House — Episode 13 (Season 5): “Big Baby”
A much better episode of House this week. While it wasn’t quite up to the standards of the first two seasons, there were definite that classic House was trying to break through.
Sarah is a 29 year old teacher of special needs children who suddenly begins to cough up blood during class and then collapses. She is admitted to the hospital under House’s care. The team’s initial differential diagnosis includes ulcer, leukemia, von Willebrand’s disease (a blood clotting disorder), or a thoracic tumor. House agrees with Foreman that the problem is likely within the patient’s blood and orders a bleeding time test. The test is abnormal, showing that her blood is not clotting correcting. A check of her clotting factors is normal, but her platelets turn up abnormal. The differential diagnosis now includes lymphoma and ITP (idiopathic thrombocytopenic purpura), with the latter being more likely. House elects to start her on methotrexate (which really isn’t a recommended treatment for ITP), but he also wants to treat her with total body irradiation (which is also not a recommended treatment for ITP, only it can have even nastier side effects than methrotrexate). In actuality, House has no intention of using the radiation but is just trying to test Cameron’s limits. She calls his bluff and allows the procedure, so now House and his team pretend have to pretend to use it. In the meantime, the methotrexate has shown no benefit, so House doubles the dose and adds Prednisone (a steroid, and the actual recommended treatment for treating ITP). During the (fake) radiation treatment, Sarah mentions that she has to pee. When she tries to get off the table, she collapses and is found to be pulseless. Thirteen and Taub rapidly pull out the defibrillator and shock her back into a normal rhythm.
The team meets again to discuss the latest findings. Tests, including a transthoracic echocardigram and a bubble test, show no structural defects of Sarah’s heart. Thirteen suggests a high vagal tone from urinating may have caused her to develop an arrhythmia and collapse. The rest of the team half-heartedly suggest heavy metal poisoning, toxin exposure, drug use, or alcohol use. Thirteen then mentions cold agglutinin disease, which seem to fit the case. House wants to put Sarah in an ice bath to test the diagnosis, but Cameron wants him to test some of the blood first. Reluctantly House agrees. The blood clots when exposed to the cold, confirming the presence of cold agglutinins, so Sarah is put into a three minute ice bath. The test, though uncomfortable, is normal (so while she may have some cold agglutinins — and most people do at various levels — she doesn’t have the disease; but please note this is not the recommended way to diagnose the condition).
House now decides that Sarah’s offhand story of transposing the digits of her room number, combined with her need to urinate during the radiation treatment, are signs of a brain lesion — a left hippocampal lesion to be precise. He thinks it is most likely multiple sclerosis (MS), and wants to perform a brain biopsy to confirm his diagnosis. Kutner thinks she has a pancreatic tumor and wants to perform an ERCP instead, but House wins — sort of. Cameron won’t let him go through with a brain biopsy, wanting an MRI first. Reluctantly, House orders the MRI, but it is normal, so Sarah doesn’t have MS. Kutner performs his ERCP and it is normal, but Sarah starts to have problems breathing during the test. She is found to have pleural effusions (fluid build up around the lungs), which are drained (off camera). House now decides that Sarah has equine encephalitis, a mosquito-borne disease caused by a picornavirus (there are actually several types of equine encephalitis, but none that I can find are caused by a picornavirus), which is causing conduction problems in her brain. He wants to test nerve conduction tests along the surface of her brain. This, of course, requires removing the top of her skull and thus needs approval from Cameron. She declines. Meanwhile, Kutner now thinks that she has a lymphoma of her spleen and wants to perform a splenectomy (surgically remove the spleen). House has Thirteen and Foreman search the classroom for evidence of encephalitis, but they turn up nothing significant. Nevertheless, Cameron allows him to perform the nerve conduction study and even assists. The test is going smoothly until Kutner tattles by calling Cuddy. She demands to speak with House and is placed on speakerphone. In the background, her baby Rachel is crying, and the sound is annoying Sarah quite a bit. Her reaction is paradoxical, though, in that her blood pressure drops while she is annoyed (it should rise). The team ends the test and puts her skull back together. House is puzzled and cannot figure out what is going on with Sarah. Puzzled, that is, until Cuddy and Rachel stop by. The baby spits up on House which leads him to start a monologue about evolution which leads him to have his Eureka! moment and diagnose Sarah with a PDA (patent ductus arteriosus).
As usual, major complaints are in red, minor in blue, nit-picking in green:
Even though the PDA may not have been open when the heart was scanned, the fact that the duct still existed (it should have withered away) should have been evident.
Why would only the left part of her brain been affected?
Apparently no one in the hospital likes to run CT scans or MRIs (this week anyway). Most of the diagnoses mentioned (MS, lymphoma, tumor) would have shown up and not required brain biopsy, ERCP, etc.
A blood test for cold agglutinins is not simply a “cool the blood and see if it clots” test, but a test to see how much it clots.
An ice bath is by no stretch of the imagination a good test for cold agglutinin disease, if they have it, you’ve just done the patient a major disservice as systemic clotting is not a good thing.
ITP, by definition, has low platelet numbers — which were never mentioned, just abnormal looking platelets (though her red blood cells should have looked chewed up as well).
MTX is not a treatment for ITP. It has been investigated, and continues to be investigated, but hasn’t shown a lot of promise. IV steroids are first line.
There seems to be confusion among the team about heart attacks (myocardial infarctions) and cardiac arrest. The terms are not synonymous.
Shocking a pulseless patient? How about — at least — some CPR first, if not checking the rhythm before shocking?
If I were the doctors I would have taken a closer look at the vitals during the test. Her resting oxygen saturation was 97% — on oxygen. That’s not normal. Nor is a heart rate of 116 , even though they called it “normal”. It didn’t change at all during her ice bath, when it should have shot up. Sure, I know the fancy vital sign machine was just there as a prop, but at least put in a little effort to make it authentic, prop people.
It would have been nice if they had run labs on the fluid they pulled out of the effusion. It would have helped to rule out cancer and pancreatic disease at least.
On another note, parent/baby bonding is often delayed in adoption situations and post-adoption depression in common, so what Cuddy was feeling was fairly normal. I’m glad to see she did not give up Rachel because of it.
The medical mystery started out weak (coughing up blood? That’s it?), but got better earns a B. The final solution was a stretch, but at least it fits more symptoms and seems more logical than usual and thus deserves a B+. The medicine had too much jumping from diagnosis to diagnosis while overlooking the most common and useful testing, so can’t really be considered anything more than average: C. The soap opera was subdued this week, but that felt appropriate, and earns a B.
Last week’s House review
A list of all prior House reviews
January 26th, 2009 at 11:31 pm
Thanks for another great review Scott. I’m sure my friend who’s studying neuroscience was grinding his teeth at the last few minutes of the episode. As for the soap opera, I was worried for Cuddy and glad that she eventually bonded with the baby, but was surprised that no one had told her that delayed bonding would be normal.
One last thing, when they shocked the patient after she got up to use the restroom, did they shock her through the hospital gown? It didn’t look like they removed it.
January 27th, 2009 at 12:06 am
Foreman: House, I need to talk to you about Remy
House: Who?
Foreman: Thirteen.
House: What did you just call her?
