House — Episode 7 (Season 5): “The Itch”
Tonight’s episode of House was fairly light on actual medicine, focusing more on the personal aspects. Though there wasn’t much, for the most part, the medicine was well done.
Stewart is a thirty-five year old man with severe agoraphobia — he has not left his house since a mugging seven years before. Cameron stopped by and helped him with a case of the flu the previous year, and it is brought to her attention that he has had several days of a crushing headache as well as 3 seizures in the past 2 days; she in turn brings it to House’s attention. The initial concerns are a bleed, a clot, a tumor, a metabolic disease, or an infection (though they also mention vasculitis, which doesn’t fit in any of those categories). Since he refuses to leave the house, the team has to diagnose him with whatever they can bring to his house. The preliminary plan is to run an EEG while inducing a seizure to see if that will suggest where the problem in the brain is located. While Cameron runs that test, the rest of the team will search the house for toxins. At the end of the day, both the search of the house and the attempt to cause a seizure are fruitless.
House now decides to induce a seizure his own way, by bringing the outside world to Stewart. He pretends Stewart’s house is up for foreclosure and brings a passel of potential buyers through the house and into Stewart’s bedroom. Stewart immediately reacts, but the EEG reveals it’s not a seizure; instead he’s having severe abdominal pain caused by a partial small bowel obstruction (diagnosed by portable x-ray). Atrial fibrillation and Crohn’s Disease are mentioned as possible causes. House thinks surgery is the best option, but Stewart still refuses to leave his home. So they tell him that they will perform the surgery at his house, but plan on sneaking him to the hospital for the actual surgery, then returning him home before he awakens. Cuddy learns of the plan and insists that Stewart remain in the hospital for recovery; House agrees. Cameron decides it would be best to let Stewart know of the plan and wakes him from anesthesia to tell him that he’ll have to stay at the hospital. Surprising no one (except maybe Cameron) this causes him to freak out, and not only does he decide leave the hospital before having the surgery, but he gets a lawyer involved.
Cuddy responds by kicking Cameron, House, and Chase off the case, but since when has that stopped them? House has Cameron try some lactulose (a potent laxative) on Stewart, but his symptoms worsen. House now decides that they’re going to have to proceed with surgery, and actually perform it at Stewart’s house. Taub is roped into the job. The bowel obstruction is relieved and a bowel biopsy obtained, but not before there’s a little accident involving cautery, bowel gas, and fire. The biopsy shows flattened villi (tiny finger-like projections from the inner lining of the small intestine), which suggests Whipple’s Disease (a rare gastrointestinal infection), so House starts Stewart on antibiotics.
Stewart’s symptoms don’t improve, and in fact they worsen: he begins to develop numbness of his legs. The differential diagnosis now consists of porphyria, amyloidosis, and celiac sprue (an autoimmune disease caused by exposure to the wheat protein glutein in certain individuals), with sprue the most likely. This can be diagnosed by a blood test, but House prefers to feed Stewart wheat so that his symptoms will worsen and he’ll voluntarily decide to come to the hospital. He stops by Stewart’s house late at night to check on him, and Stewart happens to go into cardiac arrest at that moment. House views this as a chance to admit him to the hospital (it being an emergency and all), but Cameron shocks his heart back into a normal — albeit dangerously slow — rhythm. Taub sets up an external pacemaker to control the heart beat. The differential now consists of lymphoma or a toxic exposure, possibly organophosphates (a common chemical in insecticides). House then discovers that Stewart is something of a neatnik, and cleans his bathtub frequently with ammonia and bleach, which when combined, release chlorine gas. Could his symptoms all be due to chlorine gas poisoning? Stewart is started on steroids and sodium bicarbonate, but his symptoms continue to worsen. During a conversation with Cameron, House deduces that Stewart’s symptoms are not caused by chlorine gas, but instead all due to lead poisoning. When he was shot during the mugging several years before, the bullet split and some of the fragments remained in Stewart, embedded in the hip bone. As these slowly dissolved, the lead was enough to cause his symptoms. House quickly, and brutally, removes the fragments, and Cameron starts him on chelation.
Major complaints are in red, minor in blue, nit-picking in green:
Defribillation is not the treatment for a flatline. In fact, it is thought to make things worse (How can it be worse than a flatline, you ask? By making it even harder to get a normal rhythm back.)
Stewart suffered a cardiac arrest, not a heart attack. The two terms are not interchangeable.
House told the ambulance it was PEA (pulseless electrical activity), but the heart monitor showed a flatline, not PEA. Anyway, you don’t defibrillate PEA either.
I find it hard to believe that bullet fragments significant enough to cause Stewart’s symptoms would be missed on the x-ray. Hint: the hip should have no bright white spots on the x-ray. I also find it quite a stretch that bullet fragments in for seven years could be removed so easily.
Chlorine gas is extremely irritating (watery eyes, cough, sore throat), and would be hard for him to miss being exposed.
Why did Stewart need a jugular line?
Surgery is not first line for partial small bowel obstruction.
Wouldn’t Stewart be suspicious that there was no anesthetist or anesthesiologist? And once again, no eye protection during the surgery.
There’s no way Kutner made it though medical school without assisting in surgery. A large part of the third year is spent doing just what Kutner said he didn’t know how to do: retracting and keeping the field bloodless.
