House — Episode 16 (Season 5): “The Softer Side”
Despite the barely above average medicine, I enjoyed this episode of House. Probably because it focused more on House himself than on Foreteen.
Jackson is a teenager born with genetic mosaicism whose parents have chosen to raise him as a male. He is playing on the school’s basketball team and he has just made the winning basket when he collapses to the ground with severe abdominal pain. He is later admitted to House’s service for treatment of this “chronic pelvic pain”. An issue is that his parents have never told him about his underlying genetic condition and have been giving him testosterone shots under the fiction that they are vitamins. They don’t want House or his team to tell him the truth, a situation that doesn’t sit well with some of the team, particularly Thirteen.
The team’s initial differential includes dehydration, congenital adrenal hyperplasia, PMDS (Persistent Mullerian Duct Syndrome), a blind uterus, or problems from the surgical reconstruction of his penis. House wants to perform a urethroscopy, but the parents want an MRI to look for a blind uterus. House gives into their suggestion and an MRI is ordered. The results are negative, so Jackson is prepared for the urethroscopy. As they start the procedure he starts to complain of chest pain and shortness of breath. Thirteen only hears muffled heart sounds on exam and notices jugular venous distention. He appears to be in cardiac tamponade so she jabs a syringe blindly into his chest to remove the extra fluid from around the heart.
The team’s second attempt at a differential diagnosis only yields the generalities of “drugs, toxins or infection.” Then autoimmune disease related to the testosterone injections is mentioned, especially polyarteritis or SLE (lupus). House has the team start Jackson on corticosteroids for the suspected autoimmune condition and finasteride to block the effects of the testosterone. (It’s not made clear at this point, but the testosterone injections are stopped as well). As Thirteen is administering the medicine, she notices red palms on Jackson. She takes this to mean that 1) he has does not have an autoimmune disease, and 2) his liver and kidneys are failing. Blood tests back this up (her second point, at least).
The third version of a differential diagnosis contains amyloidosis or drug/alcohol abuse due to depression. A search of his room yields some dismal and morbid poetry that Thirteen takes as proof that Jackson is depressed. She feels this depression is related to his sexual identity issues and wants his parents to tell him the truth, but his mother refuses. Meanwhile, Taub finds evidence of toxoplasmosis on Jackson’s water bottle, so infection is a possibility as well. He is started on pyrimethamine to treat the suspected toxoplasmosis. His parents ask that his testosterone be restarted as well. When Thirteen is injecting the medicine into Jackson, she confesses that it isn’t a vitamin shot like he’d been told — though she doesn’t tell him what it is, just tells him to ask his parents. This triggers a showdown with her and the parents in Cuddy’s office. Cuddy backs Thirteen, but lets her know it is for Jackson’s sake, not her own. When told the truth, Jackson understandably becomes angry and refuses to speak with his parents anymore. Thirteen comes back in to talk with him and lets him know about finding the poem. He tells her it was for a class assignment (”write a poem in the style of Sylvia Plath”), and was not about his feeling at all. He tells her that he doesn’t feel depressed — or at least he didn’t until his parents told him the truth about his genetics. He becomes suddenly nauseated and begins to vomit blood.
Jackson is found to have a gastric fistula due to necrotizing pancreatitis. Thirteen suggests Zollinger-Ellison Syndrome, but Taub believes it is systemic scleroderma. Foreman decides to treat the possible Zollinger-Ellison first and if that doesn’t work, then to treat the scleroderma. He and the rest of the team know that sclerodema is more likely, but also has a worse outcome, so they are treating the Zollinger Ellison and hoping for the best. It doesn’t work, so Jackson is started on anti-inflammatory medication to treat the scleroderma. The next morning, Foreman tells Thirteen that it is having some effect as Jackson’s liver enzymes are improving. Through some convoluted logic, they deduce that this means it cannot be sclerodema since he is getting better too fast. About this time, House reappears on the scene, hears about the case and instantly makes the diagnosis: it all started with dehydration; that’s what caused the collapse. The ER gave him some IV fluids, but because of his use if energy drinks (which apparently also caused his abdominal pain), his kidneys were slow to respond. When Jackson was then given the contrast for the MRI, the already dehydration/energy drink-strained kidneys could not filter the contrast fast enough so it cycled throughout the body, causing problems wherever it went. It was this contrast that caused the heart disease, the liver failure, the kidney failure, and the pancreatitis.
Methadone is a potent narcotic, and has more respiratory depression than more common narcotics, but it’s not that life threatening. Particularly in a patient with such a heavy previous use of narcotics.
I did like House’s realization that he can’t be the brilliant diagnostician he wants to be if he’s not in pain.
Mosaicism occurs when one person has two genetically distinct lines of cells. Some of their cells have one set of genes, and the other cells have a different set. Mosaicism generally occurs early in development, often from a mutation or nondisjunction. In Jackson’s case, one cell line is genotypically male (XY) and the other female (XX). This is a known, but rare, cause of intersexuality.
As usual, minor complaints are in blue, and nit-picking in green. My main complaint this week, the red one, I’d characterize as a “moderate” complaints — more than minor, but less than major. It’s theoretically possible, but extremely unlikely.
Intravenous contrast can certainly cause renal problems, my kidneys are proof of that. Contrast material can cause acute renal failure (contrast-induced nephropathy). There have also been isolated cases of pancreatitis and pericardial effusion thought to be linked to contrast material, but the patients involved all had significant other co-morbidities (such as AIDS). For Jackson to have had such problems with contrast, his kidneys must have been in bad shape, which should have shown up on simple blood tests — blood tests which radiologists are maniacal about ordering and avoiding the use of contrast if they looks even a little off.
I guess this sort of complication is what happens when you act as your own radiologist.
And seriously, how many energy drinks was this kid downing to cause these problems?
Notice how vague the writers were being when treating the scleroderma: repeatedly using the term “anti-inflammatories” instead of naming a specific drug. This is usually a sign that they’re trying to skirt around a known plot inconsistency.
Such as the fact the anti-inflammatory that they’d use would likely be a corticosteroid, the same type of drug they gave Jackson for a suspected autoimmune condition in the first half of the show. In fact, scleroderma is an autoimmune condition.
I like how psychic the team can be. Thirteen automatically knows it’s an exudate causing Jackson’s tamponade instead of the more common (and seen just two episodes ago) blood.
That’s incredibly fast for an exudate to form.
Blindly jamming a needle in the chest is still not a good idea. It wouldn’t take that much longer the properly position it, and just a little more time to attach it to a cardiac monitor.
Finasteride is not approved for use in children. It blocks the breakdown of testosterone into dihydrotestosterone (DHT), which I guess might help if it is the DHT causing the lupus reaction and not the testosterone itself. Otherwise, you’ve just made things worse by increasing the levels of testosterone.
Toxoplasmosis is a common parasitic disease, but does not typically cause problems in people with healthy immune systems. It is a worry in patients with compromised immune systems and in pregnant patients, because it is one of the diseases that can be passed from mother to fetus.
Symptoms don’t match at all.
Pyrimethamine is not used alone to treat toxoplasmosis. It is given with a sulfonamide.
I suspect a pelvic U/S would be a better choice than MRI when looking for a blind uterus, but then you’d avoid that whole contrast material concept.
Several hours of pelvic pain is not chronic.
The medical mystery was good. The mosaicism was a red herring in terms of the mystery itself — though it did add to the family dynamics issues. I give the mystery a B+. The final diagnosis was logical, but would have required a perfect storm of events to occur. I give it a B. The medicine overall remained haphazard, but at least it was more focused than previous weeks (except for the toxoplasmosis, that came out of left field), and earns a C+. The soap opera was fairly good, both the “House is happy” and “Mother avoids the issue” aspects. I give it a B.
February 23rd, 2009 at 11:50 pm
Hey heeey, A++ for the pharmacy student that totally called it this episode! It’s about time House switched to a better narcotic. Taking the quantities of Vicodins (even the 5/500 strengths) that House takes is totally putting him over his maximum APAP dose/day (4g). Methadone is actually a pretty good choice since it has NMDA receptor antagonist properties which can be useful for neuropathic pain. Seems like he wasn’t titrating it appropriately. I was so happy when Cuddy decided to compromise and started a mini-methadone clinic just for House. I really wished he had stayed on it – but then again that would kinda be the end of the show as we know it. LMAO that House hired a hooker instead of a home health nurse. LOVE IT. Oh, and where were Thirteen’s gloves when she gave the boy an injection? Universal precautions anyone?
February 23rd, 2009 at 11:54 pm
“Pyrimethamine is not used alone to treat toxoplasmosis. It is given with a sulfonamide.” — Also need leucovorin :)
February 24th, 2009 at 12:17 am
Great episode, I really thought that Fox finally gave us the House we deserve!