House: ???
January 27th, 2009 at 12:30 am
FIRST GREAT REVIEW AS ALWAYS!!!
Look, I totally agree about the shock on the heart and the wrong ” heart attack term” usage AGAIN. THATS JUST WRONG YEAH.They never learn.
Just trying to clarifying though:
The symptoms “were” in the left side of the brain because its her domminant side you know, the side of objectivity. The right side always was affect in the crysis too, BUT what symptoms would be mannifest for a doctor to diagnosis?? at the parahipocampal right region of a right-hand person?? LACK of criativity?? Nothing relevant..you see… But of course, the two sides were affected. The problem is HOuse first thought was only the left side because of the symptoms, he didnt know was a Low oxigenation issue before…He thought was specific(MS,tumor, whatever).
About parent/baby bonding, is often delayed in adoption BECAUSE its “a adoption” and we all know waht HOUSE thinks about adoption, “doesnt make any sense at all”. Cuddy should pass her genes… LOL
About the double blind stuff and the placebo, YOU see they know what is a ddouble blind, was an accident the discovery… Of Course Foreman was wrong doing that but he KNEW he WAS.
Once more, great review of your!
Congratulations!
Sorry my english is not so good”
Till E14
January 27th, 2009 at 1:19 am
I’m in no way a doctor and not saying I understand any of it, but in the show, House clearly says that the artery BIPASSES the left side of her brain. “Little detour” is what he says. Maybe that makes no sense, the artery being in the lungs region, but I’m pretty sure that’s what’s suppose to explain why on the left side is affected.
Could it be that when the DA opens up it lowers pressure in the branching artery, the latter being reposible for circulation of your left hemisphery?
But for that to work you’d have to have 2 different arteries for the brain, which isn’t the case right?
January 27th, 2009 at 1:25 am
Oh, just want to add a general thank you:
Your well written, well tought reviews, always on time after the show, are part of the House experience for me now.
January 27th, 2009 at 1:25 am
Excellent review. I’m always impressed with how quickly you get them up.
The producers should consult you for future episode, methinks :D
January 27th, 2009 at 1:54 am
I think the producers are already reading here – too many times those guys seem to strike something suggested in these comments (Fore-teen was the latest one). I found this episode way more amusing than the previous one and the way House kept on jerking fore-teen around was downright hilarious. The advise he gave Foreman was so “House” I almost wept for a second (truly guys he is not such a jerk – everybody knows that – the team, Cuddy, Wilson, us). For the first time I am actually anxious to see how thing will unfold with Fore-teen (yeah I knew Foreman would breach the rules, it was the way he got to this decision that won me over). As for the medicine – I dare not say. While the condition is not so exotic it still is way too complicated for me to absorb. A heart problem, that presents itself with so many, non heart-related symptoms is truly a medical mystery worthy of Sherlock Holmes. I started reading some stuff about PDA immediately. I will have to watch the episode again to be sure, but it seems to me that D-r Scott pinpointed both the problems and the right stuff immediately. I see ONE thing wrong and not mentioned by him so I’ll point it out (it is actually a BIG thing and if checked might downgrade the episode medicine greatly). Now if I am not mistaken one of the major symptoms for PDA is a very distinctive sound coming from the heart that can be heard on a routine examination: continuous machine-like murmur (produced by the mentioned turbulence). No fancy equipment, no echo or other study – just listening to the heart is enough. In defense of House – I think he said something about the PDA not opened all the time – may be that is how they missed it? A great episode otherwise and I look forward to see both Fore-teen and House/Cuddy action.
January 27th, 2009 at 2:20 am
Did they run a preg test on her before they shot her full of Mtx? Oops they may have given her an abortion! And where did he pull Mtx from? Pred & IVIG are used first. Cancer-y meds like cyclophosphamide, vincristine, & rituximab are all better options beyond. I’m glad they used a real baby instead of the creepy doll this week.
January 27th, 2009 at 2:58 am
I found the humour to be much more clever in this episode compared to the past few (”I think those kids are spoken for”), but the rest of the show was disappointing.
House’s comparison of the brain and the internet sounded like it was straight out of a numb3rs script, ugh.
That scene with the baby wailing like a broken record over the PA (for what seemed like several minutes) should have annoyed anybody not in a coma, not just the patient. We get it, baby crying made the patient annoyed, we don’t need to watch it for 3 and a half minutes to figure this one out. Thirteen’s change of attitude is way over the top; so is Foreman’s self doubt. The writers should give us a little credit and stop assuming we can’t figure anything out if they don’t make it blatantly obvious.
And finally i know the “double blind trial” has been beat to death already but why do they keeping making it more and more ridiculous? Yeah I’m sure nobody is gonna wonder why patient #128 has no drugs left. Oh wait, I guess the test was ruined anyway, might as well give out the real stuff to whoever is sleeping with the doctor. no biggie at princeton-plainsboro.
January 27th, 2009 at 3:50 am
I cannot disagree more about the baby. Cuddy should have given it up when she had the chance. Now, she bonded with it, and Cameron quit her fake temporary job, so we’ll have to spend more time cutting to this annoying subplot that I don’t care about.
All Foreman has to say about his double blind drug trial being compromised is “accidents happen.” Am I the only one who thinks that’s completely ridiculous? I remember when Foreman was cold and House-like. I enjoyed that Foreman a lot more than this one. This one is annoying.
January 27th, 2009 at 4:13 am
Bulgaria:
Of course the ductus arteriosus is not permanently patent, otherwise the patient would have died of cerebral hypoxia long ago.
I’m guessing the reason they mentioned specifically ischemia of the right hemisphere as the cardinal giveaway is that the ductus arteriosus leaves the aortic arch after the brachiocephalic artery does, but before the left common carotid and left subclavian.
No idea how that matches up with clinical reality though. Odds are it’s made up out of the blue and doesn’t match up with anything, but it’s a cool thought.
January 27th, 2009 at 4:18 am
BD are you sure you don’t have a bit of bad circulation yourself? Severe cases of PDA present themselves with plenty of symptoms that have nothing to do with the brain – enlarged heart and shortness of breath for one thing. Otherwise you are 100% right about the ductus not being opened all the time so I withdraw my note. There should still be a murmur I think thought…
January 27th, 2009 at 5:21 am
Hi, I have lots of comments about the comments:
* No way that last week’s rants about “Foreteen” resulted in no mention this week. Tonight’s episode was filmed well before last week. How else could they show previews of forthcoming episodes??
* Please tell me if I’m wrong, but in a witnessed arrest, are not a precordial thump and shocks the first steps recommended — even before chest compressions? See:
http://www.aims.unc.edu/resources/knowledgebase/entry.aspx?id=137
* The ductus arteriosus does not “wither away.” It becomes the ligamentum arteriosum. So there is always a structure there.
* I do not think it’s ridiculous for Foreman to say “accidents happen” when he found out 13’s drug assignment. There are tons of stories from clinical trials in which some inadvertent clue gave things away. Yeah, you’d think the pharmaceutical company would have thought about the smell, but at least it’s not the hospital that screwed up.
* That must have been a whopping huge ductus to siphon off so much blood as to deprive the left brain of oxygen. But, it was only open intermittently??
