House – Episode 16 (Season 2): “Safe”
The fourth episode of House in a row that features sex as a selling point. Enough already, please!
Melinda Bardach is 16 year-old girl who is deathly allergic to penicillin, bee stings, and peanuts. Thanks to trauma from an automobile accident, she also needed a heart transplant. She lives in a specially prepared clean room, and is not allowed out except to visit the doctor. When friends come to visit, they have to scrub down and wear a mask. Melinda’s boyfriend visits her and she wants a kiss. As he leans down to kiss her, he notices hives on her skin. Within seconds, she is wheezing and having difficulty breathing. angioedema sets in. Her mother rushes in and gives her a shot of epinephrine to stop the anaphylaxis.
By the time Melinda is admitted to House’s service, she has undergone “4 days of work-ups” which were all negative. Looking around Melinda’s room at home, Cameron and Chase notice that one window is unlocked, does not have and alarm, and is conveniently near a tree. They confront her boyfriend who admits he snuck in the night before her attack and that he and Melinda had sex. They test his semen, but Melinda shows no allergies against it. House questions him more closely and discovers that he took a week’s worth of antibiotics — penicillin, he thinks– before visiting her because he didn’t want to get her sick. The team deduces that just enough penicillin molecules were in his semen to set off an allergic reaction the next day. Just as House is ready to discharge Melinda home with a diagnosis of ‘allergic reaction” she goes into pulmonary edema, with sudden onset of wheezing, crackles in the lungs, white frothy sputum, and jugular venous distention.
Tests show that Melinda has developed congestive heart failure (the heart isn’t beating strong enough and fluid is backing up into the lungs). There is question whether this is a separate event from the allergic reaction, or if the two are connected. Cameron suggests a toxin of some kind, but that is ruled out. Other thoughts include an infection, heart disease, or rejection. A CT (apparently of her entire body) was negative, as were blood tests to rule out infection (though they came back way too soon. Negative blood cultures take forty eight hours) and a heart biopsy to rule out rejection. Meanwhile, Melinda has fled from her room. Foreman finds her on a back staircase, wanting to go outside, but too scared to go. As he escorts her back down to her room, he notices a left foot drop, which he refers to as steppage gait, but that’s a neurologist for you. As she is being examined for the foot drop, he also notes muscle fasciculations in her leg and diagnoses her with an ascending paralysis (a paralysis that starts at the extremities and works its way in, rather than the other way around).
Cameron suggests tick paralysis, but this is discarded when House points out that thorough exams showed no bites or ticks. ALS and MS — the usual suspects — are mentioned, as are Guillain-Barre Syndrome, botulism, and the catch-all viral infection. A spinal tap is obtained but is shows no evidence of viral infection. EMG (electomyography) shows increasing weakness in her lower-extremities and Foreman is convinced she has Guillain-Barre (an overactive immune response that causes paralysis). She is started on plasmapheresis, which filters out the offending proteins, but shows no improvement. Clearly depressed, she once again develops trouble breathing. This time her lungs are clear and there is no evidence of any allergic reaction. She is intubated and Foreman informs her parents that the paralysis has spread to her lungs (though presumably he means her breathing muscles, and not the lungs themselves).
Foreman and House agree that the paralysis has spread too fast for Guillain-Barre. Cuddy has taken over the case and ordered a spinal MRI to look for a possible lesion there. The team discusses but quickly dismissed the possibility of a toxin from glue inhalation or pesticides. House now decides the answer must be botulism and figures that the boyfriend smuggled in some food. He pulls his usual extubate-the-patient-so-I-can-question-them-as-they-are-gasping-for-air stunt, but Melinda is adamant that her boyfriend did not bring her any food. She also mentions that he had not been taking penicillin, but instead clindamycin – an antibiotic that she is not allergic to. The team now realizes that all three conditions (the allergy, the heart failure, and the paralysis) must be related – House belatedly decides that Cameron was right all along about the diagnosis: tick paralysis. He deduces that the boyfriend must have accidentally brought the tick in with him and that the team must have missed the tick on exam. As Melinda is sliding into a fatal heart rhythm, House declares that he must find and remove the tick before anything else. As Foreman pumps her full of atropine, House searches her entire (and I mean entire) body and manages to find the tick, lodged in the most unlikely of places (and during the most ridiculous scene in quite a while).