Great review as well!
February 24th, 2009 at 12:18 am
I actually called House’s line “I’m choosing lack of pain over this job” right before he said it (since Cuddy set it up so obviously).
They dropped a lot of extraneous plot elements, like dealing with Cuddy’s baby, and Cameron and Chase disappeared altogether. I don’t know if that has anything to do with the fact that this episode was much tighter than the last few shows.
February 24th, 2009 at 12:51 am
Great ep, although all I could think about was Jeff Ross’ brilliant line: “Courtney Love is like the girl next door… if you happen to live next door to a methadone clinic.”
February 24th, 2009 at 12:57 am
By the way… wouldn’t the rational decision be to TRY the methadone treatment for a month or two, and know for sure if it truly did interfere with your diagnostic ability? Yes, I know that practically, that would interfere with the show’s dynamic, but in keeping with the logic-obsessed eponymous lead, surely you could try mentally reminding yourself to BE a jerk, rather than suffer through pain that CAUSES you to be a jerk. :)
February 24th, 2009 at 1:13 am
Gee, do ya think Gilligan et all will finally get off of the island?
Seriously, how many times must we revisit the tired old theme of…”House is different, out of pain, off the drugs, cured….oops, nope. He’s gonna be the same old flawed character. Psych!”
So, House being in pain is the root of his genius. Hmmm. I don’t buy it. I also don’t want him to be “nice.” I think I remember at some time in the first two seasons (”Three Stories?”) it was asserted that House was brilliant and an ass BEFORE the infarction.
Why must the creators of this show continually imply that there’s something to “fix” in this character? He’s far more realistic than most of the mamby-pamby do-gooder heroes on TV and in movies. Anyone see “Seven Pounds,” that movie with Will Smith? That character is one that needed fixing! Wilson needs fixing! (Although, at the end of a show last season when he was playing Amber and House and got them to do menial labor, I liked him a little). Cameron needs fixing. They’re all one-dimensional little twits. House is the only one who comes close to being realistic, but the writers just won’t let it be. Are we viewers so unsophisticated that we yearn for all characters to be Dickensonian?
February 24th, 2009 at 1:55 am
I read the comments, I watched the previews on fox.com and I was actually bemused by the idea that some of the people here trew in – that may be House found enlightenment, may be he found RELIGION. This is HOUSE for crying out loud! The only thing he is capable of finding is a better fix than Vicodin – and he did! The last two episodes were so classical House that I am finding myself in dreamland – I realy thought for a second that the show permanently lost it and will be cancelled eventally. There is hope there yet! Not much to say for this episodes medical mistery exept that I’m biting my ass off! In the “House challenge” I was sure that something simmilar would happen – a patient will come in with nothing wrong and they’ll make him sick! It was bound to happen with their shoot (medicine) first ask questions later aproach. However I tryed to be way more specific and I ruined it – instead of dehydration I said pannic attack and as end result instead of multi-organ faillure, I said allergic reaction. Does half a good guess counts? Damn it. My own nit-picking of the medicine in this episode is pretty much the same as D-r Scott’s. I’ll add just a few more ideas:
1. In the episode “Role Model” S1E17 when they discovered Toxo, they immediatly concluded AIDS. That would have been my conclution in the case with this kid – Toxo only occurs in severly immunocompromised patients. It is one of this things that a normal immune system tramples without even looking
2. Pulp Fiction anyone? Why on Earth did 13 do the same mystake as Kutner and stabbed the kid so mercylessly? May be I should send a video to the producers with a scene from ER or Grey’s anatomy to show them how you drain fluid from the pericardium?
3. Scleroderma has some external symtoms that can be seen on a physical right? Such as tight skin in certain places?
4. Since the whole thing with the contrast MRI was required for the plotline to work I won’t complain about the test beeing unnecessary? what I WILL complain is the parents givving advice for tests/treatments. Would you do a contrast MRI? Would you please put him back on the testosterone? In what freaking bizzaro hospital this is allowed? If you can treat yourself – don’t go to a hospital. If you are in the hospital – let the doctors do their mojo. It’s one way or the other – you can’t have both. I may be a little overworked here but I think I’m speaking from the name of every doctor here when I say there is nothing more annoying than a patient that comes in with a diagnosis and a treatment plan.
I enjoyed this episode immensly otherwise and they even managet to put a bit more interesting spin to the whole Foreteen boredom. House and Wilson outthinking and outwitting each other again and Cuddy doing the wrong thing for House again because she can’t handle him was classic and I thing the soap opera deseves a solid A again.
February 24th, 2009 at 2:05 am
In season 2 when House let Stacy go back to her husband, Wilson specifically accused House of trying to remain brilliant by remaining miserable. So this episode felt rather like a rehash. 13/14, Taub and Cuddy are just so uninteresting that they had to turn back to the real character for whom we watch this show.
I think they must be almost out of ammo on House himself to go back to old ideas. They had him almost lose his job, get shot, lose the cane, get the cane back, almost go to jail, detox numerous times, get taken hostage, etc. There’s only so much they can do with such a deliberately limited character.
I’m waiting for Fox to jump the shark and make a terrorists episode with House & Jack Bauer for a 3-hour mega-monday night event.
February 24th, 2009 at 2:07 am
Darn, I was hoping you’d address nipple-twisting as a way to make a patient start breathing again. Would that really work (well, at least the application of pain of some sort, not necessarily nipple-twisting specifically )?
February 24th, 2009 at 2:51 am
Madrian, Usually you’d go with a sternal rub since nipple twisting works well but is considered low-class, demeaning, and unacceptable (classic Foreman). It’s used for neurologic assessment .
February 24th, 2009 at 3:43 am
Good episode!! Some nice and very unexpected twists.
My only very small nitpick (besides that nipple thing burned on my retinas) would be that the House on methadone storyline would have been a bit less rushed (and give us 2 weeks full of speculation -> fun!) if they stretched it out over 2 episodes.
But I liked everything else, and it’s been a very long time since I could say that about a House episode. Even though it was a cleanly-shaven-dressed-in-a-suit-and-briefly-in-no-pain version, we got some good old House back! Yay for Liz Friedman!
February 24th, 2009 at 6:06 am
I’ve never watched the show. From your writeups, it seems that these fictional docs get so wrapped up in lab results they forget how to do a physical exam.
February 24th, 2009 at 6:52 am
I loved the Presidential trifecta: (1) The kid’s school was named after Franklin Pierce, (2) the kid was named Jackson, (3) the episode aired the day after Washington’s birthday!
February 24th, 2009 at 6:55 am
Having lurked in this great blog as well observed the complaints about the Foreteen for a while now, I have to bring up a theory I’ve seen about why Foreteen gets so much screentime in this season.
So, we have Thirteen, whose life has been turned upside down by her illness, and as a consequence she’s behaved self-destructively. When she does go and get help, she gets involved with Foreman. Foreman finds out that she’s been getting placebo instead of the real medicine and flips them without her knowledge. In other words, makes a medical decision that has a major effect on Thirteen. This is exactly what Stacy does to House before the series. Foreman and Thirteen are playing the roles of Stacy and House.
Also, notice how the Foreteen-storyline began to develop around the same time House/Cuddy-storyline began to develop. House has been obviously torn about the idea of a relationship with Cuddy, only he refuses to outright deal with it. Instead his advice to Foreman convinced him that he needed to do what he did behind Thirteen’s back and his advice to Thirteen convinced her not to be so unforgiving to Foreman. So in a way, he helped Foreman and Thirteen to overcome the problems he and Stacy weren’t able to deal with, and as a consequence their relationship survived. Then House began to break the two of them up, probably so that he could see what happens.. and if it’s worth for him to get involved with Cuddy, who was about to take him deeper into her life.
I have no idea if this theory is true, but this sort of thing has been done in fiction before. In Dark Knight, for example, Joker and Two-Face represented different kind of struggles for Batman, which is why their stories were the focus of the film; he developed as a character through them. And in my opinion it would explain why both the show and House himself have been so interested in Foreteen.
February 24th, 2009 at 6:56 am
This is the third episode in four weeks where the writers started something that could have been a decent multi-episode story arc, then blew it and wrapper the whole mess up by the end of the show:
* Cameron running the hospital
* Thirteen being sick
* House on methadone
Are the writers getting scared to actually write dramatic stories?
February 24th, 2009 at 7:14 am
I have a question for all of you doctors out there. When I saw the clinic patient sitting there with pain in 3 of 4 limbs, it was obviously the broken finger gag. Do things like that ever happen?
As for House choosing loosing some of his diagnostic ability without the pain, it makes sense at a level beyond a needed plot point. When he solves a case there is an obvious pleasure reward. Taking away pain could blunt that craving.
