House – Episode 10 (Season 4): “It’s A Wonderful Lie”
House finally returns to television with new shows, with a sadly mediocre outing, though it started out promising.
An episode recap, medical discussion, and spoilers follow!
Maggie, a 34 year-old single mother develops sudden and complete paralysis of her hands. A series of workups by orthopedists, neurologists, and immunologists is negative so she is admitted to House’s team. At this time her symptoms consist of flaccid paralysis (paralysis with loss of muscle tone) of both hands and intermittent numbness of her arms. There is a known family history of breast cancer and Maggie is positive for the BRCA1 gene (one of the breast cancer genes), so she had a double mastectomy (both of her breasts surgically removed) several years before because she felt her risk for cancer was too high. It also turns out that Maggie, and her daughter, never lie to each other. Never, ever. This becomes a source of fascination and aggravation for House.
Taub suggests paraneoplastic syndrome from some remaining breast tissue that may have become cancerous, but an MRI of the chest is negative. Later, he and Foreman talk to her most recent sexual partner and trick him into admitting that he slipped her some Ecstasy. In light of this, Maggie is started on dialysis, but she shows no sign of improvement — in fact, she gets dramatically worse and goes completely blind. The differential now includes problems with the dialysis solution, Kearns-Sayers Syndrome (a rare genetic disorder that includes abnormal heart conduction, paralysis of the eye muscles, and degeneration of the retinas), Multiple Sclerosis, or a vascular (blood vessel) problem. A variety of tests are run including an MRI and a fluoroscein angiogram of the eyes but both are normal. There is no evidence of any pathology including macular degeneration or optic neuritis. Her house is also searched and her computers brought in for House to examine. To him, her e-mails suggest increasing joint pain and fatigue, but nothing ever comes of this.
The differential diagnosis is now conversion disorder — a psychiatric condition where mental concerns are “converted” into physical problems — so the team lies to her and tells her that she has “infectious parapheresis” (a fictitious condition) and they have a medicine that will cure it right away. They believe they can trick her out of the conversion disorder. Unsurprisingly, it doesn’t work (because she doesn’t have conversion disorder, and even if she did, you can’t cure it that way), and once again, she gets worse with swollen lymph nodes closing off her throat. She is intubated initially but Taub is able to reduce the size of the lymph nodes so she can once again breathe on her own. A fungal cause is now suggested, as is sarcoidosis. It doesn’t really fit, but House orders a bronchoalveolar lavage (washing the lungs with sterile saline and then testing the fluid) just to be sure. As before, the test is negative, but as is usual for House’s patients, her symptoms dramatically worsen during the test. She is now bleeding into and out of her eyes. It turn out that her platelet count is extremely low so her blood cannot clot right. The differential diagnosis now consists of splenic sequestration (the spleen is trapping all the platelets), tuberculosis, gaucher disease (an inherited disease), TTP (thrombotic thrombocytopenic purpura, a blood disorder that leads to increased blood clots and then to low platelets), hemolytic uremic syndrome and lupus. House cuts off Kutner before he can finish suggesting more causes and orders a bone marrow aspiration (note the pictures at the bottom of the link — no drill is used). Chase attempts to perform the aspiration but runs into trouble when it turns out that her bones are as hard as rock — it seems that Maggie has osteopetrosis, a condition where the bones are harder than normal.
The team initially hopes the she has Carbonic Anhydrase Type II deficiency (CA2), because it is the only cause of osteopetrosis that is not fatal (not true, patient with adult osteopetrosis — also known as benign osteopetrosis — can have lives of normal length). The start to arrange a bone marrow transplant, but then tests reveal that Maggie does not have CA2, therefore they assume that she must have one of the fatal causes of osteopetrosis. (Along the way, House also determines that Maggie’s daughter is adopted, a fact Maggie never told her, meaning that she does lie to her daughter.) A causal conversation with Wilson convinces House that he missed something, so he injects Maggie with Risperidone. This antidepressant antispychotic drug can cause breast tissue enlargement, and House figures that Maggie has abnormal breast tissue somewhere in her body that has become cancerous and is using the Risperidone to find it. Sure enough, an area behind her knee swells up and House is even able to get breast milk from it. Maggie has osteopetrosis related to Breast Cancer and paraneoplastic syndrome. He tells her and her daughter that after surgical removal of the cancer and chemotherapy, she should recover.
The medicine, particularly in the second half, was pretty shaky tonight.
First, there is a difference between osteopetrosis and osteosclerosis. Osteopetrosis is a type of osteosclerosis, but the terms are not interchangeable. All the causes of osteopetrosis are genetic, and if Maggie had one of these diseases, it would have shown up with other symptoms long before now.
Osteosclerotic (and osteosclerotic) bone is harder than normal, but so hard that it is actually brittle and fractures are common. Chase would have shattered the bone, not scorched it — plus I find it harder to believe that any bone, even hardened bone, would be stronger than surgical steel. And a drill for a bone marrow aspiration? No way, a special needle is used.
Breast cancer can cause osteosclerosis…in metastatic lesions (breast cancer that has spread to the bone). This means that individual spots on the bone will be sclerotic, not the entire skeleton. It is also only in metastatic disease, which has poor survival even with surgery and chemotherapy…so not quite the rosy recovery House suggests.
Risperidone may cause breast tissue enlargement and galactorrhea (milk production), but that doesn’t mean it will. It’s a very rare side effect. It certainly doesn’t occur that fast and after a single dose.