Let’s look at the diagnosis and the three main complaints:
- Anaphylaxis: There have been cases of anaphylaxis from tick bites, though the time course seems a little off. Anaphylaxis usually kicks in quickly, or at most four hours after an exposure, not a day later — though it is possible that the tick had been wandering around for a while before it decided to settle down and bite. I’d also like to know that if it was an allergy to the tick bite that caused her anaphylaxis, then why didn’t she continue to have the reaction while in the hospital as the tick was still attached.
- Heart Failure: I’m assuming that the paralysis is what led to the heart failure, though some animal studies have shown that tick venom has a direct affect against heart muscle. While atropine is used as an antidote to some neurotoxins, and it can speed up the heart rate under certain conditions, I think its use as depicted here is quite a stretch. It is not indicated in the treatment of tick paralysis or the routine treatment of heart failure. Speaking of heart failure, I never saw them do anything to treat the failure, and the CT scan is not a good way to evaluate heart failure (echocardiogram with doppler is much better).
- Ascending paralysis: Right symptoms, but the time course is wrong. The symptoms of tick paralysis are fairly slow, taking several days to progress once they appear, not just a few hours. It usually occurs in people who have ticks that have been attached for 5-7 days, and that seems to fit this case as Melinda underwent “four days” of tests before coming to see House. I will agree that House is absolutely correct in that removing the tick solves the problem.
The soap opera again centered mostly on House and Wilson being roommates. House was cruel, but Wilson got him back in the end. Foreman is becoming the strongest of the junior doctors, standing up to House on several occasions this episode. Finally, for Hawk, who thought that Cameron wasn’t getting her share of the limelight: not only was she correct about the diagnosis, she also got the best zinger of the show in her little crack about Chase’s “staying power.”
The mystery was good, so I give it a B+, but the solution was quite a stretch so earns a C-. The medicine overall gets a C because there were too many holes. The soap opera was slight, but fun, so earns a B+ as well.
Still want more top of the line medical information? This week’s Grand Rounds are being held over at UroStream.
April 5th, 2006 at 6:55 am
Was I the only one who thought the dialogue for this episode was strange? House’s comments weren’t very House-like at all — his jokes are generally abrasive but witty; they tend to cut like a scalpel. This time they seemed just irredeemably rude; cutting like a sledgehammer. Not House’s style.
Camron and Chase both weren’t acting like themselves and their dialogue felt forced and unnatural. Cuddy, Wilson and Foreman were fine, all acting pretty much like themselves.
Also I had two comments on your review (plus I think a C and C- are bit harsh, the medicine and solution weren’t *that* bad…):
1) You’re right that the girl probably should’ve continued to experience anaphylaxis so long as the tick was attached, but I remember reading that often an allergic reaction occurs only when the tick is disturbed (such as scratching the bite site) as it releases different proteins when it is disturbed versus dormant. The girl and boyfriend were kissing when the reaction occured, which might’ve been the source of the activity in the region of the tick. Not sure on this (running off memories from a while ago), I’ll look into it a bit later.
2) While tick paralysis moves slowly as you said, I am never quite sure how the progression of time plays out in House — sometimes we can view the night/day transition, other times we get a seamless movement between two days with barely any warning. So again, it’s difficult to judge the progression of time, although in this episode they seemed to take every chance to get the nighttime drama between Wilson and House, so I’d say you’re probably right about the timescale being wrong.
April 5th, 2006 at 7:13 am
Don’t watch the show so forgive me if this was explained, but why should allergies to penicillin, bee stings, and peanuts require such strict isolation? Isn’t that usually reserved for someone who lacks an immune system, or who is really a sophisticated satellite with delicate optics being prepared for launch into space?
April 5th, 2006 at 7:29 am
Aaron: Her heart transplant was why she was immunocompromised (due to immunosuppresive therapy to prevent rejection).