February 24th, 2009 at 7:50 am
I haven’t seen this episode yet but I am updated. I’ve seen episode 15 of season 5 already. So this new episode’s case is some kind of kid being a hermaphrodite? I can’t wait to see this one. Too bad I won’t be able to see it until Saturday.
February 24th, 2009 at 8:07 am
I enjoyed this episode. It wasn’t my favorite, but it was better than it has been. It kept me engaged.
Thirteen didn’t annoy me very much. I actually felt for her. Foreteen? Yeah, together Foreman and Thirteen are annoying. But Thirteen herself didn’t annoy me.
I thought the patient with the broken finger was a junkie looking for drugs. It was the way he kept saying “Ow.” Is it wrong that when he kept pointing out “It hurts when I do this. Ow.” that I said “Then stop doing that!”?
How do you break your finger without knowing? If he presses on his limbs with his other hand and they don’t hurt, wouldn’t that be a hint?
By the way, Taub forever has my love by his impression of Foreman on the happiest day of his life and on the saddest day of his life! I was laughing until I cried!
I did like that even though House was pain free, he still had a limp.
Kat
February 24th, 2009 at 8:40 am
Actually, it’s reasonable for them to miss the contrast agent reaction.
The contrast agents for MR are gadolinium based, which can cause nephrogenic systemic fibrosis(NSF), but it’s only been observed in patients with some level of compromised renal function. Given that NSF has only been an issue in the last two years or so, I’m not sure what the overall screening policies have become–I’m an MR researcher, not a radiologist–but to the best of my knowledge, most places DON’T routinely check if they have no reason to suspect compromised renal function.
February 24th, 2009 at 8:54 am
Also, did anyone else hate the PotW’s mother? I wanted to slap her every time she said something about Jackson “Not being ready.” It looks like someone besides Jackson needed to grow up. I couldn’t figure out why his parents just didn’t tell him. House was right–just because the kid was born “a freak of nature” didn’t mean that he needed to be treated like a “freak.”
Poor Jackson. No wonder he was so confused.
Kat
February 24th, 2009 at 9:18 am
Are there a lot of schools that teach Sylvia Plath to kids of that age?
What is the ethical choice here? Isn’t this kid old enough to have some say as to what medicine he takes?
February 24th, 2009 at 9:28 am
It can be that the parents were overprotecting Jack, BUT it doesnt mean that Thirteen had any right to try to reveal the boy’s real condition, after all, it can’t be easy to know all of a sudden that you aren’t what you thought you were your whole life. It can cause too many problems, and It wasnt for Thirteen to decide when it was the time to tell him the truth. It had to be done with therepists indeed, and when the father asked her for a therapist in the hospital, (which would be the best thing to do), she didnt say anything, recommended anyone, she just assumed that maybe it was time to tell him (or her) the truth. Like if 13 was any therapist or anything.
I was also disappointed that the House issue wasnt taken further. It would have been nice to see him being “nice” for another while. And whoa, I didnt know he could be so handsome wearing a tie!
It seems that the more I read the reviews, more flaws I find on the episodes, haha, thank you Scott for opening my eyes! It was really annoying to see Thirteen AGAIN blindly jabbing the needle into the patient’s chest.
Ah, ok…Maybe I just dont like Thirteen, I miss Cameron…
Thanks Scott for another great review!
February 24th, 2009 at 9:28 am
It was an amazing episode….god, Hugh Laurie is just…GOD
February 24th, 2009 at 9:28 am
The more I think about it, the more I’m wondering why they used contrast agent in the first place.
MR has excellent contrast between soft tissues on its own, without the use of contrast. That’s one of the main reasons it’s used. Again, I am not a radiologist, but I know that in general T1 images are used for looking at anatomical features. MR contrast agents are most commonly used when there’s some vascular component–tumor angiogensis, blood-brain barrier damage in MS, angiography, etc.
The uterus is very muscular, and generally muscles don’t take up much contrast agent. (Presumably the placenta wouldn’t be an issue, because, well, the patient wasn’t menstruating). I don’t see what would be gained by the use of contrast agent–is there a radiologist in the blog who’s ever looked for a blind uterus?
February 24th, 2009 at 9:31 am
Agreed, Wendy. I got chills when he tossed away Little Greg (hee!) and said that the methadone doesn’t help with the pain, it eliminates it.
But, then again, I freely admit that it’s Hugh Laurie and Hugh Laurie only that keeps me coming back week after week.
Kat
February 24th, 2009 at 9:41 am
As usual, skipping the routine tests before preparing someone for an MRI ;) We get requests at the lab when someone is scheduled for any procedure involving contrast, the radiologists really do ride on them.
Great soap opera this time around, though. The lesser focus on Foreteen was nice, as I still feel that it came out of nowhere and just doesn’t belong.
And a big A+ to the clinic patient, haven’t seen one of those in a while.
February 24th, 2009 at 10:02 am
I too found the school Sylvia Plath assignment quite disturbing. This kid looked to be in middle school, which I would think a tad early. My own kids in high school had some quite depressing book assignments, but middle school?
When parents are told their child is intersex, I believe they are usually advised to give the child a gender-neutral name even if they’ve decided on the child’s gender. I think “Jackson” is too masculine, although it is reflective of these particular parents’ decision to manage their child’s sexual identity.
When House stopped breathing in his office, I flashed on a line from the delightful movie “Galaxy Quest”: “I see you managed to get your shirt off…”
I too think the methadone storyline should have been stretched out to two or more episodes. The clean-shaven, gentler House was a refreshing take on his character, and should have been explored more. How did a pain-free House view Cuddy? They should have had more time together.
—Kimberley
February 24th, 2009 at 10:06 am
The solution this week was a real kick to the head for me. In 2004 my father had a stroke. He had a reaction to the contrast agent in the hospital, which led to renal failure, sepsis and death. I certainly wasn’t expecting to see that in House.
I also was surprised at the Sylvia Plath thing. I went to a really good high school and we didn’t get anything that high level and misery inducing until at least sophomore year.
February 24th, 2009 at 10:21 am
I enjoyed this episode so much I was holding my breath for all the snarky comments I assumed would be coming on this site. Thank God I was wrong. It appears the writers read them too are have been making an honest attempt to address them, given the difficulties of coming up with fresh ideas for a fifth-season show where the medical and character constraints and expectations are so high. Conan Doyle himself ran out of fresh ideas eventually. External factors like network priorities, the actors’ strike, world and national economic pressures, and competing programs also enter in whether we like it or not. This is the ultra-conservative Fox Network, don’t forget.
February 24th, 2009 at 10:48 am
Thank you,Scott, for your great review and for your clarity in explaining the medical issues.
House practiced medicine before he had his injury and pain issues. Presumably he was pretty good since he had the same job he still holds. Why does he assume that being pain free would permanently make him a worse diagnostician? I would have assumed that his normal, cranky personality would have emerged once he acclimated to being in a pain free state.
February 24th, 2009 at 12:01 pm
House had clinic duty, finally!!! I’m so glad to actually see house again!!!
February 24th, 2009 at 12:45 pm
I was sure the clinic patient just had a case of Gamer’s Limbs, or whatever it is the kids call it these days.
February 24th, 2009 at 12:52 pm
No, I guess the guy with the broken finger was just an idiot, and the writers actually wanted to say that even someone being an idiot couldn’t spoil House’s good mood, or in other words, he HAD to be sick or under the influence of sthg really heavy…
February 24th, 2009 at 12:53 pm
Reminded me of the movie “As Good as it Gets”, when the Nicholson character tells the Helen Hunt character that he is taking his pills because she makes him want to be a “better man”. More than the pain, was House trying to be a better man for Cuddy? Should we forget the serenade in the last episode?
February 24th, 2009 at 1:26 pm
Did they actually say that being in pain makes him a better thinker? I assumed that somehow the Methadone screwed up his cognitive abilities — he wasn’t losing his intellect because of the lack of pain. He was able to think fine when he was pain free (and limp free) after the Ketamine treatment.
February 24th, 2009 at 1:42 pm
Rob, your comment started an idea in my head, what if House does stay on the methodone, but tmaybe after next week we’ll find out that he lied to cuddy when she wanted to provide it for him as he didn’t want her doling out his pain medication. (Which has normally caused him to suffer in the past) For a character like House to stop taking pain meds that actually works just cos he humoured a patient.
He knew the mri was a mistake yet he didn’t do it anyway, surely he should just make a mental note not to do unneceswary procedures.
After that little rant i’d like to mention one more thing… House normally has a rule of if its a simple idea, another doctors looked for it before he got the case, this allows the writers to constantly look for zebras rather than chasing horses. This rule is the reason he discounts 13s idea of a blind uterus, surely the admitting doctor would have checked for dehydration before passing the case on to the diagnostics department that ‘takes on cases that no other doctor can solve.”