* Cerebral hypoxia does not kill people with a patent ductus. Pulmonary hypertension does.
* In the Eisenmenger syndrome, pulmonary pressure is higher than systemic pressure, and deoxygenated blood can flow from pulmonary to systemic circulation through the ductus. This flow causes cyanosis, which would affect the left cerebral hemisphere more. But I do not think this patient had Eisenmenger syndrome.
January 27th, 2009 at 5:30 am
Everything after the first paragraph was in response to the review, my bad for the ambiguity. I’m was only speculating what the writers’ thought process might have been for lateralized hypoperfusion.
I no way was I trying to imply that it either had anything to do with what you said, or the clinical picture of PDA (to point out the obvious: It’s mostly an issue with much, much younger patients).
I’ll keep in mind next time that hitting entire twice doesn’t properly delineate one thought from the next. Got to get better at this ‘communicating on the internet’ thing.
January 27th, 2009 at 5:35 am
My bet :-). 10x for the info
January 27th, 2009 at 6:03 am
I’m not an MD; I’m a computer scientist. But I feel I should chime in here about logic, since I suppose I can claim some kind of authoritative grasp. Not really. Great job on this site, by the way.
There are some potential logical problems with Foreman’s switching of the IV bags. How does he even know he put her on the real medicine this time? It’s possible that he may not be able to tell. As an astute poster mentioned last time, he may not be able to smell the unique odor of the medicine. Assuming he can, are the bags supposed to be sealed before use? If he broke some kind of seal, someone may be able to find out. Or if there are now fewer bags than there should be for Patient X, who just donated his/her medicine to 13, some kind of count wont add up. He may be switching the bag with Janice, the improved older patient. But she may be experiencing placebo effects, too! If we’re supposed to believe that 13’s results can be explained by placebo effects (perhaps by suspending disbelief), then Janice’s symptoms may also be explained by them.
And that’s not to say that the writers haven’t already thought of this (or they can pretend to have thought of this ;) and then mail me a check for $10). So unless he did some important fact finding off-screen, I think the writers are setting him up to crash & burn. They also showed that his application of the bar code label was not 100% perfect, so that alone may be evidence. Maybe they’re trying to segue Omar Epps off the show. Writers, plz don’t kill 4Man.
January 27th, 2009 at 6:09 am
I thought it was kind of funny how, after this episode, on 24, two ex-CTU agents came upon someone who wasn’t breathing/didn’t have a pulse and immediately gave CPR/epinephrine, instead of just “No pulse? SHOCK ‘EM!”
January 27th, 2009 at 6:44 am
Hello, everyone! How come no one yet mentioned the hilarious bit when Cuddy and Wilson have the heart-to-heart about the “aged” photo of her 18-year-old daughter? Wilson had me sold on it until he admitted the picture came with the frame. I can’t remember the last time I laughed loudly at the show (all downhill after the Tritter angle in mid-Season 3).
January 27th, 2009 at 7:28 am
“there were definite that classic House was trying to break through.” Missing the word “signs”, I assume.
“so now House and his team pretend have to pretend to use it.” Probably should be “his team have to pretend”.
“The producers should consult you [Scott] for future episode, methinks ” I second this.
January 27th, 2009 at 7:34 am
Some good humor in this episode, much of which has has been mentioned, except for:
H: I really Need oral sex…
C: Can I go back to my phone call now?
H: I don’t see how that’s possible…
On the other hand I absolutely don’t buy House suggesting to Foreman that it’s OK to screw up the drug trial if he loves 13…House understands love, but he doesn’t condone it as a reason for absolutely insane acts. Foreman is acting dumb, and I don’t think his affair with 13 has been developed to that point yet. It was clearly stated that the trial drug will not cure 13, only moderate her symptoms. It’s obviously not worth risking foreman’s career for. This is an unrealistic plot device designed to inject highly artificial drama into the series.
Now, a good change has been Chases’s scruffy beard. Makes him look more manly.
January 27th, 2009 at 9:28 am
It looked to me like Cuddy gave up the baby in the end? Who was that holding the baby while she walked away?
January 27th, 2009 at 9:35 am
J B – Her nanny.
January 27th, 2009 at 10:26 am
equine encephalitis is caused by togaviruses.
January 27th, 2009 at 10:32 am
One of my favorite moments of this episode:
Foreman: (while insisting the pt doesn’t have brain damage)
“house, i can hear your thoughts from my apartment.” (something like that)
House: (while looking at thirteen pretty lewdly) “can you hear me now?”
Foreman: “just move on to another organ, house!”
House: (still looking at thirteen lustily) “i already have.”
January 27th, 2009 at 11:06 am
My favorite part: while Taub and 13 are conducting the fake radiation procedure, they are watching Fletch. Classic movie!
January 27th, 2009 at 11:25 am
May I also comment that, as a Medical Technologist with nearly 30 years experience, the Bleeding Time test was also completely absurd, on a number of levels. To begin with, it is much more commonly assumed that an prolonged bleeding time test would be caused by a platelet problem (either low numbers of platelets or malfunctioning platelets) rather than coagulopathy (problem with one of the proteins needed for clotting), particularly since it would be logical to be doing a Prothrombin Time and aPTT test on the patient’s blood in conjunction with performing the bleeding time test. Secondly, a lot of hospitals, and certainly one with the resources PPTH is portrayed as having, have replaced the admittedly imprecise bleeding time (make an incision and time with a stop watch how long it takes to stop bleeding) with the much more informative and reproducible function tests such as platelet aggregation time and closure times which are performed on special instruments. Finally, when a bleeding time is performed, the incision is made with a small, commercial device which causes a small, sharp blade to quickly shoot out and retract again (similar to automatic lancets used to get fingerstick blood for blood sugar measurements). It makes a tiny, controlled-measurement slit in the skin, and not the ‘use a scalpel to make some kind of incision’ technique shown in the show.
Finally, after viewing tens of thousands of blood smears, I have seen platelets vary widely in number and size, but I have never in my life seen a single instance of a ‘chewed-up platelet’, they were mixing up the red blood cell morphology which would appear from the trauma with the platelet problem.
January 27th, 2009 at 11:32 am
The doctors aren’t known for being the most professional, but the scene with Cuddy on the phone was unprofessional on a whole different level… actually letting the patient hear them argue over the safety and necessity of the procedure…
To the doctors: would the anesthesia prevent her from remembering the scene?
January 27th, 2009 at 11:57 am
I wasn’t sure how Foreman would be sure he was re-assigning “real drug” to 13. As you point out, if he’s opened it and smelled it and confirmed to himself that 13 is on placebo… now you also have a tampered IV bag. That stuff is being infused, and (not an MD/RN/etc here but) doesn’t that need to be sterile and now it’s not – isn’t that basic medical stuff?
Drug accountability wouldn’t necessarily be off, if he were to switch bags one-for-one between 13 and the other patient. I’m sure for dramatic reasons we’re not going to have a “perfect crime” thing here. And besides, usually investigational product comes from the sponsor pre-labeled with the randomization code and such and you don’t just have spools of spare labels lying around. Agree that the obvious re-labeling is going to be important.