April 5th, 2006 at 8:00 am
Can you comment on what was causing the hives? They were mentioned a few times in the episode, including right before they intubated b.c the paralysis reached her chest. It seems that that should have been some sort of tip-off that the allergic reaction was not independent of the other symptoms, but no one brought it up after that line. (It seemed crammed in to the dialog, so I was surprised that it wasn’t discussed more after.)
April 5th, 2006 at 3:03 pm
The part I failed to understand was why House found it significant to ask if she was a virgin. He seemed to imply there was something she didn’t know about sex that would be significant in the presence of a tick.
April 5th, 2006 at 3:35 pm
Official Comment
Vincent,
You’re right about point 1, scratching or disturbing the tick does often precede an allergic reaction, so that could have played into it.
I’ve noticed the strange flow of time myself on the show several times, particularly last night. For example, did 2 days past while waiting for negative blood cultures or not?
Liz,
The hives were evidence of the allergic reaction. Melinda actually only had them once during the show in the very beginning. When she was being intubated, the docs said that they were sure it wasn’t an allergic reaction because there were no hives.
Deborah,
House’s point (as I understand it) was that since that particular night was her first sexual experience, Melinda wouldn’t know how it was supposed to feel and thus would just assume the pain from the tick bite was a normal part of the process.
Of course, tick bites are very rarely painful…
April 5th, 2006 at 6:54 pm
good episode.
i liked the tricks played by house and wilson. (altho a bit overdone)
looks like chase and cameron aren’t in the latest episodes much.
and i kinda missed house doing his clinic duty this episode.
April 5th, 2006 at 8:14 pm
oh an observation, i noticed (after having to rewatch this scence a couple of times) that when House was putting Wilson’s (almost wrote ‘Watson’) hand into the pot of water, Wilson was wearing a red McGill T-shirt. (Go Canada!)
April 5th, 2006 at 8:49 pm
Just as last week I was the lone dis-liker of the episode, I seem a bit alone again, having enjoyed the quick, witty dialogue of this week’s ep. It was almost screwball-paced, which was lively and fun and made up for the medical problems. I was beginning to suspect Munchausen’s-by-proxy with the mother being so intense, but of course she was never alone with her daughter once they were in the hospital so I got over it. Wilson and House are becoming a Holmes/Watson Laurel/Hardy duo, which is enjoyable. I was glad that Wilson took his revenge, and glad that House appreciated it. I also liked the “white” board, “black” pen banter. The elevator scene was absolutely ridiculous, but in keeping with the whole comic slant of the show. Foreman is certainly becoming someone to reckon with, and I wonder how much of that has to do with the actor’s considerable status. Of the three kids, he’s the only “star.”
April 5th, 2006 at 9:33 pm
Aaron-she was in the clean room for so long ebcause her mother is overprotective.
Awi- Foreman has always been the one who can stand up to House. All of the young’uns are there to play off House.
Foreman hates House but is the most like him.
Chase idolizes House and tries to act like him, but is simply not that good.
Cameron, of course, loves him but is the most unlike him on the personal level.
April 6th, 2006 at 11:50 pm
Zach–you’re right about Foreman’s standing up to House, but I meant as a doctor, with real authority, not just fightin’ spirit. A lot of what we see in Foreman’s behavior is his natural way of dealing with people in charge. Now he’s starting to really trust himself as a doctor, and that progression is nice to see. I’m not sure he “hates” House, though. Just isn’t afraid of disagreeing with him. Nor do I think Chase “idolizes” House. I think the writers have done a good job of drawing the three characters, and therefore what we’re seeing are tendencies to agree or disagree and methods of doing so according to the personalities of each, rather than merely whatever they feel about House. Chase has just as hard a time being necessarily oppositonal, for lack of a better word, with patients as he does with House. He’s just more of a follower than a leader, while Foreman is a natural leader, even though his style is a bit of a tyrannical one. He’s a street kid, remember. Chase comes from privledge. Those things, in addition to personality, impact on how they deal with everything and everyone. Cameron is a better doctor than people give her credit for, often being the one to solve the problem, but doing so very quietly and being overlooked. We’ve heard House criticise her for not standing by her convictions, which is hard for her to do. I hate to see her reduced to merely someone who “loves him,” though your post shows how thoroughly the writers have let it cloud the issue of her competency.