Did like House back in the clinic though
February 24th, 2009 at 2:36 pm
Why would house throw out his cane? I am both a collector and a user, and own the cane in question–it costs at least $95.
February 24th, 2009 at 2:41 pm
the handle is topped with buffalo horn
February 24th, 2009 at 2:42 pm
I loved all the Wilson in this episode and of course the House/Wilson date and fight night out.
The Clinic patient was fun. 13’s interactions with the atient were good. I hate Foreteen with a passion – it;s visually unappealing.
I loved that House chose his brilliance over his happiness. Unshaved – HL looks totally British and unsexy.
February 24th, 2009 at 2:51 pm
The two things I dislike about House this season are both about his 4 lackies:
a. They constantly jump to the conclusion that the patient’s problem is due to some personality flaw (drug abuse is the big one)
b. They lecture the patient about what a bad person the patient is. What the hell? If my doctor treated me like that, I’d knee him/her in the groin. If I’m sick, I don’t want Taub telling me what a bad father I am. Little weasel…
February 24th, 2009 at 3:01 pm
I really want to get that image of Foreman twisting House’s nipples out of my head…….
February 24th, 2009 at 4:22 pm
Please forgive my obsession with the narcotics, but a lot of the information given in this episode contradicts what i know of methadone:
House describes it to Wilson as ‘Heroin without the high”. My understanding is methadone being an oral narcotic it gives a much softer, long term ‘high’ then the rush of injected heroin, so to a needle freak it seems like ‘no high’ in comparison, but to someone used to taking weaker oral narcotics like vicodin, it should be a strong high, especially if he dosed high enough to supress his breathing like that.
Secondly, methadone should be weaker then injected morpheine, which House was taking for his pain in season 3(?) and it does not make sense that methadone would miraculously clear up all pain that other narcotics, including stronger ones that all work pretty much the same, cannot.
Or are there some special analgesic properties to methadone alone that I am not aware of?
Oh yeah, the show. Much better then the last few epsisodes! Glad to see the focus back on House and less on Foreteen of late. I wish the ‘pain free House must choose’ story could have been streched out into at least a 3-part arc, instead of resolved at the end, but oh well.
February 24th, 2009 at 4:31 pm
“so to a needle freak it seems like ‘no high’ in comparison”
I should clarify, I make this comparison because Methadone is most often used in detox clinics to wean injected heroin users off of the heroin, and eventually off of narcotics period by successively lessened doses.
February 24th, 2009 at 5:09 pm
I happened to catch a rerun of one of the very first episodes of House (Paternity) on USA, and the much more understated performance of Hugh Laurie in last night’s episode is markedly closer to the early House M.D. I found it most refreshing. Perhaps the writers will learn a lesson from their own work and avoid recreating the House who brays that he needs a fellowship candidate to bring him the panties of Dr. Cuddy (how that made me wince).
Not that I would prefer a shined-up, conventional House. Just one whose complexities are explored, rather than giving in to lazy writing that renders him a cartoonish caricature of the House of the first two seasons.
Thanks, Scott, for clearing up the issue of whether Methadone is frequently lethal. I used to be a social worker and incidentally had some clients who used Methadone. I was beginning to wonder if I should have been waiting with baited breath for them to drop like flies around me (which never happened).
Boy, do they ever now enjoy writing in a blind overhand cringe-inducing chest jab for a cardiac tamponade. Don’t try this at home, folks.
Was anyone else amused when a possible diagnosis was “SLE”? Lupus! “It’s not lupus” used to be a running joke on the show. I was amazed that they didn’t make it obvious that they were adding to that canon.
Also a Cuddy performance in this episode far above what the writers have been giving her lately. For once she seemed mature, calm, reasonable, and insightful, kinda what you might hope for in a hospital administrator, rather than the indecisive, somewhat scattered-brained, but occasionally brutal Barbie Goes to the Office version the writers had forced on her most of this season.
Too bad the writers got nervous and nipped these developments at the end of the episode.
February 24th, 2009 at 9:34 pm
Final comment: They must have put Cuddy into this week’s outfit when she was young, then let her grow into them. They had to be cut off after filming.
February 24th, 2009 at 9:47 pm
I have congenital toxoplasmosis, and had a recurrence when I was 14. It is possible that they suspected he had a case of congenitally contracted toxoplasmosis and was having a recurrence, although I’m not sure how they’d tell that from a water bottle. Recurrence can occur in people with otherwise healthy immune systems, and generally happens around the early teens. It can be activated by intense stress, puberty, or anything else for that matter. Recurrence afterward is unlikely, but still possible.
A simple blood test should be able to tell what’s going on though, and usually acute toxoplasmosis is detected early on because it usually causes eye and neurological problems first.
Acute toxoplasmosis is usually treated with sulfadiazine, daraprim, and leucovorin in combination. The leucovorin is used because daraprim has a tendency to cause pancytopenia and other lovely side effects. Starting it without a positive diagnosis is a pretty bad idea.
February 24th, 2009 at 10:35 pm
Very good review, BUT I think that the soap opera deserves A+!
February 24th, 2009 at 11:21 pm
Best line of the episode: Wilson to House: You’ve got *two* ties?
February 24th, 2009 at 11:29 pm
Good stuff. I was disappointed to see House shaving with a lil’ 50 cent throw away razor. He can do better then that…
February 25th, 2009 at 12:46 am
Am I quite wrong or was the reason for not doing an MRI in the beginning that “a dozen of previous doctors had already done it”?
And when the parents showed up and asked for it, wouldn’t that imply that they would need to do an MRI (or ultrasound for that matter)?
And the sole reason for House coming off the new drugs was this call? Did I miss something?
February 25th, 2009 at 1:43 am
One nice touch that I noticed is that House doesn’t use his cane when he leaves his dinner with Wilson. He just carries it out.
February 25th, 2009 at 1:44 am
Unrelated but im just wondering.
Which episode is the one where House needs organs out a a recently deceased car crash (?) victim and the spouse doesnt want him to take them.An exchange happens in which House says something along the lines of “Dont punish her, punish me” the spouse replies “OK” and kicks him in the nuts.
Which episode is that from?
February 25th, 2009 at 1:46 am
C’mon, the soap opera deserved better than that.
Yeah yeah yeah, they did the “what if he manages his pain” idea a couple of times (I would call a recurrent theme the sign of a consistent character, not the wild-personality-changes-every-season-to-stay-fresh psychiatric disorders that plague so many shows). But I think you people are underestimating methadone.
That is some heavy shit.
And it should be noted that this pain-free House was not the jogging-every-morning chipper face from the beginning of season 3 – this was a numbly focused House. It’s not a “cure” (like before), it’s a lesser-of-two-evils call, with the price being lesser-of-everything-else-too. I figure this is why House thanked Cuddy for keeping him at her hospital and on a tight leash. He’s a “functional addict,” but on some level he knows he’s self-destructive and needs friends like Wilson and Cuddy.
Otherwise, he wouldn’t care why Cuddy cares that he’s happy.
I would’ve liked to see less Rocky Road metaphors (I get it, they’re doctors, they’re smart, blah blah blah I don’t care about their personal philosophies about life, the universe, and everything unless it’s relevant to the plot). Instead, it’dve been nice to get a quick quip from Cameron/Chase. Chase, at least, is getting some overdue recognition.
I agree about the short “arcs.” I was surprised when each of them were dropped in just a single episode. Do they think viewers are so bored they need to be yanked, not enticed, into dazzling new things? (Or, worse – are they right in thinking this?)
Thirteen getting a brain tumor and having it cured was a bit much for one episode. The methadone “arc” wasn’t as egregious, but it sort of fit – since methadone-House is pretty boring, though not without wit.
Still, I would have liked it to end with the usual brooding shot of House, probably holding his medicine cup and staring just off-camera in a mid-close-up. After all, none of the team even knew about the methadone. Don’t the writers usually like to subject us to each young gun’s attempt to play shrink for House whenever he undergoes a change?
I thought it wasn’t just about House’s brilliance being caused by his pain. You’re all missing the point, which is a little surprising since Cuddy explicitly and succinctly (if cheesily) explains it in that scene – and, as someone else brought up, it was mentioned in season 2, also.
THAT. That is the House we love. It’s not just a trade-off between smarts or happiness – Cuddy even says that “House doesn’t do happy” in this episode. Wouldn’t you have been trained better by this point than to fall for all of House’s partial deflections?
Not being a doctor, I didn’t pick up on the broken finger. I was waiting for another joke about druggie/trendster college kids – notice he was holding an iphone in his other hand?
WIlson’s line about having two ties is another reminder of why he’s the second-best character on the show, though Cuddy’s a close second.
I liked that they didn’t make gender identity a binary between dancing and sports, though they skirted close to it.