Conversion disorders are extremely difficult to treat and you can’t cure the patient with a placebo. If that were the case, then every cure would work because the patient believed it would.
You don’t use dialysis to treat an ectasy overdose, but then ecstasy is often cut with even worse drugs so who knows what was actually in the pills, and dialysis can be used for an unknown overdose (and that’s why they tested the pill itself).
I give the medical mystery a B because it was genuinely interesting. The final solution, though clever, falls apart on close examination so scores a mere C-. The medicine started out good, but ended up bad, and that averages out to a C. The soap opera was good, both with the team and Secret Santa, and the “I never lie” family. I give the soap opera a solid A.
For the record, Contagious Ecthyma is a viral infection of ruminants — usually sheep and goats — that can be passed to humans. The lesions heal on their own, no treatment is necessary. Contagious Ecthyma is also known as Orf — a disease I’ve been predicting would show up on House for several years (though I neglected to put it on my challenge list). As far as I can tell, it does not affect donkeys or mules.
The previous House review
A list of all prior House reviews
January 29th, 2008 at 11:33 pm
Two things that had me psyched: Seeing a new episode of “House,” and reading a new review by Dr. Scott.
Can’t speak to the medical aspects, although I did find myself thinking, “Yeah, yeah, she’s dying, you can’t save her, now come up with that magical diagnosis that WILL save her.” It’s terrific formula, but that’s what it’s come to feel like: a formula.
A little surprised that Jennifer Morrison had a non-speaking cameo as Cameron – was that the first time she met 13? (Very interesting to see the older and newer Young Guns come face-to-face.)
As for the Nativity pageant: I’ve heard of “Madonna-Whore Complex,” but seriously, folks …
January 29th, 2008 at 11:55 pm
Wow. Score one for the art student! As soon as House announced she had breast cancer, I thought “this means it metastasized into her bones?”
January 30th, 2008 at 12:22 am
I guess I will start the fun-hating and say that it probably would have been a better story if the patient had died. It would have been a maturation moment for the new guns and been a dark/reality response to the Christmas cheer. It certainly would have been more dramatically jarring for the team to be attending an autopsy while everybody else was partying.
At least we had a clinic patient this week (with an obscure disease to boot)! Hey, and there were even NURSES in the episode! They just needed some eye protection in the OR and they would have been set. :-P
January 30th, 2008 at 12:23 am
Sorry, Kevin, but I’ve seen a case of true total-skeleton osteopetrosis resulting from a paraneoplastic breast cancer effect. It’s not well described in the literature, but you can’t argue with reality. :-)
Also, I did not hear them mention osteosclerosis at all. That is something different that I gather you read into the the show.
Yok
January 30th, 2008 at 12:42 am
Official Comment
Who’s Kevin?
I may not be able to argue with reality, but I can certainly argue with an assertion of reality. I see no indication in the literature of what you’re suggesting. The only mentions I can find in the medical literature of osteopetrosis is in relation to an inherited condition (including mouse and rat experimentally induced conditions), or in regards to bisphosphonate-induced osteopetrosis. I can find no mention of the condition as it relates to breast cancer. I can find many mentions of metastatic cancer and osteosclerosis, which is the point I was trying to make: that I think the writers were confounding the two conditions.
January 30th, 2008 at 12:58 am
Just FYI, risperidone is an antipsychotic, not an antidepressant. And I’ve NEVER seen it cause the kind of reaction they showed. If it did, I think it would be contraindicated for females.
January 30th, 2008 at 1:02 am
Scott –
I fully agree with your points. Yok – do you have a reference for paraneoplastic osteopetrosis? Osteopetrosis requires complete inactivation of osteoclastic activity, which is pretty much impossible as a paraneoplastic syndrome unless the tumor was making antibodies to RANK-ligand. A number of tumors secrete TGF-beta which can ramp up up osteoblast activity, but osteopetrosis never results because, due to the coupling of bone turnover, an increase in osteoclastic activity follows. Paraneoplastic ostesclerosis – sure, but as Scott mentions this is isolated and not to be confused with complete skeletal osteopetrosis. “House” is quite entertaining but wildly unrealistic (if that’s how conditions were routinely diagnosed, by a shotgun approach to virtually every test under the sun, patients would be dying left and right from iatrogenic problems), and the “medicine” in this episode warrants a C- at best.
DB Karpf, Director, Osteoporosis & Metabolic Bone Disease Clinic, Stanford U. School of Medicine
January 30th, 2008 at 1:08 am
Official Comment
Jan,
You are correct. Risperidone in an antipsychotic, not an antidepressant (though it can be used in bipolar disorder as well). I’ll correct it in the post.
In terms of the breast swelling and galactorrhea, risperidone can cause hyperprolactinemia which can lead to, among other things, galactorrhea and gynecomastia, which is where the writers likely got this idea. Though in terms of risperidone, this seems to be mostly a theoretical risk rather than an observed one (this is all from the PDR, 2008 edition, page 1717. Not a resource I usually rely on, but it does have its uses).
January 30th, 2008 at 1:26 am
Man, I just loved that House not only diagnosed the clinic patient with a possible bestiality STD, but how quickly he jumped to the conclusion “donkey show”…
January 30th, 2008 at 6:17 am
When House squirts the mother’s milk into the girl’s mouth he says, “You’ve had it before.”
Why would he assume that the woman had nursed an adopted child?
