest of us. It seems quite unintelligent for House to dismiss the possibility of a patient having both a fever and an upset stomach and an illness which can be chronical.
November 20th, 2007 at 12:30 pm
In the series, patients who are intubated never seem to be sedated, and they are always extubated brusquely AND able to speak normally immediately afterwards…
March 21st, 2008 at 11:04 pm
Just saw this episode on a TV repeat, and yes, House did mention to Cutty during some of his begging that he would call this an “expiremental” treatment, so that House doesn’t mess up the suergon’s death rates should have anything gone wrong.
As an aside, it was good to see someone other than House and his team doing the surgery. For a while, I thought they would be doing that too, since they run every test ordered (blood work, CTs, MRIs, all cardiac crashes). Of course I’m kidding, but still…
April 24th, 2008 at 9:28 pm
Regarding the Hep C: I don’t understand at all why the fever and stomach ache should be caused by Hep C. It’s mostly clinically silent. True, she could ALSO have chronic Hep C, but I think it’s unlikely that she has acute Hep C. The latter would present with jaundice and upper right quadrant pain. Did they check liver enzymes at all? And what about a screening test (antibody assay)?
May 13th, 2008 at 8:28 pm
I have to say, after seeing the above ultra-sound picture of mitral valve vegetation (I assume “vegetation” is a growth and not a plant as Mark H fears) How do you interpret those pictures? I mean, I’ve seen the MRI of my mum who has MS, and spotting the bad spots in her brain was easy (it was the first MRI I ever took a serious look at and I did it at home, since my mum got the results on a CD-ROM), just find the white spots (there were a lot of them, though)…
But seeing that (and other) ultrasound pictures other than those made of cute little fetuses, really got me stomped. So basically much respect for that…
Sorry, just had to say it… :)
September 29th, 2008 at 8:30 pm
Since when do they let a dead donor’s spouse watch a transplant surgery? Since when do they let any non-hospital staff watch surgeries? That kind of bugged me. Plus the way they put the heart in him one second and less than a minute later they started it up. I’m not a doctor much less a surgeon but I’m pretty sure that some things need to be connected before you start it up.
October 16th, 2008 at 9:22 pm
uh…sorry… but I didn’t get the mini-story with the clinic patient and the cow…what point was House trying to make with him?
January 8th, 2009 at 5:42 am
Hey Matt1618, I think the whole deal with the clinic patient was this: he made up the whole story about being obsessed with the cow (sexually) in order to get some pills that would sort of… suppress his sexual desires? This is based on the premise that such a fascination with cows is unusual and warrants a suppressant.
When he came back with the bruised ankle, House noticed a wooden splinter in it and saw that he was lying (coupled with the fact that when his bloodwork came back they found indications of his having consumed beef, which runs contrary to his professed love for cows). In reality, he needed the pills to suppress his sexual desire because his superhot stepmother was walking around the house ‘in a bikini… or less’. Yup.
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