The medical mystery itself was rather pedestrian (for House, anyway), it was just the restrictions that made it challenging — I give it a C+. The final solution fit well, but was it ever mentioned before the final reveal that Stewart had been shot? I give it an A-. The medicine actually followed a more-or-less logical progression this week, though shocking a flatline is big mistake in my book, no knocks the score down to a B-. The soap opera aspects were all well done, particularly the Chase/Cameron aspect: another A-.
November 11th, 2008 at 11:50 pm
Oooh, I was waiting for this review. x]
And yes, there was several mentions on how Stewart was shot throughout the course of the episode, actually.
How do you think the medicine will be butchered in two episodes’ time?
A dramatic episode like hostage situation and medicine guinea pigs usually calls for poor medicine in the world of House, sadly…
November 12th, 2008 at 12:02 am
I have to admit I was hoping for more House/Cuddy action this week, although I did like Wilson’s attempts to hook them up. House appears to have some serious sexual frustration going on.
The heart attack/flatline/PEA thing just made my head hurt. Any first year ER nurse with ACLS would know the differences between those. The writers are really starting to loose the details in pursuit of the big picture.
November 12th, 2008 at 12:11 am
Wouldn’t there be some sort of pain associated with a bullet fragment embedded in a bone?
November 12th, 2008 at 12:23 am
Will bowel gas really burn like that?
I mean, I’ve heard of people lighting farts and whatnot - but will it really sustain a 4 inch flame shooting out of an intestine like a propane torch?
November 12th, 2008 at 12:27 am
@Jessica:
Yes, there was at least one moment during the eisode where it was mentioned that Steward had been shot. I know that there was a part where Cameron was trying to persuade Stewart that he had PTSD, saying something about how it was common in people who had been shot. He responded with how his girlfriend was the only one who made him want to go outside and she had died in the shooting, yadda yadda. I know that there was enough mention of the shooting for me to immediately respond with “from the bullets!” when House revealed that it was lead poisoning.
November 12th, 2008 at 12:37 am
Oh, House. You are so predictable. Everyone else is taking a step forward while you take a step back. :x
The entire point of me commenting here, however, is just to say I couldn’t help laughing hysterically at your comment re MS3 and Kutner.
November 12th, 2008 at 12:46 am
I needed to chime in as an organic chemist. Dr. Scott is absolutely correct that chlorine gas is very noxious and hard to miss. It is a pale yellow color, suffocating, and exceptionally easy to smell.
Kutner, on the other hand, is absolutely wrong. Mixing sodium hydrochlorite bleach and ammonia does not produce chlorine gas. It actually produces a class of compounds called chloramines. These would manifest as beach-smelling colorless gases. Chloramines are mildly toxic by inhalation, which is why mixing ammonia and chlorine beach when cleaning are patently bad ideas, although normally people who do this accidentally don’t generate enough gas to be very hazardous.
Also, blood is alkaline as I recall, and I don’t think that metallic lead would dissolve in an aqueous medium under those conditions, so I am a bit skeptical of the final diagnosis, too. Anyone have expertise in this area?
November 12th, 2008 at 2:29 am
The instant he mentioned that he and his girlfriend had been shot (and his girlfriend died) I thought, “Hm, I wonder if the bullet fragment is to blame in some way.” I figured it was either a fragment in his brain (typical House) or lead poisoning (typical reality). Go figure.
November 12th, 2008 at 4:04 am
“Also, blood is alkaline as I recall, and I don’t think that metallic lead would dissolve in an aqueous medium under those conditions, so I am a bit skeptical of the final diagnosis, too. Anyone have expertise in this area?”
From what I understand, long-term lead poisoning from bullets is a real thing. What I don’t know is if those small of fragments contain enough lead (it’s not like even hollowpoints are pure lead) to be toxic. It’s all about dosage, dosage, dosage, and even though the harmful dosage for lead is pretty small, I’d be willing to bet a few missed fragments would be below the dosage. Such would explain WHY the surgeons missed such apparently-easily removable fragments in the first place: No reason to risk additional time for the minor improvement.
Also, to those who mention that the shooting get mentioned: It did a few times, but the revelation that it was a hollowpoint did come at the end.
November 12th, 2008 at 6:10 am
The shooting was mentioned a few minutes into the episode when Kutner asked if the agoraphobia could be a symptom, and Cameron said “Only of being shot”…
November 12th, 2008 at 6:18 am
What I found as a weakness when they went for chlorine poisoning (and it was nice to hear the actual chemistry there, I didn’t catch that, thanks Scott J), is that chlorine is generally quite good at giving lung symptoms, you mentioned cough, but there’s also the chance for pulmonary oedema, which is likely to present itself sooner than the neurous system or gastro-intestinal damage. So I’d expect trouble breathing, coughing foamy excretions and such. That is if I remember correctly my studies in toxicology.
And I can’t not point out that it is advisable to make a second X-ray after treatment for removing a foreign body, especially one that is likely to break apart in the body as a bullet is. That is a big miss on part of the previous team that treated the patient after he was shot.