January 30th, 2008 at 8:30 am
So it seems like it is unlikely that breast cancer caused the bone-hardening. Does that mean breast cancer *can* cause the other symptoms? Bleeding eyes? Paralyzed hands? Does it ever present as paralyzed hands? Wouldn’t you almost always lose significant amounts of weight before these weirder symptoms showed up? And how difficult would it be, for the sake of accuracy, to show the woman looking haggard and thin?
Along the lines of accuracy: why was it necessary to make the girl her adopted daughter? It really did nothing to the plot. It was just pointless and unbelievable.
January 30th, 2008 at 8:41 am
Richard, the girl probably had had regular (cow) milk before, and that’s what she recognized.
Of course, we knew from the start House had put only his own name in the Secret Santa thingy, but I kinda expected him to have gotten some presents for the other ones, that they would’ve discovered at the end of the episode. Oh well.
…and why is the Christmas episode in January instead of December?
January 30th, 2008 at 8:46 am
Richard,
When House squirted the milk into the kid’s mouth and told her she’d had it before, he was telling one of those “white lies” to allow the mother to continue the charade that she is her biological daughter.
As for the bone marrow bit with the drill – I was thinking back to the time that Foreman shoved the needle into the black kid’s butt and was wondering why the marrow extraction would be different now.
I’m actually getting to the point where I almost don’t want to know how wrong they are on the medicine and just watch the show for what it is – an interesting character study in which medicine is an important part of the drama but they hardly ever care enough to make it realistic.
January 30th, 2008 at 8:48 am
and why is the Christmas episode in January instead of December?
Hear about the Writers Guild of America strike? Obviously, Fox has been rationing whatever new episodes of shows it has left. So this episode aired now instead of a month ago.
January 30th, 2008 at 8:49 am
Willem,
perhaps you’ve heard of a certain writer’s strike.
Obviously this episode was conceived as a “special Christmas episode”. They aren’t going to keep it on the shelf just because they decided to start running new House’s before and then immediately after the Super Bowl. It might have made sense to burn this episode off in December but they’d made the decision to hoard the few remaining episodes that were completed before the strike started.
January 30th, 2008 at 8:53 am
The medicine may have been bad, but it was nice to see more of Wilson, and more clinic time. I agree, though, the episode would have been better if the patient had died.
However, I realized that there were no seizures this episode…that’s a rare occurrence on House, MD.
January 30th, 2008 at 10:47 am
I was happy as heck to see the CGI “Innerspace Cam” come back again! It feels like it’s been forever since we saw that, and it showed up a few times in this episode.
My instructors are right; sooner or later, everything comes back to embryology.
And how interesting that although actors Jesse Spencer and Jennifer Morrison are no longer engaged, their characters still are. Also on the actor front (pun intended), I wonder how Janel Maloney felt about playing a woman with a literally flat chest?
January 30th, 2008 at 10:49 am
Re: the milk squirting scene… is there any health risk from eating someone else’s tumor cells?
January 30th, 2008 at 10:57 am
Best part of the episode: the return of CGI effects detailing the horrible things happening to the patient!
January 30th, 2008 at 11:30 am
I thought it was a pretty disappointing episode from all perspectives (entertainment, medicine etc.). The only good thing is to see House having the heart not to tell the kid about her mother.
January 30th, 2008 at 11:52 am
Usual disclaimer: I have no formal medical training and no desire to become a doctor. I am quite happy in my chosen profession, (sociology, a “soft” science) but I have always had an interest in and am somewhat self-taught in several hard sciences which interest me (mycology, the only one I would pursue formally, astronomy, minerology, medicine, and optics, in that order)
Now, the actual question: Kutner says at one point, something along the lines of “Does it really matter if it is disease #56 or disease #405?” Or something close to that. I didn’t tape the episode, and Kal Penn (who I’m no critiquing, I’m a fan of his work) mumbled the line. Are there really that many different diseases that cause osteopetrosis? I always thought it was an exceedingly rare condition. Or was it a case of every case of oseteopetrosis without a clear cause being thought of as a separate disease? Or is Kutner just understandably annoyed and exaggerating?
January 30th, 2008 at 12:03 pm
Official Comment
Pentalarc,
There are about 40-50 conditions that can cause abnormal hardening of the bone (but only a handful that actually cause “osteopetrosis”), so I think you can write it off as an annoyed exaggeration on Kutner’s part.
January 30th, 2008 at 12:12 pm
I thought I remembered at that time they were just saying the patient was dying, and Kutner was saying it didn’t matter what is was, she was going to die.
January 30th, 2008 at 12:12 pm
Bad enough the weak medicine, but the entire psychological duel about truthfulness was entirely inconsequential and immaterial? Harrumph. And even then the big A-HA hinged on the daughter’s not knowing she isn’t adopted, which is just bizarre (to me). It has always common knowledge in our family, and I’m 47. A curiosity, but hardly the source of great inner conflict. Makes filling out the Family History page of medical questionnaires quick and easy!
I suppose it’s a personal soapbox, but the idea that an otherwise forward-thinking, modern woman, in this day and age, would harbor the quaint notion adoption is somehow shameful or damaging to their relationship pulled me right out of the episode.
Not even the brief images of the apparently relaxed and happy Chase could get the snarl off my face. (He must be doing drugs, right?)
January 30th, 2008 at 1:07 pm
Thank you for the recap Dr. Scott. I wanted to add a little thing, I dont know if you mentionned, but they seem to come back with the great “inside the body” animations, like you mentionned in the last episode (or in this case, fetus animation). And did you guys noticed? In the cafeteria, Wilson stands near House helping him to see if there was a cancer on the x-ray (i guess its a x-ray) and House actually pays for his own lunch! (He never do that, usually he make Wilson or someone else pay for him)
January 30th, 2008 at 1:41 pm
On televisionwithoutpity.com’s CSI boards, CGI like this is called the TMI-cam (i.e. “too much information” camera).