Why didn’t 13 bring up her own gender identity growing up? That seemed like the perfect spot to drop it. And much as I like pretty much any casual depiction of non-straight characters outside of shit like Queer as Folk (or whatever’s on nowadays), I’d like for them to explore that part of 13 beyond just House-is-horny jokes. At least once, y’know?
Man I love that Wilson tie line.
February 25th, 2009 at 3:16 am
My comment came out as anonymous 10x to a bug I picked in my PC. Completely forgot the clinic patient and while fun (that’s a classic d-r’s joke) it isn’t unbelievable. One of the tag lines in the show is how people are idiots (and by House’s standard a lot of them not just the few he encounters in the clinic). While cynical it is actually amazing what kind of problems people are coming to see me for from time to time. The most blatant case for me was a young couple with the lady having a small lesion on her gingiva. She came to me after 3 other dental consults a bunch of X-rays already done and fear of cancer. It turned out that she punctured herself with a fish bone couple of days ago. She nearly cried after I solved the “mystery”
February 25th, 2009 at 4:33 am
“I did like House’s realization that he can’t be the brilliant diagnostician he wants to be if he’s not in pain.”
Why do you think that he has to be in pain? Are “brilliant diagnostician” and “painless” mutually exclusive?
February 25th, 2009 at 8:04 am
Even though he may have been hallucinating at the time, House did suggest in an earlier episode he could function perfectly well because he was on morphine.
February 25th, 2009 at 9:42 am
My favorite line is “This is the only me you get.”
We don’t really know that House was a “genius” diagnostician before his infarction, just as we don’t really know what he was like before.
Cuddy called him a “good” doctor, and I don’t doubt that in any way. She also said of him that he was already a “legend” while she was in college. Somehow, being a “good” doctor and being a “legendary” doctor don’t seem to go hand in hand. However, since she didn’t actually call him a “legendary doctor,” it might be safe to assume that she wasn’t meaning his skills as a doctor that made him a legend.
At least, in my opinion.
We do know that he screwed up at least one case before his infarction–that of Ester’s (Esther’s? The episode itself couldn’t figure out her name). He’s haunted by that case.
We do know that only Cuddy was able to hire him. Now, that’s probably because of his personality more than his skills as a doctor.
It also seems to me that House’s first few diagnoses in every case are wrong. If this were real life, he really wouldn’t be classified as “brilliant.”
Now, I know that people don’t think with their legs, but my point is that we don’t KNOW that he was a brilliant diagnostician before his infarction. From what the show has given us, he may have been and he may not have been.
(Incidentally, we also don’t really know the type of person he was before his infarction. We can safely assume that he was very similiar to how he is now. This is brought up by both Stacy and Cuddy, except they agree that he’s worse now. Only Wilson seems to give us some idea of how much worse House is now.)
I may just be rambling, but my point is that we really don’t know the man or the doctor before his infarction, so we can’t really judge how he was before his leg. What glimpses we have been given is often contradictory.
Kat
February 25th, 2009 at 9:44 am
While it was nice to see Wilson and a clinic patient… like musing girl this seemed to me a rehash of the in-pain-he’s brilliant, pain-free he’s ordinary theme that has already been thoroughly explored. The other thing is that ordering the MRI just because the parents wanted it really *isn’t* sufficient evidence of non-brilliance. After all, he’s ordered dozens of treatments that have done far worse things to patients in the course of the series and made many worse mistakes that have come far closer to killing the patient.
Damn. I know what the show should have done. House should have instructed the minions that they are to be the miserable SOBs he now is not and stop him any time he starts to do anything compliant.
wg
February 25th, 2009 at 9:57 am
Oh, I also want to add that right now, in House’s mind, painfree=unclear thinking. House thinks he’s more focused when he has pain.
Now, completely unbearable pain is different.
In Meaning, he was painfree, and he solved the case brilliantly. However, thanks to Cuddy and Wilson’s scheming, he didn’t know that he solved it until later–when he was hurting again.
He seems to have forgotten about that.
Kat
February 25th, 2009 at 10:12 am
I agree that pain doesn’t make House a better diagnostician. When Cameron asked Stacy Warner how House was before his leg problem, she said that he was pretty much the same. Cuddy said that House was already a legend in medical school. His being less observant and insightful is more easily explained by a transitional mellowness resulting from the cessation of years of pain. He’s cranky enough to get back to normal–attitudinally, diagnostically, and intellectually–in a couple of episodes.
February 25th, 2009 at 11:01 am
The clinic patient is totally believable. Some people really live in stone age when it comes to health issues.
Authentic dialogue from line in pharmacy few days ago:
Customer: I would like to purchase a pregnancy test.
Pharmacist: Of course… blablabla price…
C: The thing is just I don’t really know how to use it.
P: Well you take this strip and soak it in your urine, best use a little jar or something.
C: Urine? Can I also buy it here?
February 25th, 2009 at 11:23 am
At least they brought in a new “House is doing clinic” scene. Those have been getting less and less frequent with each season.
February 25th, 2009 at 11:53 am
The clinic patient with the broken finger.. That joke is older than me, but it was great to see it performed by House.
I knew that House did not have pain when he walked away just after he “cured” the moron with the broken finger… He walked away and wasn’t using the cane.
Great Episode…, great review.
Heishiro
February 25th, 2009 at 12:58 pm
@Kamik…..Wilson knew that House had at least one tie (his date with Cameron), and remember when House was allegedly in the chemical dependenxcy awaiting trial, Wilson BOUGHT House the red tie!
I’m just hoping the “Foreteen” saga doesn’t turn into an arc ala House/Stacey, House Vogler, or House/Tritter. I know House wouldn’t agree, but too much soap opera IS a bad thing!
And I felt the methadone premise started out intriguingly but came to a fizzled-out, too fast, unsatisfying ending.
February 25th, 2009 at 2:26 pm
Also good to note: If you dance, that’s because of your girl genes. The opposite is true for basketball! A lesson to all male dancers I suppose.
February 25th, 2009 at 3:03 pm
When House was pain-free in the beginning of Season 3 “Meaning,” House was still able to come up with a brilliant theory that improves the condition of the patient (Richard McNeil) who has Addison Disease. Hmmm, I smell contradiction.
February 25th, 2009 at 5:32 pm
What is in energy drinks? Does the term refer to solutions of sugar and electrolytes, or something else? Which ingredients could cause problems (presumably in very large doses)?
February 25th, 2009 at 6:21 pm
How come no one mentions how strange it is that he was taking Methadone in liquid form, at least that’s what Cuddy brought him. I give them props for getting the liquid the right color, but didn’t that seem strange to anyone else? If he was still titrating, ok I could see that possibly, but it still doesn’t make much sense.
February 25th, 2009 at 7:12 pm
I kind of noticed how House was swinging his cane and not walking with it when he was walking out of the clinic room… I kind of just chose to ignore it until I realized he probably did that on purpose when I knew he was on methadone
February 25th, 2009 at 7:46 pm
I enjoyed this episode, too. Thirteen seemed almost human, and I barely even puked in my mouth while fast-forwarding through the Foreteen interactions.
February 25th, 2009 at 10:07 pm
Isn’t methadone actually far more addictive than other painkillers? I remember reading something about it being more addictive and having far worse withdrawal symptoms.
February 25th, 2009 at 10:42 pm
To Willias: the episode you refer to is “Sex Kills”, season 2 ep. 14, if I’m not wrong. Great episode, BTW.
February 25th, 2009 at 11:41 pm
“When House was pain-free in the beginning of Season 3 “Meaning,” House was still able to come up with a brilliant theory that improves the condition of the patient (Richard McNeil) who has Addison Disease. Hmmm, I smell contradiction.” Not quite! He started feeling pain halfway through the episode and he found the answer while he was in pain (it was more an emotional pain because Cuddy at that point decide that since she cured him she can now make him do whatever she wants. They were teaching him humility at the moment together with Wilson – and that hurts for everybody especially for someone like House.
February 26th, 2009 at 10:02 am
The show used the term “mosaicism,” but isn’t that a little general? More specifically, the term would be “tetragametic chimerism,” because the child was the result of a fusion (in the embryonic or pre-embryonic phase) of a female (XX) and male (XY) gamete. Granted, they already used the term “chimerism” in one episode, “Cane and Able” (season 3, second episode), so maybe they didn’t want to re-use it (though that situation involved a slightly different form of chimerism).
Also, I would have enjoyed seeing a visual representation (as we often do) of how the condition comes into being, even though it was introduced at the very beginning of the show as the red-herring. I find the topic interesting because I did a paper for my civil rights class (in law school) involving tetragametic chimerism. In fact, it would have been more interesting had we not been told of the condition right off the bat … let the lie fester for a half-hour or so instead of making it the central theme of the episode.