January 27th, 2009 at 12:34 pm
As I understand it, Foreman switched bags between 13, who was on a placebo, and someone who was on the real thing (probably the older lady who was making so much progress). So, with regard to the study and this particular patient, it will appear as though the real thing had no signficant long-term positive effect. Hopefully, this result will be disregarded as an outlier, otherwise the drug may be deemed a failure and thousands will suffer.
Foreman should have simply dropped 13 from the study and found abother way to provide her with the drug.
January 27th, 2009 at 12:37 pm
And I just thought of an interesting direction that they could take with the drug trial story arc. Thirteen could start to experience some of the more severe (perhaps previously undocumented) side effects of the real Huntington’s drug. The researchers (other than Foreman) would then have to explain why the effects presented so late into the treatment. Meanwhile, Foreman would debate between coming clean and ruining the trial of a drug that works but he now knows to have severe side effects.
Just a thought.
January 27th, 2009 at 1:19 pm
I agree with Eric. I kept wondering if the patient was having problems, why did Kutner continue to keep the phone by the loud speaker? I know, it kept the drama going for House to diagnose, but still, Cuddy was no longer focusing on House. Hang up.
What really bothered me about the open cranial scene was the monitor behind House that allowed Sarah to watch what the surgeon was doing to her brain.
January 27th, 2009 at 1:22 pm
IANA medical professional, but I have been in a drug trial. In my trial, which was double blind, we were promised that even if we were on the placebo, we would get the drug for free, post-trial, if it proved effective. (The drug was already FDA approved, the trial was for a new off label use of the drug.)
So I’m just nit picking the plot point where Foreman is concerned that Thirteen won’t be treated with the actual drug. In my trial, she would have eventually gotten it, after the trial concluded, at the very latest. But maybe that was only because my drug was post FDA approval…?
Anyone more knowledgeable care to comment?
Lot of nits to pick, as always, but still the best show on television!
January 27th, 2009 at 1:32 pm
My very preemie daughter (now 14) had surgery for her PDA at a week old. We were told that it would kill her soon if not repaired, so the idea of a 29 year old with a PDA seemed not particularly feasible.
The bonding issues that Cuddy felt were very poignant, IMHO. I think many parents have those early moments of doubt. I was rarely allowed to touch my child and didn’t hold her for months, and every moment was plagued with fear and stress. Confidence in my ability to parent didn’t come for almost a year for me.
January 27th, 2009 at 2:28 pm
As for the PDA affecting only the left side of the brain, I have a questinon for medical pro’s on this forum (with help of human anatomy atlas):
Artery supplementig right side of the brain (Truncus brachiocephalicus->Arteria carotis communis dextra) branches from Arcus aortae as first, artery suplementing left side of the brain (Arteria carotis communis) as second. Ductus arteriosus in fetus and ligamentum arteriosum in adults are positioned aproximately opposite to the branching of Arteria carotis communis. Does this really mean, that if there was intermitently opening PDA in the patient, that left side of the brain would get less oxygenated blood than the right side simply because of being further “upstream” from heart and closer to the PDA, or is it really too far fetched?
I hope I made my question clear, english is not my native language neither am I physitian.
January 27th, 2009 at 2:45 pm
Wouldn’t Foreman have to resign (and wouldn’t the fact that they knew each other before the trial exclude her)
January 27th, 2009 at 3:06 pm
Longtime reader, first time poster. I love how quickly you do these, seriously. It’s wonderful to read it all and see what’s going on, here. I’m a pre-med student, so it’s really cool to read over what a real doctor is saying to try and get some facts straight.
So because I don’t know much about medicine, I wanted to comment on the whole “post-adoption depression” thing. While I understand that it’s realistic, I kind of think that trying to completely emulate real life isn’t the best idea for any TV show. Yes, people get depressed after adoption, and in real life, it’s a real problem. But on TV, it’s more like an annoying black hole for screen time and creativity. Is it just me, or did it feel like excessive angst?
January 27th, 2009 at 3:25 pm
I was sad when House said Eastern Equine Encephalopathy with 10 minutes left in the show. Too soon for a final diagnosis. Boo.
And, has the girl not ever taken Ibuprofen or Aspirin or any NSAID in her life? Don’t those drugs promote the closing of the ductus arteriosus? And I don’t understand only the left brain being starved of oxygen either.
Over-all, boo. But my favorite line of the show (as someone said above) was the oral sex comment towards Cameron. I lol’d.
January 27th, 2009 at 3:28 pm
Yeah, I think this episode of House was much better.
And maybe the drug-trial storyline will finally end. It wasn’t incredibly interesting up until the whole “zomg Thirteen izz on placeboh i think im gunna changeee it!” thing. I doubt they’ll get rid of Thirteen/Foreteen anytime soon though.
This episode was definetly better than the last one. I was pretty surprised myself at the ending…if anybody else was.
January 27th, 2009 at 5:09 pm
to charly: Read the post by warble at the beginning about Eisenmenger syndrome – this is what causes the LEFT hemisphere to get oxygen deprived. I do not think that the positioning of the PDA is that important. However may be that too plays a part. I also noticed couple of the posters to mention the disease to be a child condition – that is incorrect. Depending of the presence/absence of symptoms PDA may remain undiagnosed for years, or even be discovered on a routine check for something else. If found in a child sometimes doctors do not take action, cause it is only an EVENTUAL problem, not a definitive cause for surgery/treatment. If the child shows no symptoms, then treatment is not on the agenda – observation only – thus he/she may grow old before any real measures are taken.
January 27th, 2009 at 6:53 pm
Dear Pharmacy Student: Any patient coming to House would have a battery of basic tests already run before the referral-HELLP syndrome causes platelet counts to drop, and may lead to serious bleeding issues, and so would be considered if there was a chance she could be pregnant.
AGAIN, people, ENOUGH of the grammatical corrections?! Who cares?
January 27th, 2009 at 6:54 pm
I thought the medicine was convoluted and ridiculous, epecially the cranial electrical stim scene. Loved the Wilson scenes even though he had to share them with Cuddy. Wilson had me going with that story about the frame. My love is a masterful liar. House and Cameron scenes were great – really wish Cameron hadn’t given up so quickly. I hate – with a passion – Cuddy’s baby momma drama. Geez I hope it ends soon.
January 27th, 2009 at 6:58 pm
No mention of Foreman flushing his medical career down the toilet?
January 27th, 2009 at 7:27 pm
Maybe Foreman is playing everybody, he could have taken a blank real medicine IV bag and switched 13s with it.
January 27th, 2009 at 9:30 pm
Phred : “Maybe Foreman is playing everybody, he could have taken a blank real medicine IV bag and switched 13s with it.”
LOL. Love it. That would be a fantastic and sadistic turn that we wouldn’t expect.
January 27th, 2009 at 10:08 pm
In real drug trials are atempts made to try and make the placebo more like the real drug to both patients and those conducting the trial, so smell in this case or maybe taste for a tablet?
What about in trials with drugs that have well known side effects like anti-depressants or chemotherapy? Wouldn’t some patients be able to tell if these effects were absent?
January 28th, 2009 at 12:01 am
In drug trials where a currently approved treatment exists, subjects are often given the established treatment in place of a placebo. It would be unethical to randomly take someone completely off heart meds just to see if your new drug is marginally better than what the patient would otherwise have been taking.