Testing for possible bone marrow transplant — did they say that the patient had no siblings? A sibling would be most likely to be a good match. Did they give the results of the daughter’s test? Even if she were the patient’s biological daughter (and the parents were unrelated), she’d likely match no better than 3/6.
January 30th, 2008 at 2:19 pm
From a climbing point of view…. The rope in the mother’s had ran out of length and the end of the rope ran through the belay device before the girl hit the ground. So it does not matter if she had hand paralysis or not, the girl would have hit the ground anyway!
January 30th, 2008 at 4:28 pm
Hey everyone,
So nice to see House again.
Now, a question for Dr. Scott that’s been bothering me ever since I found your medical reviews (wich by the way I love, thank’s again for doing it). As a medical student who has been through a very hard time to study Medicine I am very concerned about knowing as much Medicine as I can. Still, I can’t spot most of the mistakes that are made in “House, MD”, and what really concerns me is that, when reading your reviews you seem to know as much Medicine as Dr. House himself. My question is: do you do some research about the medicine that is played in each episode or do you just go from your TV to your PC and start writting your review? Maybe a silly question but the worst that can happen is that I don’t get an answer… lol
Thanks,
Best regards from Cádiz, Spain
January 30th, 2008 at 5:05 pm
so glad to see house back to normal!! welcome back the the C.G.I cutscenes and clinic duty
house episodes were kinda limp wristed until i saw this one! i hope if stays on track from now on
January 30th, 2008 at 6:25 pm
Dr. Scott, this is the first review I’ve read right after an episode appeared! Thanks so much. I always knew House was pretty unreliable, but after last night I was left saying “…huh?” and as a pre-med student with a real interest in medicine I like to think I have “some” knowledge just from my own research and by talking to physicians, but you cleared it all up for me.
=]
January 30th, 2008 at 6:34 pm
I’m glad House is back (with one episode at any rate), even if the medicine was a bit haphazard. I didn’t manage to follow the diagnostic process very well. And someone ahead of me asked this, but what was with the milk? Can that actually be produced by cancerous breast tissue elsewhere in the body?
Wow, I’m second. Amazing.
January 30th, 2008 at 6:54 pm
Scott, love your “House” reviews! I was wondering what you thought of the “all fetuses start out covered in breast tissue” explanation. I’ve forgotten probably 95% of what I learned in Embryology class, but I’m pretty sure I’ve never heard that before (I think I’d remember it!). Is that true or made up for dramatic effect?
January 30th, 2008 at 7:13 pm
As a Psych Nurse I have had a few patients experience galactorrhoea, probably in the region of 1% and usually after week or more of administration. Interestingly the majority of these patients were Indigenous Australians.
January 30th, 2008 at 8:34 pm
The best part of the episode was Wilson wearing that hat.
January 30th, 2008 at 9:46 pm
If I had the breast cancer gene, I’d be VERY sure to tell my daughter that she was adopted, so she wouldn’t have to worry that I’d passed it on.
January 30th, 2008 at 9:58 pm
This episode was pretty alright. It had its funny moments but not like it normally is, it was more of a goofy funny and I’m not sure if I liked that. Although I do think the best part was Wilson’s hat. Best scene had to be:
“Take off that hat.”
“It’s a reindeer”
“It’s a moose on a jew!”
*Wilson Flaps hat*
I seriously about died when Wilson flapped that hat.
January 30th, 2008 at 10:30 pm
Wow – 13 was really putting on her Cameron impression this episode. I really liked Kumar’s goofy christmas enthusiasm this episode. Though that scene at the end where the old team and the new team came together seemed really clumsy and forced to me. Poor Chase and Cameron got about 15 seconds of screen time :(
January 30th, 2008 at 10:42 pm
1st — thanks for the review — I always come here first to get a better understanding of the medical side of things:)
2nd — Just to finish a comment about the opening climbing scene. The end of the rope flying through the belay device before the daughter reached the ground was impossible in the set-up shown. The rope was set up as a “top-rope”. Basically the rope runs from the belayer (mom in this case) directly to a “pulley” at the top of the climbing wall and then back down to the person who is climbing.
I wasn’t watching that close to see if the mom was using what is called an “auto-locker” belay device, which would have prevented even the rope running free in the first place. An auto-locker belay device requires “intervention” to allow the rope to run through it when there is weight on the rope.
However — the possibility of “dropping” someone while on a top rope is a real risk in climbing, usually the result of the belayer not paying attention. The number of these types of accidents have dropped somewhat due to more widespread use of auto-locking belay devices (sometimes mandatory in indoor climbing gyms). And there is also a real possibility of having the end of a rope run through the belay device *if* the climber is lead climbing and is lowering off a climb and is higher then 1/2 the length of the rope.
January 30th, 2008 at 10:47 pm
This was the first episode of this season that had the old “House” feel. Unfortunately though, as mentioned above, it becomes very predictable. The healthy person who suddenly develops weird symptoms, new (worse) symptoms during tests and/or treatment. At least in this one they didn’t try dangerous treatments on a hunch. The bone marrow aspiration was hilarious – general anesthetic, a drill – ROFLMAO. But the psychological, “human” aspect was well done. The new team doesn’t seem to be as easily intimidated by House – looking forward to many more episodes where his mind games just bounce off or even better backfire.