November 12th, 2008 at 8:06 am
So, House is going to cut open a mosquito bite to “let the poison out?” He *is* a doctor, right? Has anyone checked his credentials? He might just be a clever faker…
November 12th, 2008 at 8:42 am
I don’t remember at what point it was but at one of the mentions of being shot I figured it was lead poisoning from the bullet. What I didn’t see coming was the lame excision of the bullet fragments.
I did like at the end how Stewart mustered the courage to change his life by leaving his house (and Cameron too) but House failed to have the courage to change his life by knocking on Cuddy’s door. Again showing House dispensing advice in the harshest way possible but then not swallowing it himself.
November 12th, 2008 at 8:45 am
Either Greg House or Hugh Laurie is an awkward kisser. The “soap opera” House/Cuddy storyline this week didn’t work for me because of the memory of last week’s kiss, which for some reason I found uncomfortable to watch. I recall having a similar but not as strong reaction the one time House kissed Stacy in a previous season.
Also, this week after awhile I started to find the agoraphobic patient alternately boring and annoying. Maybe I was just tired or in a bad mood.
I realize these comments aren’t medical, but I fear the series may “jump the shark” soon due to its non-medical elements, which would be a shame because it was so good for the first several years.
November 12th, 2008 at 9:13 am
So what should be done during flatline?
November 12th, 2008 at 9:36 am
Was there anyone here who, as soon as it was said that the patient wouldn’t leave his house, didn’t immediately think “naturally, House will knock him out and take him to the hospital?” I was wondering if they were going to try that nifty “medically induced coma” trick to keep him out until they cured him, but still… that one was easy to see coming.
@ Scott - why would Stewart be suspicious? It’s obvious that in addition to his mastery of every aspect of surgery, Chase is also an anesthesiologist, and, even cooler, can handle both the anesthesiology *and* the surgery simultaneously! Did they show anyone doing the anesthesiology for Taub?
@ Schmapdi - we’ve seen the House team exaggerate physics for effect previously this season, i.e. when the pressurized cadaver bowel exploded and blew crap all over Foreman and exam room. So let’s ignore the propane-tank flame. Bowel humor = laughs = ratings, I guess.
Harping on ethics once again, why does Wilson even for a second think that House and Cuddy dating is a good idea? *Maybe* if Cuddy wasn’t House’s immediate superior it could work, but as it is, it seems like so many lawsuits waiting to happen.
I also thought to myself that whoever mugged Stewart must be quite the big spender… those hollow point bullets aren’t cheap. It was interesting that the bullet shattered in the animation rather than mushrooming, but that’s pretty low on the list of House anomalies.
Can anyone explain to me the last scene, where House looks at the mosquito on his other hand and doesn’t swat it? What was that about?
November 12th, 2008 at 9:54 am
Animations + ton o’ Cameron?!? Damn how I love this show!!
Hopefully this is just the beginning of re-featuring the true gem to what made this show so good seasons 1-2!!
(Is the cold shower ready yet??)
November 12th, 2008 at 10:30 am
Is it my imagination or is the medicine on House more “fantastical” than ever before?
And … woohoo, I had celiac disease in the House game!
November 12th, 2008 at 12:08 pm
Spotted one “whoopsie” when the exploding gas scare was followed by taub wiping his bare forehead with his gloved hand. So who is doing the closing, now?
November 12th, 2008 at 12:43 pm
EngineeringDr
The episode was titled ‘The Itch,’ with House arguing that it was caused by a mosquito and Wilson thinking it was psychological. It turned out that House was right, but that he *should* still follow Wilson’s advice. Because Wilson may have been partially right about the cause of the itch, House spared the mosquito in a Eureka moment.
November 12th, 2008 at 12:58 pm
I can’t help thinking that a guy who hasn’t been outside for seven years is not going to get over it just because House tells him to. Woulda been nice to see him receiving any sort of psychiatric care at all.
November 12th, 2008 at 1:19 pm
I loved this episode! I followed the medicine a lot more easily than usual (could be because the case was just more simple) but I also liked the POTW and enjoyed the mirroring storyline between House and the patient. Loved the Cuddy/House/Wilson aspects as usual and it was nice to see Chase get a line. Thanks for the review!
November 12th, 2008 at 2:39 pm
While I’m not a medical expert, I am quite familiar with how bullets perform. What House described and the animation showed was not a hollowpoint reaction, it was a partial disintegration, which only happens with small bullets propelled at extremely high speeds, such as through a varmit or “sniper” rifle in the .22 caliber family.
Most modern hollowpoints are conical rounds that are striated in order for the round to peel back when they contact something solid, like bone, creating a bigger wound channel. Older types are not striated, just hollow cones of lead with, usually, a copper jacket.
While occasionally a striated hollowpoint will throw one of the petals completely off, this is very rare, and throwing off any volume significant enough to cause lead poisoning extremely unlikely. The partial vaporization of the round that House described and that we saw is so unlikely as to be statistically impossible from a handgun.
November 12th, 2008 at 2:53 pm
Ok now i am a bit confused. Basically you say that what every TV show does is wrong. Don’t missunderstand me, i believe you but this is somehow strange.
Whenever you hear in a medical TV show the typical “flatline” noise everybody uses this nice little electro shock thingies.
So what to do when somebody flatlines? When do you use the defibrilator?