January 28th, 2009 at 1:54 am
Interestingly, of all the opinions Foreman “collected” about switching Thirteen to the real drug, House’s was the most “humane”.
Cameron just said “Don’t be an idiot” – which was funny as shot, but shows her to be a shallow bitch. Maybe it wasn’t intended to, but that totally undermined her cutesie-wootsie character on the show.
January 28th, 2009 at 2:31 am
I am an ICU nurse with some experience/education in research studies (though not drug trials).
My guess is that Foreman switched the drugs of the only patient he “knows” is on the real drug: the woman showing progress. He can’t have walked around asking nurses if any of their bags smelled funny without arousing suspicion. So, logically, he would have switched labels on the bag that he thinks has the drugs with 13’s.
This could play out in several ways. Here are two I can think of:
-The woman who was making so much progress could relapse to her former twitchy self, leaving Foreman feeling morally bankrupt and making 13 reconsider her participation in the study.
-Or, the woman making so much progress could have only been feeling the placebo effect; Foreman risked his career for nothing.
Either way, Foreman will feel like an ass. Several characters have left the show after being a part of a relationship: Stacey and CTB aka Amber to name two. I think this trend will continue with either Foreman or 13 leaving. I hope it’s 13, as she just annoys me now.
JB: They attempt to make the placebo and the trial drug seem as much alike as is necessary. However, participants don’t normally smell the bag of IV fluid they are getting, so smell wouldn’t normally be taken into account. Usually they keep the actual medication administration separate from the researchers; that’s what people like me (research assistants) are for.
Side effects do not usually happen to every single person who takes a medication. If you read the insert that comes with prescription meds, you will usually find a section where side effects are listed with their percentages effected. Sometimes they will include a placebo column as well to compare. Usually the placebo column has decently high percentages of feelings common to everyone. For instance, a medication might cause stomach upset in 13% of people it is administered to, but people on the placebo reported stomach upset 5% of the time. While some of the side effects can be attributed to the medication, some to random chance.
As a final remark on this already too long post, I am pissed off at how badly the nurses are portrayed (if they even exist) on this show. I love House, but we are not babysitters, housekeeping, etc and we are certainly allowed to talk to/question the doctors. The one time a nurse has a line in the last few episodes is to break the double blind on a drug trial? Please….that’s discouraging. At least in Grey’s Anatomy nurses get laid. Scrubs portrays Carla as smart and powerful. ER, IIRC, has a few nurses with brain cells. Many of us have at least a BS (mine’s from an Ivy). We need *some* credit.
January 28th, 2009 at 2:39 am
To the computer scientist:
If Foreman wants to give 13 the active drug, all he has to do is fish some empty IV bags out of the trash can in the clinic (i.e. after the bag has been disconnected from the patient). Bags do not empty completely. There is always some residual fluid in them. As soon as he finds one that stinks, he knows which patient’s bags to swap in the future.
And even if he doesn’t want to fish through trash cans, he can pretend to help the nurses by saying “Oh, I’ll go in and disconnect Janice.” Then he spills a little on himself and later smells his skin.
Easy as pie.
January 28th, 2009 at 3:47 am
I have also participated in a couple of drug trials, and they were really quite sloppy. This is not surprising, since the goal of drug-company funded trials is to sell drugs, not to do science. Also, even the more research oriented MDs who participate in these trials are not career scientists. I have no trouble believing that the protocols could be violated.
If the drug is effective enough to be commercially viable, the trial doesn’t have to be perfect.
Foreman could have gotten the extra drug from a subject who dropped out of the trial (there are usually plenty).
I don’t see why it would hurt his medical career if he were caught. It has nothing to do with patient care… it would just be a matter between him and the drug company.
January 28th, 2009 at 7:17 am
I’m no MD but I basically have the same bones to pick as you, Scott.
If the blood sample clotted when ‘iced’, shouldn’t it be warning enough that they shouldn’t have gone through with the ice bath? Whatever happened to common sense?
This whole double-blind trial and Foreman thing is really annoying me. But I think this has been addressed before. I *could* see how this could affect his medical career considering we are talking here about a patient conflict of interest. He can’t be the only head of this trial, so why not someone else deal with administering and that?
With Sarah and the baby crying, indeed she may be able to work with disabled children easier than others BUT isn’t it a normal reaction of a person to be annoyed/stressed/anxious if they hear a baby crying for a prolonged time while dealing with a conversation and working out whether or not you’d just had your skull sheered off for no good reason. Cuddy’s baby was crying for a few minutes, and I’m positive that would annoy me midway through a procedure.
Sorry, maybe I’m being anal retentive but seriously… where is the common sense? It’s not even drama-inducing. Even with the conclusion and trying to work it out from there, it’s just down right, wtf?!
January 28th, 2009 at 8:01 am
David – Of course Foreman still carries with him the stench of “becoming House”.
I wonder if that would still carry over to his interviews with other hospitols, should his alledged tampering with the drug trial come to light and Cuddy decides that he’s no longer useful for keeping House in line, if he thinks he can pull crazy crap of his own. I do have to say that I miss the Foreman we had at the end of season 3. I personally think that him extracting the bone marrow out of that poor kid in one of the later episodes should have been a scene to ground his character for a little longer then it did. Cold and authoratative.
January 28th, 2009 at 8:46 am
I have no maternal instinct whatsoever (don’t have kids, don’t want them) but when Cuddy was confiding in Wilson at the beginning and said “I feed her, I burp her, I change her” I immediately said “Do you talk to her??” I can’t believe none of those books she read never mentioned it either.
I’m so annoyed with Foreman’s decision to change the meds. Like House said, it’s one thing if it’s a potential life-saver; that would be worth destroying your career. But MAYBE a year or two? What a pointless gesture.
January 28th, 2009 at 8:58 am
I think this is the first time I respond to your review, but I always like reading them, because I love watching House, but am always left wondering whether the medicine was wildly imaginative or actually plausible. You usually manage to set things straight for me :P
Anyway, I enjoyed this episode a lot. First time in a while it felt Houlse-like as we remember from the first seasons, rather than the let down that has been most of season 5 (and come to think of it, season 4).
@David: wouldn’t purposefully compromising a medical trial stilll be a betrayal of some code of ethics and cause for countless lawsuits that would compromise any future in a medical career? No matter how “sloppy” the trial is, it’s still their job to be as objective as possible. Compromising the trial for the sake of a loved one seems to be very much over the line. Not to mention a violation of doctor-patient relationship ethics.
January 28th, 2009 at 9:04 am
I thought you might like this: http://obamiconme.pastemagazine.com/entries/1137-not-lupus.html :)
January 28th, 2009 at 10:35 am
Does anyone know the song that ends the episode?
I tried to google the Lyrics but did not find it.
January 28th, 2009 at 10:57 am
I think that the over-the-top change in attitude with 13 (and her attraction to Foreman) is driven by unscrupulous means. I have a theory that she knows that she’s on the placebo, and is manipulating Foreman to get on the real drug. Just a theory.