January 31st, 2008 at 12:32 am
I couldn’t help but think about that kid from “Paternity” in the first season who figured out that he was adopted because of his cleft chin.
January 31st, 2008 at 4:12 am
Even if breast cancer cells metastisize somewhere else, how likely is it that that they will actually start producing milk and function like a normal mammary gland? Wouldnt that suggest that the cell is functioning properly and expressing the correct genes?
The only tumors that I know that abnormally express genes for fully formed body parts are teratomas. (they have hair and teeth in them)
January 31st, 2008 at 1:49 pm
So glad to have House back, and so bad to see your recaps back, Scott. Missed you both!
Jeri, I thought the same thing. The promise to the birth mother shouldn’t outweigh the daughter’s burden. I thought maybe she took the daughter for genetic testing and has already proven to her she doesn’t have the gene.
Wilson was hysterical. No Cuddy, and barely any Cameron. I kind of liked not using the characters rather than forcing scenes that feel forced; nothing more glaring than Contractually Obligated Screen Time.™
Risperidone is also given for OCD (my son takes it), and if it caused breast growth routinely, surely it wouldn’t be given to males.
Human breast milk tastes very different from cow milk, and I doubt the daughter could have had a taste and recognized it as milk. And I had the same thought about milk from a tumor. YUCK.
January 31st, 2008 at 2:02 pm
House was being ridiculous about the “breast milk.” Human breast milk neither looks nor tastes like cow’s milk (as it did on the show).
While the highjinks were amusing, they were embarassingly predictable (I called House putting himself into the drawing immediately, and the adopted child about twenty minutes beforehand), and the medicine again was a serious WTF.
I’d like to blame the crappy writing on the strike, but…
January 31st, 2008 at 2:12 pm
Human breast milk tastes very different from cow milk
Er – how do you know that?
January 31st, 2008 at 3:19 pm
MrBuddwing, I’m sure there are mothers who have nursed who have never tasted their own milk (while reheating it and testing for temperature, or out of curiousity, or whatever) but they are surely a minority.
It is, after all, both edible and hygenic.
January 31st, 2008 at 3:31 pm
Deborah: No arguments. I’m sure I benefited from the goodness of my mother’s milk. My memory just isn’t that good.
January 31st, 2008 at 4:35 pm
Hey scott! Why did House squirt the milk in her mouth? To prove that it was milk? He didn’t need to do that though? Was it just for fun?
January 31st, 2008 at 5:39 pm
An internist, a sports medicine specialist and a plastic surgeon replacing a neurologist, an immunologist and an intensive care specialist? Is it just me, or are the new team’s specialties not nearly as useful for a diagnostic medicine department (as fictional as that department may be)?
January 31st, 2008 at 6:17 pm
@41 Strangelove: there are plenty of tumors that actively produce stuff; adenocarcinomas, for instance, are hormone-secreting tumors. Anything a healthy gland can make, a secreting tumor can kick out in ridiculous amounts. Usually this applies to vasopressin, growth hormone, thyroid hormone, adrenaline (epinephrine), or something like that.
In the real world, breast milk isn’t a hormone; it’s the secretion of an exocrine gland. So you’re right to wonder why a tumor that’s secreting… whatever is causing all those bizarre symptoms… would also secrete milk. In terms of how things work on “House” it’s not too crazy to think it could work.
January 31st, 2008 at 9:23 pm
Did I miss it, or did an entire episode go by without House popping a single pill?
January 31st, 2008 at 11:21 pm
I do believe you’re right! Maybe House was having so much fun, he forgot his leg pain. When you have recreational messing with an 11-year-old kid’s mind, a patient who claims to never, ever lie, and the strong suggestion of a hooker who does a donkey show, who needs Vicodin, right?
February 1st, 2008 at 10:12 am
Here’s one that’s been nagging at me: House diagnosing strep throat in the clinic patient with just a visual exam. Isn’t a culture required for that? (That’s been the case every time I’ve sought medical attention for a sore throat.) Or is House just such an uberbrilliant diagnostician that he can spot strep with the naked eye?
February 1st, 2008 at 12:31 pm
Official Comment
Strep throat has distinctive symptoms (which House didn’t ask about) and a distinctive look (hard to miss petechiae, not the exudate — white spots — everyone seems to think equals Strep. Here’s a good picture).
An important thing to remember about Strep is that our goal in treating it is not to make the patient feel better, but to prevent serious complications that Strep can cause in kids (rheumatic fever, acute glomerulonephritis). So we test to make sure we don’t miss Strep, or that we don’t over-treat non-Strep. A negative test is also a good way to convince a parent that there kid does not need antibiotics, not always an easy task. Testing also keeps the insurance companies happy (well, content, at least)
February 2nd, 2008 at 3:53 am
anyone noticed there was no visible breath in the scene where house and wilson were talking outside.. and also no footprints in the snow..
February 2nd, 2008 at 8:31 am
As someone who always thinks I have the symptoms I see on medical shows, I’d like to thank the creators of House for making me paranoid that I’m now going to grow boobs on my knees.
February 2nd, 2008 at 11:27 am
Re: the climbing accident
Man, that was pretty wrong from many aspects. The first – and most ridicilous – is the already mentioned rope going through the belay device. Regardless if the girl was leading the climb or was in a “top rope” position (and I think it is obvious it’s the “top-rope” for plenty of reasons, the biggest one that the top is already set), on sport routes you always use a rope that is at least twice as long as the height of the route. Even if you never ever climbed at all, it’s, like, duh. So yes, the girl was doomed to fall, paralysis or not. That’s some careless mother there.