And one question that is bugging me for years: Are these heart monitors really build in a way, that they make a beep at the peak of the graph and still do the monotonic beep when it is a constant line?
November 12th, 2008 at 3:08 pm
Wouldn’t Stewart be suspicious that there was no anesthetist or anesthesiologist? And once again, no eye protection during the surgery.
Maybe he watches House M.D.’s counterpart in the TV life version of House’s New Jersey, so he thinks that’s standard operating procedure?
8^)
BTW, I missed what House’s dream or nightmare was. Could someone tell me what he was dreaming about? I assume something to do with Cuddy (and Wilson?), but I don’t know.
November 12th, 2008 at 3:42 pm
- the flaming bowel was interesting- can that really happen?
- hugh laurie is a master of controlling accent, but I caught some british when he said ammonia- us north east yanks would pronounce the last syllable YUH, but I thought I heard a EE-AH.
November 12th, 2008 at 4:23 pm
I think this episode was decent dramatically. It was more or less a setup for the House/Cuddy relationship that appears eminent. Was anyone else surprised that his agoraphobia had nothing to do with the actual final diagnosis? I was sure there was a brain tumor pushing on the “indoorsy” center of his brain ala China girl from three episodes ago or something. I suppose I’m so used to all the ailments of a patient- even ones they’ve lived with up until House is introduced- being explained away via his final diagnosis (we’ve seen this with the elf from two seasons ago, Jazz guy back in season one, the paralyzed man in season 3’s opener, and the guy in John Laroquette’s episode, which I can’t remember the specifics of except he was in freakin’ John Laroquette’s episode!)
Anyway, on the review: You’ve just given up, haven’t you Scott? The fact that he had been shot was mentioned a few times, yes, and I’m surprised you missed it. I was with the people that thought it had something to do with his affliction. Guess you figured it’d be too obvious for House, huh, lol? Great review other wise, and I’m glad you cleared up what could be worse than a flat line- in another review I think you mentioned you could make it worse, but you didn’t say how before now.
November 12th, 2008 at 4:32 pm
From what I remember of our digestive system and the break down of organic material in our bodies does produce what I’d always heard was essentially methane gas. I’m sure it can be lit on fire but I didn’t think what was shown was truly possible. Then again with an anything is possible mentality I guess with enough of a blockage and certain circumstances…. I’m more curious about the heating element of whatever device they would most likely use to cauterize the wound, is it capable of igniting gas? I would imagine it doesn’t use an open flame or spark, I’m sure it’s quite hot but hot enough to ignite the gas? No idea.
As for the mosquito, my take on it, was that the mosquito is imagined. As he held his hands up the mosquito was on essentially the exact same spot on the opposite hand. At least that was my observation. What are the odds of that? Is that spot a mosquito favorite? Or a hotspot of the human body for them to target? If so it’s outside my knowledge. I prefer to think of it as he’s going nuts, he knows he’s going nuts, and the mosquito didn’t exist. He laughed at the whole situation, and ran to Cuddy just to wuss out. He’s a logic and rational thinking power house, how can he be a hypocrit? Then again I guess he can just use logic and rational to indulge the idea his situation is entirely different.
I don’t recall it ever being truly discussed, or House ever using it as a currency that Cuddy is in some ways responsible for his handicap. It’s implied, but I don’t think he’s ever actually used it. I think her guilt heavily effects how she treats him. And I do recall him pulling his pants down to show off his thigh, but I believe he was just making a point, not trying to guilt her from her involvement. But he did at least get his placebo “morophine” injection from that display. I don’t recall it ever being truly examined in any episode just hinted at. I definitely do not recall him coming out and blaming her or displaying anger towards her decision as what was hinted to have happened between him and Stacy. I could be wrong and oddly forgetful on the subject though.
On a note, my future wife and I LOVED the nightmare scene where he blew up his apartment, the little “ugh” noise he made when realizing everything was about to go boom was quite funny imho. Someone normally so proud of their ability to be witty and weave together as much as possible as quickly as possible being reduced to a capacity where it is difficult to pull together one noise and implement that noise while barely understanding what was going on.
November 12th, 2008 at 4:54 pm
Glad to see House is back on form. But my biggest compliment, at least in this post, goes to the first poster; Jessica. I just want to thank you for those great spoilers for not even next weeks episode, but TWO weeks away. Thanks. I try really hard to find spoilers, I practically spend my day searching for them. Just so, ya know, nothing comes as a surprise in any way, shape or form. Thanks again.
November 12th, 2008 at 5:05 pm
@ Harvey - thanks! That was too deep for me…
@ andy in toronto - House’s nightmare involved him trying to kill the mosquito that had been chewing him ragged. He brought some sort of propane-burning device into the house (I was unclear on what it was supposed to do). Then he sees the mosquito on the machine’s handle, so he starts swatting at it with a newspaper, eventually managing to both open a valve on the propane tank and (later) turn on the (gas) stove by hitting the burner knob. He then jolts awake right after the explosion.
@ Roland - I agree that the terminal ballistics were pretty poor in the show. I was going to complain about it more, but I figured (1) compared to some of the medical issues, it’s small potatoes, (2) Hollywood is notoriously poor at getting anything related to firearms correct, and (3) there are so many parameters in terminal ballistics that it’s very hard to say that the lead chunks in the show would *never* happen.