February 26th, 2009 at 1:59 pm
I think Mr. Brett nailed the pain/jerk/brilliance bit.
Just wondering about smocks and lab coats. Are they to protect the clothes of the care-giver or is it a bit of fashion vestigiality akin to King’s Court Judges wearing powdered wigs?
February 26th, 2009 at 5:04 pm
Finally I get the chance to congratulate you for your amazing reviews!
I am a lurker for the most part, and have never posted being to not sound as smart as most people here xD. I enjoyed this episode, but I do agree that they should’ve stretched the methadone plot a bit more. This would have given us an intriguing episode ending, and would have also kept us in suspense for a few weeks.
February 27th, 2009 at 1:23 am
It’s not strange that Cuddy brought him the liquid formulation of methadone. It’s used as an oral liquid in methadone clinics (to ensure patients aren’t cheeking it), & it’s often cheaper that way too.
Scott, Nice call on the finasteride mechanism of action. What would have been better? Degarelix? Leuprolide?
February 27th, 2009 at 2:18 am
Hang on a sec… a pain patient given methadone would NOT have weekly drug tests and each dose given and supervised by a doctor or nurse.
In methadone treatment facilities, people who have been on heroin or other illegal narcotics are given methadone to replace the illegal drugs. Because they are addicts receiving the meds to help them get off of their drugs they are required to submit to stringent controls. They are given each dose by a nurse who makes sure they put it in their mouth and swallow. And they are given regular urine tests (weekly sounds right) to make sure they haven’t relapsed and aren’t abusing the system.
In contrast, a pain patient who is switched to methadone for long-term chronic pain management signs an agreement that makes clear the responsibilities of both patient and physician, and is given a bottle of pills and only gets tested whenever the doctor feels there is a need.
It seems that House should be in the second category. Why is he being treated like a heroin addict coming down off the drugs rather than a pain patient receiving long-term pain medication that are for the first time controlling his pain?
February 27th, 2009 at 2:26 am
Also, I’ve been wondering about this since the first episode I saw. How is it possible that House has been on vicoden for four years at the dose level he is at? The narcotic in vicoden isn’t a problem, the acetaminophen is. Every pill of vicoden he takes has 500 mg of acetaminophen in it, and he was taking two or more pills each dose, right? That is a thousand mg or more of acetaminophen each dose. And I somehow think he was taking more than four of those doses per day. 4000 mg is the maximum daily amount of acetaminophen you can take a day, more than that will trash your kidneys and liver over time, and more than 7000 mg in your system should put you in acute liver failure. So how is it possible that House has been doing this for years with no adverse effects?
February 27th, 2009 at 3:21 am
Gee, they’ve stabbed so many people into the chest with syringes on this show – I wonder how many people are out there right now, jabbing away because they think that’s a normal first aid practice =;-)
February 27th, 2009 at 3:55 am
Mani,
Thirteen’s gender identity hardly has anything to do with her bisexuality. I always thought she was very confident as a femme — no sign of gender confusion there. What exactly connected her to Jackson, in that regard?
February 27th, 2009 at 4:50 am
the episode really jumps around too much, the list of symptoms doesn’t match, rather, a more knee-jerk approach was adopted – when they found gastric fistula, Thirteen immediately jumped upon Zollinger-Ellison Syndrome, and completely ignoring previous episode of cardiac tamponade. And there is confabulated concept where steroid improves LFT indicates it should be renal failure instead.
House’ final arrival at contrast agent induced multi-organ failure is anything but psychic. Assuming renal protective N-acetylcystein and sodium bicarbonate are not used prior to MRI scan, there shall be at least some renal function test pre-MRI – which would reveal the dehydration state.
And just how incredible that throughout the entire differential, not one single renal function test was performed/examined? Simple blood test would have revealed renal failure pretty early during the differential, esp when liver function test is taken. – If I practice my medicine like what House team did, I would not get one patient diagnosed.
Less medical, more drama, is this where House is going?
February 27th, 2009 at 6:21 am
That clinic patient was the dumbest ever in the history of dumb-clinic-patients that showed up in House. “It hurts when I put pressure here… ouch… and here… ouch…. Thanks, dude!! [rock on]” I literally rofl’d – I fell to the floor laughing!
February 27th, 2009 at 11:07 am
I think previous commenters here have nailed it — the early part of the episode was great, but winding up the methadone story within 42 minutes of story time was bizarre. It would have worked better as a three or five story arc, perhaps longer.
I also liked that the old team was completely left out. The story moved forward cleanly with fewer characters, and the new team is interesting enough to support the show.
Taub and Kuttner remind me of the thieves from The Hidden Fortress (or, in a bit a stretch, R2D2 and C3PO). I think they may be my favorite characters on the show.
February 27th, 2009 at 3:34 pm
Ahem ,
I know I’m not who you directed this question to but I think there is a relation, since Jackson said that he thought he liked a buddy of his like more than a friend.
February 27th, 2009 at 4:27 pm
Loved this episode: very old-school. I skimmed the comments here, so sorry if someone already mentioned this, but did anyone notice that the final shot, of House walking away from Cuddy, was an exact match of the shot of Wilson walking away from House at the first episode of this season? What exactly were the writers/director trying to tell us here?
February 27th, 2009 at 5:49 pm
Impact of House on Google Searches
http://www.manu-j.com/unplugged/articles/impact-of-house/10/
February 27th, 2009 at 6:06 pm
bring the beard back.
February 28th, 2009 at 9:37 am
I don’t know if anyone else feels this way, but every so often I think to myself that I’d just like to see House act like a normal human being once in a while: treat people decent, be in a good mood occasionally, and don’t be such a non-stop caustic, sarcastic sob all the time. (Especially some of the stuff he says to Cuddy: really makes me wince.) This episode provided that fix. I’m fine now and am all set for House to be House again.
February 28th, 2009 at 2:12 pm
I have a silly question. I am sure it has been asked and answered already, but I can’t find it.
House takes Vicodins constantly. While I understand that codeine addicts can down astonishing amounts of the stuff and not die (just like you can have chronic alcoholics with BACs at 0.5 and they’re not even close to being dead), how do the writers get around the massive acetaminophen overdoses the character gives himself on a daily basis? He is not merely just taking massive overdoses of this drug, but he regularly combines Vicodin with alcohol. Acetaminophen and alcohol nukes the liver even worse.
What’s up with this?
February 28th, 2009 at 5:55 pm
Oh, and another question that might be kind of stupid. When someone goes into cardiac arrest and either needs CPR or the paddles (sorry, don’t know the technical name for them), what are the odds they are cognitively going to end up in the same shape they were beforehand? What are the odds they are going to survive to leave the hospital?
March 1st, 2009 at 1:35 am
Karin (and Kali before you), you are both 100% right about the toxic side effects of Vicodin. Of course there was this episode with the girl with CIPA where House himself mentioned: “I have to check my eyes every morning for jaundice to see if the Vicodin didn’t finally shot my liver”. So he is aware of the risks and I suppose your comparison is spot on – he is like an alcoholic – wich means that he gradually got used to the increasing amounts. That doesn’t mean that he is safe of course. And I just thought – what if they make later a story arc where House suffers chronic liver failure and needs a transplant? May be Cuddy or Wilson will be a match? That would be interesting…
March 1st, 2009 at 1:41 am
Side effects for Vicodin are most commonly upset stomach, nausea, constipation, and altered mental status (eg. dizziness, light headedness). Other more rare side effects include allergic reaction, seizures, clammy skin, severe weakness, dizziness, hyperventilation, unconsciousness, jaundice (yellowing of eyes or skin), unusual fatigue, bleeding, bruising, stomach pain[4], constipation, dry mouth, decreased appetite, muscle twitches, sweating, hot flashes, itching, tinnitus, hearing loss, decreased urination, and decreased sex drive.[5] Vicodin also has depressant effects on the central nervous system.[6] However, some of the less mundane effects can be desirable effects that are sought after by some. Those effects include euphoria and drowsiness, as well as slowing of the pulse.[7] Vicodin may also be a cause of stomach ulcers, although this is assumed to be due to the addition of other non-narcotic analgesics to hydrocodone preparations (e.g., aspirin, and ibuprofen). Unlike NSAIDS, Paracetamol does not cause ulcers. However, severe liver damage can occur in patients consuming more than 4 grams of acetaminophen per day. This liver damage can range from abdominal pain to outright liver failure, and can necessitate a liver transplant to avoid death.