But it does not end there. Mother uses a gri-gri, which is an auto-lock device (the auto-locking mechanism is pretty similar to the safety belt you have in your car, if you pull hard, it locks). This device would lock immediately when the girl put all her weight on the rope. Of course, the mother could have set up the belay device incorrectly, which wouldn’t be so strange because we already saw how careful she is in choosing rope length sizes.
Finally, I loved how the camera zoomed in on a hand holding a rope as it started to cramp like this hand was crucial to the girl’s safety. In fact, the hand not even visible in the shot was supposed to be doing the safety work.
February 2nd, 2008 at 12:59 pm
Loved all the Wilson and House/Wilson scenes. I think the lollipop scene between House and the 11 y/o violates FCC standards and pretty much all child abuse laws. If Robert Sean Leonard wasn’t on the show, I’d definitely stop watching.
February 2nd, 2008 at 9:43 pm
Anyone notice the heavy Apple product placement in recent episodes? Wilson clearly had an Apple Mac laptop in his office in the last episode; this episode the patient had the same laptop (which they showed close-ups of House trying to log into). House also advertised the iPhone and even name checked Steve Jobs…
February 2nd, 2008 at 11:18 pm
Cuddy’s hot!
February 3rd, 2008 at 4:23 am
I’m not a doctor, but as a EMT-I, I jumped when Taub started the intubation: He had it right in the hand (well, assuming he’s a lefty), but then, turned it before going for the mouth! Hey man, you perforate the brain in this direction! :-) And of course, he inverted also the tubus. … just my 2 cents.
February 3rd, 2008 at 10:46 am
you americans are having an extra house episode tonight, right?
February 3rd, 2008 at 11:37 am
Official Comment
Yes, there is a new episode following the Super Bowel tonight.
February 3rd, 2008 at 3:17 pm
> Yes, there is a new episode following the Super Bowel tonight.
That would be the Super Anus, then? ;)
February 3rd, 2008 at 3:53 pm
I’d just like to say that I love your reviews, Scott, and I look forward to reading the one about the episode coming on later tonight.
February 3rd, 2008 at 4:28 pm
Scott, wondered if you saw Rafael’s question (post 28), I am a family doc 10 yrs out of residency and often find myself on emedicine after the shows checking the ‘data’. Any favorite sources?
February 4th, 2008 at 8:52 pm
LabbRatt said:
“Testing for possible bone marrow transplant … did they say that the patient had no siblings? A sibling would be most likely to be a good match. Did they give the results of the daughter’s test? Even if she were the patient’s biological daughter
(and the parents were unrelated), she’d likely match no better than 3/6.”
THANK YOU!
I was already in serious “WUH?” mode after the smoking drill and g.a. for a bone marrow aspiration (I should only have been so lucky!), but the issue of testing the daughter for a match really bugged me.
Wouldn’t the newbies already know that the child – assumed to be biological at this point – wouldn’t even warrant testing? Granted, I’m working off a single experience -my SIL died of AML, and her oncologists ruled out the testing of my niece straight away. My SIL did have a sibling, but her brother wasn’t a close enough match. So yeah, I’ve always understood the thinking to be “a parent or a child is rarely – if ever – going to be a suitable donor for a patient. If there is no sibling or the sibling isn’t a good match, you go to the Registry.” May I assume that’s still correct? (Personal exp was almost 10 yrs ago.)
Since House went so quickly to the “ah, she must not be your daughter” conclusion”, I assumed that the mother refused to have the daughter’s marrow tested because she knew it would reveal their lack of genetic connection. In light of that, wouldn’t the adopted daughter be as legit a candidate as anyone else already listed on the registry?
I’m usually OK with an adequate level of sensible medicine in “House”, but when several mistakes are made that clash w/my own personal experience, that really takes me out of the show. Hoping tomorrow night’s is better Last night’s “FROZEN” was outside my realm of knowledge, so I was perfectly fine with that episode.
February 5th, 2008 at 12:15 pm
For more information on bone marrow transplants, see the National Marrow Donor Program site, http://www.marrow.org/
A patient’s child or parent may be a good match if the parents have similar sets of HLA markers, but this does not happen often.
February 6th, 2008 at 7:12 pm
Hey, wow, a real Stanford professor weighing in. I bow down, but my memory is clear that the case I saw was osteopetrosis with breast cancer. The woman even had a “superscan” — pan-positive bone scan — like the patient on the show, and like the professor claims is unlikely (although he outlines a way it could happen; I wish I were that smart about molecules). There was also a lot of trouble doing her bone marrow ?aspirate ?biopsy because of the hardness of her bone.
Isn’t there some sort of nuclear scan they could have done to find ectopic breast tissue more easily?
Yok
February 7th, 2008 at 1:10 am
Sorry Steve, but your comment on enlargement of breasts and production of breast milk being caused by risperidone being only theoretical is not entirely true. I’ve seen it myself. However the production was nowhere near the amount that seemed to be produced from the “breast lump” on that woman, instead just a small amount and mostly exhibited when the nipple was squeezed (sorry if this is politically incorrect language-wise, but I don’t really know how else to put it.)
I’m sure you are right about the time-span esp. because most anti-psychotics or even anti-depressants take 4-6 weeks to show significant behavioral changes in patients (though some can take as little as a week), so I can’t imagine any side-effects occurring within hours.
One other thing, though not a officially established usage for risperidone, you are correct that it can/is used in bi-polar cases generally because of its overall mood stabilizing effects.