November 12th, 2008 at 5:28 pm
The medicine and the Cameron drama were boring. Didn’t find 50 year old House “terrified” of a relationship with Cuddy who he’s worked with the past eight years as believable. Felt more like junior high school.
The only thing that saved the episode for me was Wilson and House/Wilson. Other than that it was a collosal waste of time.
November 12th, 2008 at 6:03 pm
@ above poster; Wow, way to be really off-handed and “mature” over a synopsis that was offered by FOX as a teaser. Sarcasm much appreciated, even when I know no less than what’s been given.
November 12th, 2008 at 6:24 pm
As best as I can tell from Wikipedia and my limited searches, a defibrillator is used when the heart goes into ventricular fibrillation (V-fib); essentially, there is uncoordinated contraction in the heart muscles, which makes them tremble rather than contract properly. A defibrillator restores the natural contraction rhythm of the heart.
As for a flatline, there’s a few drugs you can push (epinephrine, vasopressin, and atropine), but the majority of treatment options seem to involve a pine box. Medical shows use the flatline because everyone recognizes that nice sound of doom along with the line on the monitor. V-fib literally looks like trembling on the EEG line, and although it has the same result as a flatline after a few minutes the show would rather not waste precious time explaining things to the viewer. Medical shows (and by extension every other show based on a real-life profession) work like they do because normal medicine and police work and science is comprised of short bursts of excitement surrounded by extremely long periods of boredom. And usually paperwork. If we wanted to watch that we’d tune into C-SPAN or something.
November 12th, 2008 at 7:55 pm
Here’s the only part i don’t get. . ..why did people from the “outside” exacerbate his symptoms if they were all caused by the bullet?
November 12th, 2008 at 8:49 pm
Did anyone else think Stewart looked like Joe the Plumber?
November 12th, 2008 at 8:52 pm
I have to say that the quality of the writing, specifically the writing focusing on the ’soap’ aspects of ‘House’ , has become teeth-grindingly poor.
Fifteen seconds into the first non-medical conversation of the episode, when Cuddy calls House out of his office, we had the following subliterate cliches: ‘We need to talk…’, ‘You were so emotional…’ and ‘I’m there for you…’.
Later in the episode, we had Robert Sean Leonard having to say: ‘You’re scared! Scared to get inolved!’. His complexion seemed to turn lime green with self-disgust as he said it.
Who is writing this trash? Who is editing it? Why are they letting it by?
Only the quality of the chartacter acting is keeping this side of the show going - and, with the best will in the world, Laurie and Epps can act their hearts out but unless the words they say are meaningful and real, they’re going to come off looking like ninnies. I mean, all this fuss about House and Cuddy’s kiss - these people are supposed to be senior teaching and research doctors but their behaviours and dialogue were straight from High School Musical.
The pastoral, ’soapy’ conversations were never so formulaic or pedestrian in the past. Can anyone tell me if anything has changed within the production team to cause this diabolical lapse in quality? A new writer whose first language isn’t English maybe? An editor whose secret crack habit is becoming evident? A producer trying to crash the show for the insurance?
November 12th, 2008 at 10:03 pm
Thank you, EngineeringDr, for the scene description.
November 13th, 2008 at 12:07 am
I pretty much agree with Alex. I’m surprised at the fairly good review on this one. I really found this episode boring, and the fact of the bunch of doctors just throwin a diagnostic party at the guy’s house felt like a jumpin of the shark to me. Let’s hope it’s the last season.
When has Cameron become this harsh? She was downright mean to Chase for no reason at all, and acted like she didn’t notice. She used to be more subtle, but I guess there is no time for that now that she’s a secondary chracter.
November 13th, 2008 at 10:59 am
I thought the parallelism between the patient’s medical condition and the soap-opera plot was especially close this week. House’s personality disorders are deep-seated, but made worse by the leg condition and Stacy’s “betrayal”. Interesting that Cameron was the one to bring up that subject when House proposed a similar undesired surgery.
Speaking of Cameron, I thought it was interesting that after Wilson told House he was afraid that no one would love him and challenged him to go to Cuddy, House went to Cameron instead. He even told her he missed her, and later that he loved her. Kidding on the square?
November 13th, 2008 at 11:50 am
Erik is right - you defibrilate a patient in v-fib or v-tach, not flatline. Nicely researched, Erik.
The coverage of what medicine there was is so interesting here, as always.
I loved seeing so much of Cameron, especially the scene where she and Foreman were working together in the differential like the old days. My boyfriend, who is basically in love with her, at the beginning of the episode, said “who’s the hot blonde?”
Is she actually getting thinner? She looks great, whatever.
John- I actually disagree with you - I adore Hugh Laurie, but I hear his accent slipping ALL the time (to be fair, so does he, based on an interview I saw…somewhere)
and Ellen Smith - LOL, I thought the same thing, that just looked like the grossest kiss ever. Then again, have you ever kissed a British guy? (I joke because I love! I love you guys! But go to kissing school)
November 13th, 2008 at 12:54 pm
Alright episode, at best.
November 13th, 2008 at 6:27 pm
“So what should be done during flatline?”