April 7th, 2006 at 5:41 am
>The fourth episode of House in a row that features sex as a >selling point. Enough already, please!
I heartily agree. To paraphrase Foreman from the ‘Heavy’ ep. “OK, sex is risky, we GET it.”
>Finally, for Hawk, who thought that Cameron wasn’t >getting her share of the limelight: not only was she >correct about the diagnosis, she also got the best zinger >of the show in her little crack about Chase’s “staying >power.”
Thanks. ;) ITA on both points. Chase surely deserves it, after the way he handled his little ‘date rape’ adventure (ugh). Although I found it odd that both he and Cameron ‘vanished’ during the closing sequence (too bad she wasn’t there to witness House confirming her Dx)…did Foreman draw the short straw to stay late into the night, or something?
Great medical recap, as always! :)
April 7th, 2006 at 1:09 pm
I think House’s wit it goin to continue to degrade, and cut more like a hammer as time goes on. After all, we all know a drug addition doesn’t have any rea impact if noone talks about it, don’t we?
April 8th, 2006 at 12:00 am
Awi- I was talking about the characters in the context of how they play off of House (and trying to do it in as few words as possible.)
Basically, whenever they get together to discuss the latest shocking thing House has done, you can count on Foreman to take issue with House and Chase to support it. Couple that with all of the times that Chase tries to do things the House way and falls flat, and I really get the feeling that Chase looks up to House.
As for Cameron, I am well aware that there is more to her personality than her feelings for House (my father was aware of them long before I was). She really cares for people, to a fault some times, and House in particular does, I believe, trigger her sympathetic responses. And this in turn solicits the most sympathy and tenderness from House.
But I’m hardly putting together an essay here, and I am utterly unconcerned ATM with the Young’uns on their own (IOW, outside of their relationship with House)
April 8th, 2006 at 4:42 am
Zach, it sounds like you think I was arguing with you–I was merely expanding on your thoughts and discussing in less simplistic terms the personalities of the individuals you’d mentioned, and how those personalities affect their dealings with House (and how their dealing with others are similar). I’m not sure how one can see any character only in relation to the central one–any well-drawn character’s actions must be consistent with the personality they’ve been given by their creators, which is what makes them believable. As I said and you reiterated, Foreman is a leader and Chase a follower–in general, not just with House. My criticism about Cameron being reduced to a young woman “in love,” rather than a competent doctor, was directed at the writers who have muddied the character, in my opinion. It wasn’t a criticism directed at you at all–I felt your post only highlighted that problem.
May 3rd, 2006 at 1:04 pm
[...] At http://politedissent.com/archives/1184, a doctor watches “House” and analyzes what’s realistic and what’s not. [...]
May 4th, 2006 at 4:07 pm
“Chase surely deserves it, after the way he handled his little ‘date rape’ adventure (ugh)”
His what now?
July 20th, 2006 at 8:23 am
i) removing the tick does NOT cause immediate improvement – might release a bit more venom but the course isn’t usually that fast anyway – at least, not in an adult although I admit unfamiliarity with USA arachnids. Odd that an Australian intensivist (Chase) didn’t pick the diagnosis though.
ii) Developed countries – such as Australia – have tick antivenom. I guess CSL haven’t offered a product placement bribe – or is it not effective against USA species?
iii) She needs doxycycline as well and I do trust the medics contributing to this discussion – if not the show advisors – know why.
Thanks Scott, great site.
July 21st, 2006 at 2:54 am
Addit – CSL antivenom was developed against I Pacificus - Eastern Australian and Western USA seaboards – unlikely contender in this case but antivenoms are not necessarily effective against only one species & I think one might at least ask. See http://www.cdc.gov/mmwr/PDF/wk/mm4516.pdf for a nice description of a more typical case.
August 2nd, 2006 at 7:52 pm
Does putting a sleeping person’s hand in warm water really cause him to pee? If so, why?
October 13th, 2006 at 11:09 am
Carol: muscle relaxant. Simple.