As for the cardiac arrest questions the chances are directly dependent of the reason for the cardiac arrest. So if he had a heart attack for example (a myocardial infarction) that depends from the amount of dead muscle and the overall shape of the patients heart (healthy, non-healthy). Remember Amber and the way she died? Or the other patient in “Control”. If a heart that is severely structurally damaged stops it stops for good and nothing you do will help
March 1st, 2009 at 1:52 am
Hmm. I wonder if Hugh Laurie was having issues limping around everywhere again (that was apparently the cause of the Ketamine storyline– Laurie was supposedly developing leg pain from being House.) I really did think this was going to be a multi-part storyline, though… leading up to a possible *terrible disaster* for House in the finale. I mean we’re… what, eight episodes away now? Ah well. I hope they keep doing more like this, anyway– it was a good episode, despite the sort of random case mystery. (”Oh wait it was our fault all along.”)
March 1st, 2009 at 1:55 am
Karin– I was just reading up on CPR, and its actual effectiveness is really, really low. It’s something like 5-10% for CPR only. If you can get defibrillation (paddles) within a few minutes, the survival rate goes up to maybe 30%. It is by no means the instant cure that TV/Movies show it as. D:
March 1st, 2009 at 2:56 am
I didn´t like this ep very much (again) while we saw kinda case I´ve been waiting for – missing a simple diagnosis because of hunting zebras.
1. Energy drinks are sure harmful because of the amount of sugar, caffeine and other stuff they contain, but can they really trash one´s kidneys thar way?
2. House on methadone? Wow! But if he decided to deal with his Vicodin habit, why that way. I guess lowering the doses or at max. buprenorfine would be better. Methadone is usually saved for severe heroine addicts and only special centers can administer it. But I´m not from US, maybe it´s different there. Sure this could have been a multi-ep story arc.
3. House without Vicodin wouldn´t be the House we know, and this is the only reason why the ketamine treatment didn´t work for long and why he cheated and quit his rehab.
4. House needs pain to function well, but just a certain amount. Yeah, true, he actually solved the case in Meaning, but he thought he didn´t. And remember Finding Judas? House was experiencing so much pain he couldn´t think logically and didn´t solve the case, Chase did!! On the other hand, remember Detox, but he was off Vicodin voluntarily that time. Maybe it´s all just in his head???
5. Painless House always acts nice, but shaving and tie? Wow!
6. The moron with the broken finger was a typical clinic case for House, but House didn´t treat him his typical way. I´d sware he was faking but my sister said “he´s got a broken finger, yeah” and she was absolutely right about this classical joke.
7. Some people are very resistant to some toxic effects of different stuff, maybe House is resistant to acetaminophen toxicity? True, never heard about a case like this. Liver failure story arc is a great idea, but you wanna see House sick again?
March 1st, 2009 at 5:21 pm
Anonymous, while House might be able to withstand the increasing amounts of codeine he consumes in the Vicodin, I don’t think you can increase your body’s tolerance for acetaminophen. Or can you? I would love to hear what a doctor had to say about this. I mean, House walks around popping Vicodins like candy — and it’s part of his character. Why isn’t his liver completely blown?
March 1st, 2009 at 7:03 pm
Okay episode, although I was screaming for an U/S from the beginning. The thing that really bugged me was this: I know that they’ve been doing this illegal home invasion thing for a while, but if some doctor came into my hospital room and said “I found this really emo poem under your bed, let’s talk about it” I would be seriously, seriously freaked out. How was that kid so calm? Second, I agree that the Sylvia Plath assignment was just… weird. I mean, obvy it existed to be a giant plot point, but damn, what assignment does this kid have next? Suicide letters? If anybody had written anything like that at my middle school, it would have been a 1-way ticket to the guidance counselor, no doubt. Just… weird.
March 1st, 2009 at 9:30 pm
This was the worst episode in two seasons. Do the writers even try anymore? They have absolutely no idea what any drugs are actually used for… they’re just rehashing the same old crap over and over. In reality, House would have been in pain management a long long time ago, not “gosh let me wreck my liver by popping tons of APAP all day long.”
I’m a chronic pain patient. Pain interferes with concentration and memory and attention. It doesn’t improve it. Lack of pain does. If I found some magical drug that took away my pain I wouldn’t care what else it did.
This show used to be so good. The first two seasons were awesome. It’s like a relationship that starts off amazing and then spirals downhill but you don’t want to leave because you’re already in love: it can only end in disaster.
March 1st, 2009 at 10:34 pm
Good point, Karin, about the alcohol + acetaminophen being a bad combination. Wow, Anon, House actually said he was watching for the vicoden to be trashing his liver? (Please tell me which episode was that?) But WHY would the writers of a medical show have House on Vicoden at all? I had assumed they just didn’t realize, but if they really had House say something about it then they must be aware of the problem. If they wanted to keep him on a “milder” narcotic, they should have him be on Hydrocodone, not the Vicoden (which is just Hydrocodone + Acetaminophen). There is no reason in the world for him to be risking his liver! And although people gain tolerance to things like narcotics and alcohol, no one can gain tolerance to acetaminophen. Being on acetaminophen long term, far from making you more tolerant, causes more problems. I believe that some people have a higher natural resistance to acetaminophen poisoning, but it shouldn’t be humanly possible for anyone to be taking these levels of Acetaminophen (at the very least 6,000 per day, probably MUCH more), for four years as well as all the alcohol House drinks, and still not have problems…
Still I must say – for for all my grousing about this aspect of the show, I love House. I especially LOVE the clinic scenes (the idiot with the broken finger had me rolling around laughing).
March 2nd, 2009 at 1:54 am
From a Pharmacy student: you cannot develop tolerance to APAP’s damaging effects everyone! You deplete your Glutathione stores & eventually accumulate the toxic metabolite NAPQI. This happens later rather than sooner in some patients, but it’s frankly a plot loop hole. Also, Hydrocodone is ONLY available in combination with other ingredients for the treatment of pain and cough (with APAP, Ibuprofen, Aspirin, Chlorpheniramine, Guaifenesin, Homatropine, Pseudoephedrine, etc.). I keep wondering– does anyone reread previous posts before rehashing the same ideas?
March 2nd, 2009 at 2:51 am
It was in episode 3 – 14 “Insensitive” with the CIPA patient. Byt he way as a doctor I can tell you for sure – you’d be amazed how much people can adjust and accommodate to drugs. In the episode in season 1 – 11 “Detox” we see House have a conversation with Cuddy about how he GRADUALLY increased the dose of Vicodin over the years. The human body have a way of dealing with bad habits (such as alcohol to return to the previous example) – the more you strain it and burden it the more it deals. In cases of alcoholics it will be increased production of alcohol dehydrogenase and acetaldehyde dehydrogenase the two enzymes that are used to metabolize alcohol. That is why chronic drinkers need more of the stuff to get drunk. I suppose same can be said about acetaminophen – UDP-glucuronyltransferase production is increased as well as the other enzimes that are responsible for acetaminophen metabolism. It’s just a theory but I know it is the general way human body adjusts to regular stimulae. This is why House needs more and more – the slow increase ensured the increased resistance. It isn’t an infinite process though – his liver will fail eventually…It might be interesting to watch as I said…
March 2nd, 2009 at 5:55 pm
I hated this episode. Why can’t House be happy? Is status quo that important that they need to destroy any chance of him actually changing as a person? Stupid, Stupid.
March 2nd, 2009 at 6:12 pm
Manu
February 27th, 2009 at 5:49 pm
Impact of House on Google Searches
And as “danube river” was No.17 on the Google Search Top 20 list, Manu, everyone must know about Dr. Bulgaria posting here at Medical Reviews of House too!
8^)
March 2nd, 2009 at 7:03 pm
Pharmstu,
My issue with acetaminophen was a rhetorical question. Obviously it’s a stupid plot hole. I was wondering if a doctor had addressed how the writers get around this.
I understand that they are trying to portray him as some kind of maverick with the pill-popping. However, if he were a typical junkie doctor he’d be shooting himself up with Demerol and then passing out in the middle of a procedure, not improving his effectiveness with massive overdoses of acetaminophen. And codeine.
I was wondering if I was missing something.
March 2nd, 2009 at 7:05 pm
Oh, and in case you’re waiting to pounce, Pharmstu, the phrase “improving his effectiveness with massive overdoses of acetaminophen. And codeine.” was sarcasm.
Another question too — isn’t there an issue with bleeding and acetaminophen overdosage? Or massive ulcers?
And yes, whoever raised the issue of the chronic burglary problem, yes, the rational patient would be filing a police report.
March 3rd, 2009 at 8:52 am
Really Karin read my post on Vicodin. Acetaminophen does not cause ulcers. As for bleeding – yes and no. It is directly related to the liver status. Might cause bleeding problems but healthy people generally don’t bleed. And House seems reasonably healthy :)
March 3rd, 2009 at 1:32 pm
OK, Here goes. I am a pain patient. I have disabling pain in my back. I am now on Morphine and Vic’s. I am not an addict. I am dependent on these pills or I will go into withdrawal. I am not an addict because I don’t abuse the pills, I don’t take them to get “High” I take them to make it through a work day or to walk around the block without doubling over.