———————————————————
The treatment of choice would be injecting vasopressin and/or epinephrine, combined with chest compressions (or heart massage if the option was available ).
De-fib doesn’t work because if the heart flatlined, then it would already be depolarized. There’s nothing in the heart for the shock to work with.
“Wouldn’t Stewart be suspicious that there was no anesthetist or anesthesiologist? ”
—————————————————————-
I think most of the lay population are not aware that anesthesiologist is a seperate doctor needed for surgery. I didn’t know it till I started nursing.
“Can anyone explain to me the last scene, where House looks at the mosquito on his other hand and doesn’t swat it? What was that about?”
———————————————————————-
House is transferring his focus so he can obsess over the mosquito instead of focusing on his Cuddy problem. When he decides to let go of the itch obsession, he decides admit to himself that it wasn’t his real problem and to go face the real source of his pains.
But then he didn’t.
November 13th, 2008 at 6:51 pm
To RusselAthletic :
Yes, I’m sorry to say that those medical shoes are wrong, or at least showing very outdated treatments….Real cardiac flatline cannot be defibrillated, although some doctors might do it just in case the flatline on the screen was actually “fine ventricular fibrillation” (Where you do have a bit of heartbeat, it is just so tiny that the line looks flat). Such a choice of action is pretty rare.
“When do you use the defibrilator?”
Defibrillation is done to treat ventricular fibrillations, where the heart is fanatically trying to keep itself beating and isn’t doing a very good job. It shows up as fast small jerks on the screen. The patient will likely die without defibrillation. The defibrillation shock basically wipes the heart electrically clean so that when the SA node fires again, it works on a clean slate and will (hopefully) start a normal heartbeat. It’s kind of like rebooting the heart.
Defibrillation might also be done to patients showing ventricular tachycardia (ventricals going way too fast), because that can quickly turn into ventricular fibrillations. Some other cardiac arrhythmias (irregular heartbeat patterns) might also get the shock treament depending on severity and patient history.
The beep thing is programmed onto the heart monitor when you set it up, you can adjust what you want it to beep you for. This is because some patients have normal cardiac issues, and you only want the machine to alert you when abnormal abnormalities develop. But all machines would beep like hell if the patient flatlines no matter how you program it.
November 13th, 2008 at 7:03 pm
A defibrillator restores the natural contraction rhythm of the heart.
——————————–
Just a minor correction, the defibrillator can’t really restore heatbeats. It can only wipe away the trash waves and hope for the body’s biological pacemaker, the SA node, to send down good jolts of electricity, which will hopefully restore the natural contraction rhythm of the heart…….If the SA node doen’t work, then the patient is toast…a little more burned form the defibrillator perhaps, but still toast….
And yes, the success rate of treating flatline is pretty low. Even if pt emerges alive, there’s permant brain damage more often than not.
November 13th, 2008 at 8:13 pm
House has I think definitely gone downhill this season. The “medicine” is a mess, which kills the detection aspect; many of the early comedic elements are gone; and the loss of those edges means the personal soap opera sto,ies lack bite. It’s hard to think of *any* show that’s as good in its fifth year as it was in its first - but quite often, as someone else suggested - it’s because the original writers/producers/creators have run dry (or locked in their syndication money) and left for new projects. I don’t know if that’s happened on House, but usually it’s the writing that’s the fundamental problem. Without good writing…nothing.
Jessica: not everyone sees the teasers the networks show (they may be reading the topic from another country on a different broadcasting schedule, for example). Whether or not the original poster was rude, for this reason spoilers are always a contentious issue in every online forum, and the convention is usually to label them as such so someone not wanting to know what’s coming can skip ahead.
wg
November 13th, 2008 at 9:42 pm
Wilson was the mosqito. In House’s nightmare the mosqito (Wilson?) guides him to one ingredient, gas, then guides him to the other ingredient - fire. Then, an explosion because those two elements have been brought together. Similiarily the penny drops for him at the end of the episode when the mosqito brings both his hands, perfect partners, together. That’s my take on it anyway.
November 13th, 2008 at 9:44 pm
The perfect partners being House and Cuddy, obviously. I’m either a genius or a tool. I have a sneaky suspicion it may be the latter.
November 14th, 2008 at 1:55 am
Pretty vanilla medical conclusion, eh?
PS, Scott, I would pay hard cash to sit and watch a new House episode with you!
November 14th, 2008 at 3:05 am
I think the whole intestinal obstruction/flattened villi thing was a red herring. First, whipple’s and celiac don’t ordinarily cause an obstruction and how was the biopsy misinterpreted as Whipple’s and then celiac was introduced as possible cause despite its apparently having been ruled out by the biopsy.
And, of course, what’s intestinal obstruction/flattened villi have anything to do with the final diagnosis?
He had a small bowel obstruction and they biopsied the upper small bowel, but there are no combustible gases in there, so the human fireplace demonstration was just for show.
Oh, lactulose is a rather wimpy laxative. For something potent, try Golytely.