February 26th, 2007 at 8:25 pm
I’m sure it’s been pointed out before, but I just noticed House’s appartment number, whilst watching this episode… 221…
http://en.wikipedia.org/wiki/Sherlock_Holmes#People_in_his_life
December 14th, 2007 at 7:07 am
He built his team with a specific balance … you agree with everything I say, you disagree with everything I say, and you get morally offended by everything I say. Cameron is also the only one he hired without a clear-cut personal motivation to do so, since I assume he was just screwing with her when they talked about it, which means it was her clear-cut personal morals that actually got her the job.
I’d seem much more precognitive if I’d said this before House explained it.
February 21st, 2008 at 11:05 am
The “out of sequence” involvement of the girl’s heart in the progression of the Tick Paralysis was addressed in the show. I think they said that weakness from the transplant made it faster to succumb to the tick poison.
March 5th, 2008 at 11:52 pm
Hi, thanks for the blog. Nice for someone without profound (if any) medical knowledge for finding out what makes sense and what does not.
As to the House – Holmes issue, Wikipedia has the evidence:
“House is in many respects a medical Sherlock Holmes. This resemblance is evident in various elements of the series’ plot, such as House’s reliance on psychology to solve a case, his reluctance to accept cases he does not find interesting, his drug addiction, home address, playing of an instrument, relationship with Dr. James Wilson (a reference to Dr. John Watson), and his encounter with a crazed gunman credited as “Moriarty”, which is the same name as Holmes’ nemesis. Also, series creator David Shore has said that Dr. House’s name is meant as a “subtle homage” to Sherlock Holmes (i.e., “homes”).”
March 7th, 2008 at 5:28 am
Oh dear, how late this comment was. But only because the one before was late, too… And I do not really know at what time which episode was first aired. I myself started watching House only the last year. But this one was before he was shot, of course…
July 7th, 2008 at 5:15 pm
I can’t believe they just threw away the tick! I guess that would explain not trying to use an antivenin, since they obviously didn’t even try to identify what kind of tick it was. The parasitology/vector biology labs would like you to save the tick in a little vial (ideally still alive) and send it in. Maybe if it’s the right kind of tick she can get Lyme disease too, before her heart quits working.
July 28th, 2008 at 8:46 am
@whitebat: You should know House by now. The man has no respect for hospital policy, both one of his best and worst character traits. Would have been even more like him if he took it and put it in something Wilson cooked.
October 16th, 2008 at 9:58 pm
Now, when I hear “tick” I think “deer tick” which is really small… and I know its more dramatic to see House retrieve a beetle-sized tick… but are ticks that big? I thought it was funny how you could see the tick’s legs moving like it was a toy spider, hehe
November 15th, 2008 at 11:04 pm
Several species of ticks found in the Eastern US can be 1/2 inch long when fully engorged with blood. Most folks are used to seeing the hungry flat ticks, not the adults when fully fed.
February 4th, 2009 at 10:31 pm
He did toss it in a vial, I think, though it appears it’s just one sitting on a cart in the hallway and not one he should be using. Especially as he doesn’t retrieve the vial. It’s definitely not a deer tick; it’s too big, even engorged. Looked more like a dog tick (Dermacentor variabilis), which is certainly endemic to the region.
February 12th, 2010 at 6:59 am
Late to the party, but maybe there’s someone still reading on old eps. I have two doubts, not strictly medical. It’s said that the girl needed a heart transplant after a chest trauma following a car accident.
1. At one time Cameron (?) considers reporting on the boyfriend for them having sex, as Melinda is a minor. Is the age of consent in NJ older than the driving age? I’m not American, but aren’t both 16, so if she can drive, she can legally have sex (and the sex was after the accident and transplant).
2. Still about the accident – they say that the trauma was related to the steering column damaging her chest. This would suggest an old car, without a driver’s airbag, even without a collapsible steering column. Surely an overprotective mother wouldn’t let her daughter drive an old unsafe car like that. Steering column to the chest injuries are very unlikely on any recent car thanks to the airbags, collapsible steering column and crumple zones. No way this mom would let her daughter anywhere near a car without those features.
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