As far as I can tell House may not be an addict!!! He seems able to get off the Vic’s when he wants to. Everyone will become physically dependent on these not everyone will become addicted.
Now, I have tried methadone. My doctor gave it to me for pain and for me it was better than the Morphine or the Vic’s or Norco. However, it gave me horrible chest pain. Horrible! I felt like I was going to keel over several times and I had to get off of it. However, it worked GREAT on the Pain and no loopy head in the clouds feelings at all!
House was very responsible for trying to got the Methadone route. It worked for him, except for the almost dying part. He should have stayed on it. He has been trying to be pain free for years. Now he gets his wish and he dumps it in one episode. I don’t believe it as a pain patient I don’t believe it. Should have F***ed up a few times before he even thought about this. That could have been an entire other episode.
Overall Grade C+ Medicine -D Story-B but it ended WAYY to quick. and yes Methadone Kills do a little research on the net from people who have lost loved ones after just one dose. It is nasty.
March 3rd, 2009 at 5:56 pm
Aren’t Lortab and Vicodin the same thing, hydrocodone with acetaminophen? Why doesn’t House sometimes switch over to Vicoprofen, hydrocodone with ibuprofen, taking turns assaulting the liver and the stomach? Isn’t it easier to deal with gastric ulcers vs needing a new liver? Then again, why doesn’t House take Oxycodone, which I don’t think has anything in it except for a synthetic opium derivative?
As far as the level of federal control, Oxycodone is a schedule II drug here in the US, while Vicodin and Lortab are schedule III, so that might help explain it. Then again, so long as someone keeps writing the prescription for House, it’s a moot point to him. Who does write his prescriptions now, particularly after the Tritter episodes? His methadone adventure implies that it’s someone outside of Princeton-Plainsboro. The question remains, why not Oxycodone first, which has fewer potentially dangerous side effects than methadone?
Oxycodone used to be called “hillbilly heroin.” I live in Appalachia and read med records for a living, and know that now it is very rarely prescribed here for someone who is at least a bit functional, but nonetheless dealing with chronic pain. And did you know that some doctors will keep track of what other doctors prescribe for you, and if a tox screen shows an unprescribed drug in your system, they will refuse to treat you any longer? Something to think about if you consider borrowing a Lortab from a friend because of a killer toothache. If an unprescribed schedule II or I drug shows up if you should have to go the ER for something completely unrelated, you are also immediately suspect. It is true about drug-seeking behavior in the ER and elsewhere, so anything not prescribed that shows up automatically puts you into that potential category.
I wonder why doctors might have put House in the drug-seeking behavior category when he had his leg muscle infarct (as was implied in the episode when House taught the class and they flashed back to his time in the hospital with Stacey). Had he been using before his infarct? It would fit with the Sherlock Holmes analogy around which the show is structured, the seven percent solution of cocaine the brilliant detective used in between cases to relieve his boredom.
Oh, well, some of our Nobel Prize -winning writers were alcoholics, such as William Faulkner and Ernest Hemingway. Perhaps there often is an inextricable link between genius and the use of drugs.
March 4th, 2009 at 5:52 am
The mg breakdown (hydrocodone/APAP):
* Vicodin comes in 5/500
* Vicodin ES comes in 7.5/750
* Vicodin HP comes in 10/660
* Lortab comes in 5/500, 7.5/500, and 10/500
* Lorcet comes in 10/650
* Norco comes in 5/325, 7.5/325, and 10/325
Now, for those at home who actually aren’t on this stuff, you may notice that LORTAB always has 500mg of Tylenol and NORCO always has 325mg of Tylenol. Amazing! You may also notice that Lorcet and Vicodin HP only have 10mg difference in Tylenol in them. Weird! You’d think his prescriber would switch him to Norco, but “Vicodin” is more generally recognized (I see more forged scripts for it too).
Methadone is a really good option for chronic non-malignant pain (CNMP) due to its NMDA receptor antagonist properties. But w/e, the writers killed it. Oh i love drugs :)
And now everyone can be an expert: http://www.aafp.org/afp/AFPprinter/20000301/1331.html?print=yes
March 4th, 2009 at 10:44 am
when they say energy drinks, im assuming they’re talking about things like Red Bull and the like.
Who the hell drinks soft drinks before and during basketball games? the gases make you burp heaps, and you’re usually gonna end up vomiting. stupid ten year old kids
March 4th, 2009 at 6:40 pm
I don’t have anything medical to contribute — I just love watching house… Anyone notice that House was putting on the red tie (while talking with Wilson) and when he shows up in Cuddy’s office he is wearing the blue tie?
March 5th, 2009 at 2:41 pm
Thanks for the info, PharmStu, Cow and Kim! Now I know that Methadone really does have value as an improved long-term pain solution over the vicodin as well as a weaning from heroin value.
As a sufferer of kidney stones, I am very familiar with injected Demerol and Morpheine for the ones that send me to the hospital, and Percocet (great) and Tylenol 3 (worthless) pills for the ones that don’t, but other opiates are unfamiliar ground for me. But knowlege is power. :)
March 7th, 2009 at 5:02 am
Hi Scott,
long-time reader, first-time poster. I have nothing to say about the episode but, considering how many medical professionals hang out here, I thought it might be a good place to pass along this article from the Annals of Clinical Microbiology and Antimicrobials, published yesterday (March 6, 2009):
Are we aware how contaminated our mobile phones are with nosocomial pathogens?
Thanks for the great reviews.
March 7th, 2009 at 7:03 pm
anyone else go “huh?!?” when SLE was in the differential to explain the pancreatitis? would be a pretty rare manifestation of lupus, and google tells me it’s mostly in adults (and the number of kids that have had it, especially just after presentation, can be counted on one hand)…
March 7th, 2009 at 9:04 pm
To all the people who think this episode (along with others) is saying House needs pain to be a brilliant diagnostician: I suspect the whole point is not the lack of pain blurring his intellect but rather the generally mind-blurring effects of narcotics.
Actually I had thought that that was obvious. I realize now, on writing this, however, that there is at least one point against it: that taking Vicodin (a narcotic) still allows him to do his job up to his own standards. It is possible, of course, that it’s dosage-related and that he knows his reactions to Vicodin well enough to be able to stay just below the threshold at which his thinking would be impaired (at least until he chooses to go home and bliss out on an extra-high does).
March 7th, 2009 at 11:19 pm
House is a classic Romantic hero, a flawed genius who is contemptuous of social convention, melancholy and lonely. He’s a compelling character in the tradition of Heathcliff, Rochester, and Lord Byron, which helps to explain why he is so attractive while being such a jerk. So no, he can’t be happy, or he ceases to exist as House. He has to be constantly searching for that which will make him happy, without ever finding it. It’s rather a tough position to put TV writers in, since instead of one epic story, his character has to repeat that approach toward happiness only to lose it, again and again.
That said, I agree that the methadone story was wrapped up too quickly. The choice would have been more poignent and tragic if House had had more time to savor achieving his dearest wish before deciding he must give it up.
Yes, I was an English major. And no, Sylvia Plath is not standard reading for middle school kids.
March 8th, 2009 at 11:14 am
@Some PA dude: Its on a different day i think, thats why he’s wearing a different one.
March 9th, 2009 at 3:38 am
Next episode tonight and I’m brimming with impatience! A patient so House-like with no social inhibitions? There’ll be jealousy and sarcasm and conversations with the patient one on one…See you soon guys!
March 11th, 2009 at 11:43 am
Viewed this episode last night on the Web!
From what little I know about pre-hospital care, I believe the ambulance crew would have started an IV
at the scene or on the run unless Mama was in their face and insisted on sitting in the jumpseat.
Jackson would likely have had leg cramps before the end of the game or passed-out on the bench.
Mother had her Designer-Child (is male-designation surgery more expensive?) She dotes on an Only-Child (by choice?) Fears having made the wrong designation (dance!) Injects “vitamins” and issues “energy drinks” That kid should have had more facial hair than Dad and House!
Jackson is the smallest kid by far on the BBall team. Maybe a small, private, expensive school that couldn’t field a tall team and would hire an instructor who would use a Sylvia Plath template for an assignment.
I’m afraid that this episode Fore-shadows Thirteens’ instability, Her history of Sex and Drugs and Rocky-Road (thankyou IanDrury!) and involvement with this patient and thinking Cuddys’ deflection was for her sake, doesn’t bode well.
March 12th, 2009 at 1:08 pm
“I found this really emo poem under your bed, let’s talk about it”
Devon cracks me up!
And thanks for the eternally great reviews, Scott; love them. You’re on my links list.