November 14th, 2008 at 3:44 am
If he were actually mixing chlorine and ammonia in his cleanings, he wouldn’t be merely in pain, he’d be dead. I knew someone who did just that while volunteering at a camp. She commented to her friend about the horrible smell (which her friend luckily did not want to smell for herself). As they walked back to their room, she started finding it hard to breathe. By the time they reached their room, she couldn’t breathe at all and was turning blue. She died before medical help could arrive. She was 15.
Apparently the chloramines react in the lungs to form ammonia gas and hydrochloric acid. The acid causes edema and pneumonitis. So basically you drown from it.
So accidental exposure probably wouldn’t kill him. But if he were actually mixing the two–which would be probable since he’s a neat freak and seemed clueless about the danger–they’d be burying him.
November 14th, 2008 at 4:30 am
“The final solution fit well, but was it ever mentioned before the final reveal that Stewart had been shot?”
Uhm, I think they DID mention he got shot at the start of the episode.
“Wouldn’t Stewart be suspicious that there was no anesthetist or anesthesiologist?”
Uhh… He writes tech manuals for living and his main focus in people is that they’re scary, he probably WOULDN’T even know terms like “anesthesiologist”, let alone know to expect one in the surgery.
Us commoners can miss a lot of the medical stuff that seems totally obvious to you docs. ;)
As for the surgery, if they let a lawyer with no real protection at all just sit there chilling during the surgery (at least he didn’t have anything covering his mouth and seemed to sit there just meter or so from the patient), would they really notice the eye protection issue?
November 14th, 2008 at 8:25 am
Thoes anti-House/Cuddy, you are absolutely proven wrong by official plot develepement. In the lest reverence to firendship, House can never joke around with her by putting his tongue into Cuddy’s mouth even in the worst part of his personality. For that part, Wilson got more acuteness.
However, I can not help but thinking their relationship, if they do start regular dating with each other, just like chase and cameron do, will become even more complicated than it is now. Because House always dominate over Cuddy before they are involed, but now Cuddy can use that as a threat to win back. Anyway, House is sill worried about facing her and keeps ignoring her at this moment, yet as soon as they begin to recognize their feeling to each other and decide to have a relationship like “regular people do”, those missed fights and flirtations will be coming back. :)
On the other hand, Chase and Cameron seems run into a problem with each other. Just as I noticed, before several episodes, he had already dyed his hair back to brown. I persume that’s his natural color. Since it had been brown in the first season, and then it became blond, I guess he dyed it, and Cameron, too, hers used to be brown, and then after she stay with Chase, she dyed it into blond as well.
They are both blond when they coupled, but now Chase’s has been dyed back to brown, and not long after that, he “warned” Cameron that he cannot chase her forever. It’s all because of the drawer. Likewise a male cat always want to pee on the ground when it got to a new place to define its territory. Luckily Cameron really cares about him that much she doesn’t want to lose him because of the drawer.
At that very moment when Chase told her about how badly he needs the drawer thing, Cameron was startled.
“no wonder you changed your hair color back. You really want that drawer, I so give you a big one.” echoed in her mind, I can see.
And you never find a more sweet smile on his face when chase heard about that. Like a child. :)
November 14th, 2008 at 10:48 am
well, I’m going to give House some credit for the PEA. Yes, I know the monitor read flatline - BUT, it was Cameron who wanted to shock the patient. House said, “Continue CPR”. So I think House deserves that while he read the monitor wrong, at least he knew the correct treatment at the time (for both PEA & flat)
November 14th, 2008 at 6:08 pm
mike, I think that’s being much too generous to House. I think we were supposed to recognize that House didn’t want restoration of heart rhythm until the patient was on his way to House’s lair, or even better, in the hospital itself.
If it was a “choosing the right treatment” thing, the writers wouldn’t have had Cameron’s shock succeed.
November 14th, 2008 at 7:53 pm
I would assume that anesthesiologists would be common knowledge for most people, Matti. He may write tech manuals for a living and be an agoraphobe, but that doesn’t limit him from basic knowledge.
November 15th, 2008 at 2:33 am
If we are still on the subject of what is a potent laxative, I think the winner should be a laxative nicknamed “Rush’s Thunderbolts”.
For those of you who dont know it, it was a “treatment” devised by Dr. Rush during the Lewis and Clarke expeditions for……everything basically.
November 15th, 2008 at 3:13 pm
I believe that the mosquito represents the new situation with Cuddy. It simply bugs him, he’s not sure what he’s supposed to do with it, he’d like to…but he’s afraid - it’s like itching, the more he thinks about it the more annoying it gets. (It’s not the first time when his problems manifest with physical condition.)
The dream means that doing something about Cuddy would blow his orderly and predictable life up.
At the end, though, he doesn’t kill the mosquito - he decides to give the relationship a chance. (The fact that he eventually chickens out is a different matter.)
November 16th, 2008 at 11:16 pm
As House suggested: it’s poemish. But I can’t imagine what will that change effect House in the future. Would he spend less time hanging around with Wilson? Wilson could be the one who is left alone this time and it’s not gonna be easy to perdict what would happen next.