February 10th, 2008 at 2:50 am
Hallo, all.
I’m not a doc, not a medic, not even a student. I’m entirely on the receiving end in all medical situations beyond first aid. Usually, I sail right on past the medical errors in the show–I’m in this to see Hugh Laurie, frankly. But this week, I noticed something I’d like to ask about.
I caught this episode at 9 o’clock on broadcast, then hopped over to USA, catching the 11 o’clock House there, “Sleeping Dogs Lie.” In both episodes the big revelatory moment consisted of House seeking out a bump on the body, brandishing a huge syringe, and plunging it straight into the bump/bubo/tumor in question. I’ve never seen any medical professional–doctor, nurse, PA, phlebotomist, veterinarian–stick a needle in a spot if they hadn’t already swabbed it with alcohol or painted it with iodine or something. Is this skipped at all in real life? (Maybe I’ve led a sheltered existence.)
Second, would you really get a big dollop of liquid milk if you stuck the needle in and just drew back on it?
Anyway, thanks for all your work on the site. It’s always my first stop after an hour with the mad doctor.
P.S. Second edition Conan Doyle, eh? Betcha it wasn’t a Professor Challenger. Wonder which one he gave him…
February 15th, 2008 at 5:43 am
Re: the “whore/Madonna” side plot…
I think Mudwing got the wrong end of the stick on that one. First of all the conclusion that she was a whore was based on a typical Holmsian leap of logic based on the “patron saint” necklace and the fact that she didn’t flinch when he said it was also the patron saint of prostitutes.
I don’t think she was ever a prostitute; she just let House lead himself down the wrong path by not contradicting him and by selecting her answers carefully so as not to give away that he was completely wrong. In a story about lies it was a sideshow demonstrating how the truth can be a means of lying, too “I do a donkey show, yes”. “I guess you could say there is a certain contact element to it, yes”.
February 17th, 2008 at 2:11 pm
About the placement of the extra breast tissue, sure everything is possible in House, but doesn´t it usually develop somewhere along the “mammary ridge”, going roughly from the arm, through the actual breast location and down a bit lateral to the umbilcus to the leg?
February 21st, 2008 at 3:18 am
Dr. Strangelove, the breast tissue behind her knee wasn’t metastatic breast cancer rather ectopic breast tissue. Ectopic tissue is typically ‘normal’ tissue in an abnormal position. Therefore it has the same Physiological and Pathophysiological aspects as correctly positioned tissue.
In the case of this patient it has the same potential to become cancerous as her original breast tissue did. If she carried children and lactated she would have had an evident lump behind her knee until she stopped lactating. This is based upon the utterly fantastical response this ectopic tissue had to a single dose of Risperidone.
The whole episode was quite clinically offensive – sorry. Otherwise it’s an interesting show to watch.
Scott.
February 26th, 2008 at 10:31 pm
Hey Dr Scott,
Love your reviews mate, but didn’t the new guns only say that CA2 was the only treatable cause, not the only non-fatal one?
And do you have a nickname for the newer, younger Young Guns? And does Foreman count as young anymore, he’s been with house for like 3 years
Anyway, love your reviews
March 16th, 2008 at 10:27 pm
As an orthoptic student I was surprised when they went for the fluoroscein angiography to try to find the reason for the sudden vision loss, a full electrophysiological study would have been the correct protocol. I know they were testing the theories they had but this way they could have pinpoint where the problem was within the optic path.
April 8th, 2008 at 1:52 am
I am Bipolar, and I have taken risperdone, and it made me lactate. My psychiatrist didn’t seem that surprised — all of which is incongruous with the statement that this is a ‘theoretical risk, not an observed one.’
April 16th, 2008 at 3:45 am
Risperidone can cause an increase in prolactin levels which may cause enlargement of breasts and in some cases production of breast milk. In men and women. However this is a side effect and does not occur in all cases and as said before certainly would not occur so fast.
April 28th, 2008 at 12:33 am
Re: the “whore/Madonna” side plot…
I agree with Neil’s comment that she wasn’t a prostitute and was just enjoying letting House think she was.
My hit was that she was something like an elementary school teacher and that’s why she was wearing a pendant with a patron saint of children.
May 22nd, 2008 at 4:36 pm
To the comment about an adopted daughter being a potential bone marrow donor: This bugs me too. I read a book once (completely unrelated to House) where they wouldn’t let the siblings be tested because the girl was adopted; the insisted on the registry instead. Well, they aren’t related either! Honestly.
I do have one question…Do Catholic churches normally have Christmas performances? I don’t remember if it was a Catholic church or not, but if it wasn’t, then what’s with all the ’saint’ talk? Yes, everyone knows about Saint Nicholas (basis for Santa), but very few nonCatholics would have said, “Saint Nicholas, patron saint of children.”
Apparently the writers don’t know much about bone marrow aspirations or transplants. :)
June 14th, 2008 at 1:37 pm
The girl was adopted. What was the grap about the fetus starting of stuff in the mothers body? She didn’t carry one.