January 28th, 2009 at 12:04 pm
i agree with Nurse Gracer on the Foreman plot.
the patient who was improving will not only make Foreman feel bad when she relapses, but it may disrupt thirteens believe in the treatment and she might also show syptoms although she now is on the real meds.
and as for the authors reading this site: it might be so, but all of our conclusions are just additions of the hints they give us, as all the seasons are already filmed, edited and well planned long before we even get to think about them,., methinks.
January 28th, 2009 at 1:46 pm
To zypchick:
That stuff is being infused, and (not an MD/RN/etc here but) doesn’t that need to be sterile and now it’s not – isn’t that basic medical stuff?
——————————————————————–
IV bags contain a little rubber stud at their bottoms. It is primaily used for injecting additives/medications with a syringe, but Foreman could just as easily use a syringe to withdrwal a little bit out of the bag and sniff it. It wouldn’t compromise the sterility of the fluid inside.
January 28th, 2009 at 2:09 pm
@Chris
The Song is “On My Side” by Cory Chisel and the Wandering Sons. Check them out at http://www.myspace.com/thewanderingsons.
January 28th, 2009 at 9:22 pm
I think it would be quite hilarious (but not really) if it was the placebo that gave off the smell, and the real drug that was odorless. Foreman would be jeopardizing his job to screw Thirteen over. I’m more inclined towards the House/Cuddy storyline, and I thought that Cuddy bringing Rachel in, and House actually HOLDING her, was a nice subtle hint that his human side is showing a little more plainly to Cuddy now.
I’ve always thought that the medical part of the show has always been a bit (alot) far fetched, but what else is to be expected of a Medical Drama?
January 29th, 2009 at 12:25 am
I found this episode horribly annoying. I’m tired of Cuddy and her baby already and the subtle-as-a-sledgehammer scenes of her with baby “and House makes three.” The crying baby over the phone during that procedure was ridiculous, but then, I don’t have any respect for Cuddy left to lose, anyway. Who wouldn’t be annoyed by a crying baby and its desperate, ineffectual foster mother? Especially if the top of one’s head has been sawed off.
Worse than that, though, is the Foreteen/clinical trial drama. I cannot believe House would endorse Foreman’s actions, which can only be considered reckless, selfish, and unethical. On the plus side, the previews for next week showed 13 going into “possible side effects” mode, so that’s nice. On the down side, another 13-centric episode. Someone correct me if I’m wrong, but HD is autosomal dominant, yes? 50/50 shot of inheritance? And the tested treatment only helps symptoms and does nothing to actually reverse/cure it (and of course wouldn’t change her DNA). Yet 13 is willing to contemplate the idea of having children. My god. Good for her that she’s feeling optimistic, but that’s just too much for me.
Also, is it really THAT important for Foreman to jeopardize… everything by switching her meds? The drug might minimize or delay her symptoms but not get rid of them, and 13 wasn’t even noticeably symptomatic yet! There’s nothing for the drug to make “better” yet that I can see. Gah. This might be what ruins House for me, I swear.
January 29th, 2009 at 8:54 am
To Elaine, may I suggest you stop watching House so as to keep your blood pressure and stress levels at a healthy level. You are FAR too annoyed over a TV show.
Besides, it was a good episode!. :-)
January 29th, 2009 at 10:39 am
Does anyone know the song that ends the episode?
I see a fellow Canadian already answered your question, Chris, but here’s a list of House music/songs that you might want to bookmark for future use:
http://www.have-dog.com/house/
(I’ve used it several times too as alot of the House mini-music-videos have impressed me.)
January 29th, 2009 at 11:19 am
Yeah, a House-worth diagnosis, but PDA remaining silent for 29 years and then suddenly causing serious symptoms? Kinda weird. Cuddy´s feelings are quite understandable cause she´d never had a kid before so she probably kinda didn´t know what to do with her. I guess it´s at least a bit natural for new mothers. So it´s natural for women to wanna have kids but in Thirteen´s case it´s certainly a risk of passing her Huntington gene on. Yeah, good point, if Foreman stole Janice´s medicine and she relapses, Thirteen might drop out. But what if Janice is just experiencing placebo effect too? According to the promo Thirteen will be in gr8 trouble next week! C.U.
January 29th, 2009 at 11:48 am
“Good for her that she’s feeling optimistic, but that’s just too much for me.”
I’ve learned directly through support groups and witnessed online that 13’s attitude regarding HD versus children is surprisingly common. It defies logic… but doesn’t every relationship decision?
January 29th, 2009 at 12:50 pm
all in all it was an okay house episode. i just was disappointed the way they considered ITP because i had ITP before and as a medical technologist myself i’d look at my blood smears and the problem was not that they were ‘abnormal’ , rather, it was that there were almost none to see (my platelet count would sometimes drop to as low as 20,000/uL). and i agree with scott, it is always steroids that are first given to a possible ITP.
January 29th, 2009 at 8:50 pm
I’ve been reading these since i found them on wikipedia (wish this was up at the beginning of House). All of the medical info that you guys (and girls) do is amazing. There are 3 things that I wanna add.
1. (Suprise, suprise) Chase was the only one who actually made sense about the double-blind trial and told Foreman what everybody’s been thinking (and saying) about it, that he shouldn’t have known in the first place and that he sould leave the trial because he knows. (Lol’d that everyone else that Foreman went to for advice told him to not be an idiot)
2. (I’m not sure if someone mentioned this) Why did they use the usual shock treatment on someone that still has the gown on? Maybe since they were “pretending” to do a test they were probably “pretending” to shock her and save her life.
3. I LOVED the part when House is holding the baby and she throws up on him. He don’t like the baby and the baby doesn’t like him.
4. (I know i said 3 but I just thought of something) I dont think house was expecting foreman to change the bag when he said what he said. He probably thought that Foreman didn’t love 13 (they’ve been puppy loving for like 3-4 weeks).
But anyway I can’t wait until the next house and until the next review.
January 29th, 2009 at 9:07 pm
I wonder if any of you noticed Thirteen’s patient number that Foreman put on the bag. “213″ As in, this bag is “to thirteen”
January 30th, 2009 at 10:23 am
I just finished watching the episode for a second time with translation this time and I read about as much as I can about congenital heart defects. Considering my area of interest is so different, I think I had my kicks for about the next 10 or so episode that are heart connected. Nothing to add though – House’s explanation made sense about pretty much everything (and IANAN but I thing just the LEFT hemisphere affected by the intermittent pulmonary hypertension and loss of oxygenated blood is the biggest stretch by far) brain perfusion is such a complicated matter that to explain a LEFT brain hypo perfusion alone by PDA is… well TV but not medicine. Considering the amount of tests they did to the heart they should have caught the PDA sooner (I think on the physical) Nothing further to say and I am waiting on my toes for the next episode.
January 30th, 2009 at 1:23 pm
I was reading that Placebo can be used to treat ADHD, depression, and certain type of localized pain, and I’m wondering if any doctors have ever prescribed Placebo or if you can just get it over-the-counter.