November 17th, 2008 at 2:39 pm
@EngineeringDr - The source of the propane is an artificial cow (aka “Mosquito Magnet”). They use a catalyst to convert propane into carbon dioxide, water vapor, and heat. There is no flame until House accidentally yanks out the loose supply line, releasing propane into the room.
http://home.howstuffworks.com/mosquito-magnet2.htm
http://www.mosquitomagnet.com/
November 17th, 2008 at 10:48 pm
@ Daniel Sydnes - thanks! I vaguely remembered something about a mosquito magnet, but I couldn’t recall the name exactly. I figured it had to output CO2… I guess the catalyst makes more sense than having an open flame. :^)
November 19th, 2008 at 2:11 am
Stephanie.
“Matti. He may write tech manuals for a living and be an agoraphobe, but that doesn’t limit him from basic knowledge.”
True, but I’m not talking about knowing the name, I’m talking about being there at the very moment, all freaked out, with bunch of creepy people in white outfits and goofy ninja masks.
And you’re telling me you can tell their exact specializations and what they’ll do after you pass out? ;)
“Hmmm, the black guy kinda looks like a neurologist… holy c”p! I’m having my appendix out! He’s not qualified to do this surgery! Get me out of here!”
November 20th, 2008 at 12:59 am
@ Ellen Smith & Eugenie Rose: Seriously?! I thought that kiss was HOT. um…I’m not joking!
November 23rd, 2008 at 9:30 pm
It wasn’t agoraphobia he was a hikikomori.
November 26th, 2008 at 7:52 am
Good review, however a number of the so called problems with the episode have been over-thought a little.
“I find it hard to believe that bullet fragments significant enough to cause Stewart’s symptoms would be missed on the x-ray. Hint: the hip should have no bright white spots on the x-ray. I also find it quite a stretch that bullet fragments in for seven years could be removed so easily.”
This makes sense, but for one small thing… mistakes DO happen, and although they probably would show up on x-ray, the patient is an agoraphobe, and more than likely, his follow up care would have been pretty non-existent. I imagine he would have checked out as early as possible, and would not have returned for something like a follow up x-ray. Remember, the patient claimed he would rather die in his house than live outside… is it really that big a stretch to assume he wouldn’t have cared enough for anything more than the most important emergency treatment.
“Chlorine gas is extremely irritating (watery eyes, cough, sore throat), and would be hard for him to miss being exposed.”
Also true… but a lot of cleaning products are irritating. I find that most simple, every-day cleaning products cause this sort of reaction for me, even without mixing them… If he had ALWAYS cleaned that way (which it seemed to imply he did) why would he assume anything other than that he was particularly sensitive to cleaning chemicals.
“Surgery is not first line for partial small bowel obstruction.”
No, i’m sure it’s not, but it is a very good excuse to trick a patient into coming in to hospital. Remember, many of the “treatments” were designed to convince the patient he needed to go into the hospital. While it is probably true there would be other options, i guess the theory was that few other options would also double as an excuse to “put him under” and take him to the hospital. I think it was clear that had the surgery taken place, house never intended for him to return home, and expected to continue the diagnosis, in the hospital, where he always wanted him to be. This is evidenced by his lack of argument to Cuddy’s insistence that post-op couldn’t take place at the patients home, and his future attempts to “make staying more painful than leaving” by depriving him morphine.
“Wouldn’t Stewart be suspicious that there was no anaesthetist or anaesthesiologist? And once again, no eye protection during the surgery.”
No, I don’t think he would. You’re a doctor, and know what to expect, most of us wouldn’t know the difference between an anaesthetist and a nurse when going in for major surgery, There were at least 5 other doctors present aside from chase, it is fair to assume that Stewart was not well versed in OR procedure, and simply assumed that with all of the doctors present there would be enough to safely perform the surgery, that between them they would have all the roles within the procedure wrapped up. Before going in to surgery i don’t think many of us would ask who will be doing what, and would just assume that the doctors know what they were doing.
December 9th, 2008 at 8:40 am
@Alex…….ROFLMAO!!!!!!!!
absolutely brilliant. better than i could have said it. way to hit the nail on the head, buddy. I find the soap aspects this season borderline INSANE. beyond idiotic at this point.
I’m all for a good TV romance done right, but this House/Cuddy business is just ridiculous.
Its as if the writers are purposely pandering to the under-18 portion of the demographic. Why they are doing so, I have no idea. I would have thought them to be by far the minority of viewers. Maybe Im wrong and all this shameless one-dimensional juvenile-ness on what is supposed to be an adult show will prove well-placed as everyone above college age gets disgusted to the point of tuning out, only to be replaced by teenage fans everywhere.
December 24th, 2008 at 1:53 pm
This was the second episode that I recall Celiac Sprue being mentioned. I think it was in the 2nd season where it ended up being the final correct diagnosis in one of the episodes.
I tend to notice that because I have Celiac/Sprue.
April 15th, 2009 at 7:08 pm
Just a very minor point, can you diagnose a small bowel obstruction with a AP film while the patient is lying down (looked like Cameron took the x-ray while the patient was in somewhat supine position). Wouldn’t the patient have to be sitting or standing up for the air-fluid level to show the way it did on the film shown in the show? Again, very minor point but I’ve always held high standards in House. By the way, like Scott has been saying, the medicine on the show has been pretty bad lately…I hope the show can improve on this.
June 26th, 2009 at 12:56 am
Thank God he never got near an MRI with those bullets in there, which I suspect might be the reason he was written to be a shut-in in the first place.
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