June 25th, 2008 at 3:26 pm
Wow, my wishes actually came true! “House” finally featured some Beatles music! :-))) (It was the opening bars from “Here Come The Sun King” mixed with some Christmas carol.) Nice. :-)
Aurora: Re Christmas performances in Catholic churches. They’re not that common, but they’re not unheard of. But they definitely wouldn’t be part of a mass like it was portrayed in this episode, so I’ll just give it to the artistic license. And yeah, I’m pretty sure it was a Catholic church. :-)
September 22nd, 2008 at 5:58 pm
she WAS a prostitute,
house said she got tested for STD (or only AIDS, I don’t rememberclearly) every three months; besides she knew exactly what kind of donkey show House had in mind, yet she wasn’t flabbergasted:-)
October 1st, 2008 at 7:11 pm
@ Tina:
Tina, it doesn’t necessarily make her a prostitute because she gets HIV tested every three months! How do you know she didn’t have a blood transfusion, or unsafe sex or something totally UN-prostitute-ish???
BTW, Scott….I just love your site! Keep up the great work..I look forward to reading your posts every week.
:)
October 14th, 2008 at 8:00 pm
IIRC the nice boob effects of risperidone are due to blockade of Dopamine D2-receptors and an increase in prolactine that is normally surpressed by dopamine. Thing is, then it’s related to EPS and other nice antidopaminergic effects of the antipsychotics, can you spell parkinsonoid, which are said, at least by jansen pharma before their patent ran out, to be smaller with the atypicals like risperidone, maybe by modulation through 5ht2a, maybe the affinity to d2 is lower. AFAIK the reason is unknown, and i don’t know how this translates to galactorrhoe, but a nice shot of vitamin h might have worked as well or better, or perphenazine, if i read my catie-try well. ;)
November 9th, 2008 at 10:15 am
My opinion about the drill biopsy: They tried a regular needle biopsy first (we didn´t see that) but Maggie´s bone was too hard so they used the drill then. The risperidone thing: House was looking for breast tissue and he found it. Even when affected by a tumour, there´s still some functioning tissue left, or not?
November 18th, 2008 at 1:08 am
Re: the “whore/Madonna” side plot…
The live nativity thing in Catholic Churches is rare but can be found. It was definitely a Catholic Church due to the side altars, Mary statue, high altar with tabernacle, etc. Maybe the show was going on as a separate event and not as part of a Mass… but then again, they showed the Church pretty full for just a live nativity thing. This could probably go on before Mass starts which explains why the priest doesn’t have a chasuble on yet, just the alb and stole… but all this may be moot as I doubt the writers thought it through as deeply as I am now!
I’ve never heard that St. Nicholas is the patron saint of prostitutes… maybe the writers gathered that from this story of him:
“Upon hearing that a local man had fallen on such hard times that he was planning to sell his daughters into prostitution, Nicholas went by night to the house and threw three bags of gold in through the window, saving the girls from an evil life. These three bags, gold generously given in time of trouble, became the three golden balls that indicate a pawn broker’s shop.”
Another thought: Maybe House is a fallen-away Catholic? He felt comfortable enough from previous experience to show up at a Catholic Church and he knew of whom St. Nicholas is the patron saint. I also remember him saying a line in another episode “If you want absolution, call a priest”. Another time he tried to make a metaphor that fell a part, something like “its like if a priest prayed for something… oh wait, that actually works”.
Maybe as he got more and more into science he fell more and more away from faith? I think he would find Fides et Ratio illuminating: JPII’s document on the relationship between faith and reason – they should be distinct but never separate.
December 17th, 2008 at 9:17 pm
Add me to the people saying that the lactation from risperidone (Risperdal) is NOT just theoretical. I was on it for about a week and a half before lactation started. Needless to say, I freaked out, especially b/c I wasn’t warned about that possible side effect. After talking to my pdoc, she said that has happened to about half her female patients who have taken it and most of them go off of it for that reason (I sure as hell did!). Interestingly, the lactation doesn’t always go away soon after discontinuing the risperidone – mine lasted for about six months after I stopped taking it. It’s not a super-big amount but it is noticeable and stained the inside of a few of my bras – quite embarrassing until I get to a washing machine!
April 20th, 2009 at 6:16 pm
Well, if you’re trying to make the clinic patient a saint, maybe she volunteers at an AIDS clinic, and is a little bit paranoid. The story Matt mentioned would give a Saint Nicholas connection for prostitutes and pawnbrokers. There’s a variant wherein each daughter receives a gift just as she’s about to be of age, and the father tries to spy and find out where the gift is coming from with the youngest daughter.
May 10th, 2009 at 6:14 pm
I myself have Osteopetrosis and broke my hip in the 8th grade wrestling for our middle school. My mother has the disease and after looking at my x-rays they were able to conclude I did as well.
Anyway… in regards to the drill doing whatever it does in the episode (haven’t seen it yet. just trying to figure out which one it is to watch out for it)
I know they used 6 drill bits throughout the procedure when they drilled the 3 pins into my R hip. It took so long i woke up while being stitched up.
Just thought id give me 2 cents as one of the few who has first hand experience with the condition
cheers
April 12th, 2010 at 1:46 am
[...] The script was laugh-out-loud funny. My hand got tired circling good quotes. And even though one reviewer thought the science was shaky, I felt the writer presented a novel explanation of how cancer cells can start to invade other [...]
April 22nd, 2010 at 11:33 pm
The whole point of the adoption thing was to give us a reason why she never lies to her daughter. The never lying thing was to give House something else to obsess over, and to challenge his assumptions about humanity.
July 27th, 2010 at 8:47 am
The most amusing thing about the madonna/whore side plot is that St Nicholas is also the patron saint of the falsely accused (at least according to Wikipedia).
July 27th, 2010 at 4:44 pm
For anyone who was uncertain, the CGI of the foetus was of the mother, not the child. The breast tissue spread (or didn’t retreat, whatever) and that foetus grew into the mother.
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