January 30th, 2009 at 3:56 pm
Dear reviewer and fellow readers,
firstly, AMAZING site!!
secondly, I’m a doc too, and the problem with PDA’s are that they’re what we call left-to-right shunts (left side i.e:aorta, to the right side i.e :pulmonary artery) until some time elapses, they can remain asymptomatic…we have had patients presenting rather late although history suggested easy fatigue…
Call this nit-picking with the nit-pickers : About the debate on Eisenmengerisation (Eisenmenger’s synd. is VSD with reversal; the other Left-to-right shunts when reversed are simply called Eisenmengerisation)
For non-meds: its simply that the blood in the L-to-R shunt starts flowing in the other direction R-to-L i.e Pulmonary artery to Aorta thus bypassing lungs and oxygen…usually indicates (or screams!) Pulmonary Hypertension which is like a death sentence…
anyway, a step before Eisenmengerisation, the pressure in Pul. and Sys. circulation is approaching equal so the shunt becomes neutral since no pressure differential exists here it’s more plausible that the shunt gets reactivated during times of stress (= increased BP) and pushes blood into the lungs, thereby reducing the blood flow to other organs…(in a normal case of High BP the brain is protected against BP effects on vessels, it does get it’s normal quantum even during high BP states)
but here,due to the PDA the fow to the brain might be reduced leading to the symptoms….quite convoluted…but if it was simple we wouldn’t be watching now, would we?!
A very penetrating remark was the one by a fellow reader about the use of aspirin and other NSAIDs ( we use Indomethacin here…) to close the PDA…
to all ye language purists : sorry about the abbv.s…simply got no time…
to the rest and to all comers : find some holes in my statements…i assure you, the science is pure…but ask any questions and i’ll try and answer…
until epi.14…out! (sh***%$% code blue!) gtg
January 30th, 2009 at 4:11 pm
phew! false alarm, was Ob-Gyn call out..
oh i forgot this : for Lord Vader :
a placebo is a latin word meaning I Shall Please…often, it’s been seen that the patient’s faith in the healer is all that is needed to cure them or make them feel better…this when augmented by a placebo works twice as well…the brain believes it’s being treated with a real drug and so it induces a sense of well being in the patient…(usu. most illness are worsened by psychological factors like stress, fear etc…placebos help mainly against these)
sorry to bust your myth but ANYTHING that you might take which will not have any harmful effect on you, and, at the same time, has no (or little) curative effect on the disease in question is a PLACEBO….salt pills, peppermint, vitamins….all placebos (please attack me on the vitamins somebody…heehee…cant wait)
January 31st, 2009 at 11:24 am
Lord Vader, yes, docs prescribe placebo for depression, insomnia etc. I´ve prepped a lot of capsules containing Calcii carbonici 0.2, Saccharosi 0.2, Amyli tritici 0.2. Seems like they work:-)
Dr. Grindelwald, the question of vitamins hasn´t been answered yet, but some trials suggest that vitamins ARE placebo, but people who take them regularly have a healthier lifestyle in general, so they get sick less often…
February 1st, 2009 at 2:58 pm
Great review! =) I really enjoyed this episode, although medically its pretty ummm fake?
Although a bleeding time can be used to help diagnose vWD, you use a small lancet and some filter paper, never touching the developing clot NOT a scalpel. CLS or Med techs do it, not docs normally. An abnormal time would be >10min (theirs did not remotely approach that. And an aspirin tolerance bleeding time is better. To have vWD — you must have clinical symptoms — she should have had heavy menses etc — and you would test for the actual antigen levels, ristocetin cofactor etc. Bleeding times are so archaic — what they don’t have the money for a PFA100?
Also coughing up blood — first thought would be TB, GI or lung problem… not coagulopathy. Oh well. I don’t watch it for the medicine, though I find it amusing. Still not fond of this new team I prefer the old one.
Thanks again for a great review as always =)
February 2nd, 2009 at 8:37 am
Pause at work, so I´m posting again:-) I watched this ep again on saturday and the “normal” heart rate of 116 was noticed at the time she was just being put in the ice bath. This would elevate everybody´s heart rate!!
February 2nd, 2009 at 9:55 am
I’ve kinda stopped expecting medical realism from this show – after all there are only so many wacky hiding illnesses the writers can come up with, I’m sure. So I watch for the characters.
I’m enjoying Cuddy’s baby arc – I love that motherhood is being portrayed as HARD, even for people who really badly want a baby. That’s realistic! Somebody on the writing staff has apparently read “The Mommy Myth”!
I absolutely love Taub and Kutner, as a double act and individually. The actors have wonderful comic timing and good emotional depth. I like that their personalities are being unpeeled slowly, layer by layer. I was so happy that “Big Baby” was a relatively Kutner-centric episode – and did anyone else think he was a little sweet on the patient?
I am not a huge fan of Cameron, but I liked her in this episode. Usually I find her House crush annoying and unprofessional, but I liked that her true focus really seemed to be the greater good of the hospital and doing a good job in Cuddy’s place. And for some reason I really felt for her in her attempts to control House – everybody has someone they just can’t say no to, even when they try. I think that was conveyed very believably in this episode, in a way that did justice to Cameron’s character.
I want to like Thirteen, I really do. But I feel suffocated by the show’s unrelenting focus on her character. The relationship with Foreman does not do either character any favors. It came out of nowhere, and therefore Foreman’s decision to switch the drugs comes off as more of a jerk move than an act of love. Foreman used to be my favorite character on the show, but I don’t think they have known what to do with him since the fatal brain illness two-parter.
February 2nd, 2009 at 3:46 pm
I’m a bit puzzled on how Foreman can be so sure which is the real medicine and which is the placebo. The nurse surely couldn’t really have known (she had a suspicion based on a smell). It’s surely not written down somewhere on a lable of course. Isn’t it a real possibility that based on a suspicion he now has swapped Thirteen’s real medicine for a placebo?
February 3rd, 2009 at 2:49 am
Pooh – there’s a remote possibility, realistically, that a drug would not be smelly and the placebo would. It’s a clear IV. There’s not one good reason I could think of (though, admittedly, I’m only a guy who’s interested in medicine, and not a doctor) not to use a saline IV as the placebo. Generally, stuff smells bad to people because it isn’t so good for them; why would you give someone something that has the potential to do harm when you could give something reasonable and harmless (and reasonably unlikely to skew the test results!) like saline. If these doctors take their oaths seriously, the answer is pretty simple: they wouldn’t.
(My apologies if there are spoilers ahead; I didn’t do it on purpose. I haven’t seen the new episode yet.)
In the context of the TV show, I wouldn’t be surprised at all if they did something stupid and unrealistic and made the placebo the smelly one, then have Thirteen suffer some weird psychosomatic symptoms.
February 3rd, 2009 at 10:54 pm
“Apparently no one in the hospital likes to run CT scans or MRIs (this week anyway). Most of the diagnoses mentioned (MS, lymphoma, tumor) would have shown up and not required brain biopsy, ERCP, etc.”
House didn’t want to do the MRI, but they did anyways and it ruled out MS.
February 6th, 2009 at 3:06 pm
What bugged me was Cuddy keeping that baby at arm’s length or in a baby bucket, but saying “I’ve read every book on attachment but it doesn’t work.”
If she had really researched attachment, she would have been skin-to-skin with that baby as much as possible and “wearing” the baby in a front carrier every minute they weren’t lying next to each other.
February 8th, 2009 at 10:08 pm
Chris:
That’s one of the advantages of being locked into using “Closed Captaining” on the telly (spouse is hearing impaired). CC almost always tells you the name of the song that a program is airing…and a lot of times even the lyrics! Next time this episode is on, turn Closed Captioning on. (Wish I could tell you what the lyrics were but I’ve already recorded over that episode.)
February 9th, 2009 at 8:33 pm
@Irwin: I think that’s SOP with drug trials, for ethical reasons. I seem to recall from my research methods class (which mentioned nothing of dating your subjects, oddly enough) that trials will often be stopped with placebo subjects getting the new drug if early results show a clear discrepancy.
My question about the PDA is, would it even work like that? I’m looking at my human growth and development notes (I’m a kinesiology student), and the master diagram shows the ductus arteriosus carrying nearly all of the blood pumped by the right ventricle away from the pulmonary vasculature directly to the *descending* aorta, for transport to the placenta for oxygenation; nothing to do with shunting blood to or away from the brain. So the result of a PDA wouldn’t be loss of blood to the brain, but if anything, hypoxia in the organs and lower periphery, no?
February 10th, 2009 at 7:22 pm
I’m WAY WAY out of my league on this site…Is there really a procedure where they cut off the top of your head. What’s it called? I thought that was just for shock value in Hannibal.
February 11th, 2009 at 2:35 pm
Thanks for another round of enlightenment, Scott. These days they yell so many strange diseases I ‘m glad I can even spell them out well enough to Google them up, and your explanations always help.
Nitpick: there may be one “pretend” too many in the sentence you wrote.
February 13th, 2009 at 12:41 pm
As a CLS I found the cold agglutinins “test” they performed extremely glaring, chill the blood and look at it for about a third of a second before jumping to a conclusion? It really took me out of this episode. I did however enjoy the small amount of soap opera and House’s reactions to hearing the patient and Kutner talk to each other.
February 13th, 2009 at 8:22 pm
On what planet would somebody with a bleeding diathesis undergo a neurosurgical procedure?
February 22nd, 2009 at 3:34 am
Question, applying to all House episodes: What is the financial basis on which the House team operates. We never see anyone assessing the cost of any of the procedures carried out. I live outside the US, and it is my understanding that hospitals are very keen to ensure that everything gets paid for. Are teaching hospitals able to escape the clutches of the HMOs? Is it just dramatic licence? Are we supposed to assume that the patient will be faced with a humungous bill for hundreds of tests, scans, operations etc.?
February 22nd, 2009 at 9:18 pm
Again, it’s wrong to SHOCK a PULSELESS HEART. How many times do TV shows have to make this mistake?! Hmm… :) House, you’re more than just a TV show so learn from Dr. Scott here. :)
February 22nd, 2009 at 9:49 pm
To Kalika, the problem with Cuddy’s baby crying over the phone was not just it was annoying, but that it surprised Dr. House that the patient was annoyed and still her blood pressure dropped (it should rise when you are annoyed), so that’s the mystery to House. Anyway, I really like the scenes when Chase and Cameron are there (so it’s ok if Cameron sometimes replace Cuddy’s duties!). Taub and Kutner scenes are doing okay too.
March 1st, 2009 at 6:51 pm
Thanks for the review.
Have you thought about staring in a spin-off, or competitive series (one that gets the medicine correct)? Alternatively, perhaps the writers of House could work into the plot a Dr Scott competitor character who goes head-to-head with House? Do you limp (you might get away with limping on the other leg)? Can you talk with a completely plausible English accent? How do you feel about shaving?
Keep up the good work.
Cheers.
March 25th, 2009 at 2:48 am
ADJ, that idea (seriously) needs to happen next season. Dr Scott versus House! They’d have great argument scenes on how House’s staff is incompetent and how Dr Scott’s limp keeps changing.
I’m not too much enjoying the Cuddy sub-arc myself. Everyone’s said it already, but how can ANYONE not be annoyed by a baby’s yelling?
March 27th, 2009 at 8:59 am
First of all, let me tell you I think this is a great site.
I have got concerns about the “left side” explanation. I know what it’s said usually about left and right brains (right, warm&easy-to-get-on-with, left, cold&aloof), but I understanded, after reading “The Wisdom Paradox” by Elkhonon Goldberg, that left brain damage sometimes led to depression and anxiety while right brain damage led to manic behaviour.
Goldberg affirms that this is explained because left brain emotions are “positive” (make us feel fine), opposed to right brain ones. According to this, right hemispher should have been the deprived one. I’m not a doctor, but Goldberg is a renowned neuropsychologist and author of “The executive brain”, so I suppose he knows what he’s talking about.
Thanks for all this excellent work (and sorry for my poor English).
May 6th, 2009 at 5:08 am
great site indeed. i’m a third year medical student and really liked this episode. but, a PDA at 29 would most likely have caused pulmonary hypertension because of that “little detour”, and not a half sided paralysis. and which self respecting doctor wouldn’t notica a PDA with a stethoscope?
otherwise, a nice episode!
July 8th, 2009 at 4:38 am
I REALLY LOVE HOUSE S DIALOGS!!WHERE DO THEY GET THEM!!SOMETIMES I FEEL SAD WHEN I THINK HE IS NOT FOR REAL,THAT HE IS ONLY AN ACTOR
August 11th, 2009 at 2:35 pm
Re left brain hypoxia
According to darcy’s law, flow in circulatory system is analagous to electrical circuits – multiple branches along the aortic arch, a structure offering minimal resistance, should receive identical pressure heads, relative flow determined solely by relative arteriolar resistances. Therefore, an intermittent branch (PDA) into pulmonary trunk may well reduce total flow to the systemic vessels but relative flow must remain the same regardless of the defect’s exact position.
However, if reversal occurs due to eisenmenger complex, pressures from pulmonary trunk will equate to pressures in aortic arch, resulting in a degree of right-to-left shunting and a large amount of turbulence in the system as 2 equal pressure heads collide. It may well be that the resultant flow to the left common carotid, lying opposite to the PDA, contains more deoxygenated blood from the ductus (this blood has passed into the right atrium via systemic veins) than the right brachiocephalic branch – a cm or so upstream.
However, eisenmenger complex requires right ventricular hypertrophy – Kuthner’s “no structural defects in her heart” seemed to rule that out….
Only solution seems to be that turbulence with the ductus occured before eisenmenger and the subsequent shunt could develop, sufficiently so in order to divert a significant proportion of blood to what is now the least resistive path, the upstream right brachiocephalic.
One of the tech advisors to the show is a cardiologist anyway, he probably knows what he’s talking about :P
September 18th, 2009 at 2:43 pm
Did anyone else notice what Dr. Hedley was Patient #213 in the Huntington’s drug trial? “To Thirteen”?
February 23rd, 2010 at 2:33 pm
in the second year of med school, at least in sweden, we get taught how to use our stethoscopes. if someone just would’ve put a stethoscope to her chest when she was getting worse they would’ve heard a constant murmur throughout the cardiac cycle. though i tired of this episode after only five minutes due to the bleeding time test where they made a cut and timed the coagulation. why the hell not just take a aptt and pt inr. i used to love house but it’s too darn annoying now.
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