House — Episode 19 (Season 5): “Locked-In”
An interesting concept felled by extremely poor medicine on this week’s episode of House.
Lee is a roofer who ends up in the ER after a bicycle accident. He has suffered head trauma and appears to be brain dead, so the ER physician is ready to call the organ transplant team. Luckily, House is in the bed next to Lee after a minor motorcycle accident. He recognizes that Lee is showing purposeful eye movement so he cannot be brain dead. He realizes that lee is suffering from Locked-In Syndrome. Lee is able to communicate with House by blinking his eyes in response to yes or no questions. The hospital doctor believes that Lee’s brain damage was caused by the crash, but House suspects it was the other way around: Lee’s crash was caused by the brain damage (and Lee’s memory seems to back this up when he sees the car door but is unable to work the brakes on his bike to stop in time to avoid the collision). House’s initial differential diagnosis is fairly general and consists of stroke, cancer, or infection. The rest of his team (excepting Taub) shows up at the ER. Foreman suggests a basilar artery stroke, Kutner suggests cardiovascular disease, and Thirteen suggests a tumor. House thinks Thirteen’s idea has the most merit so he forges a set of orders for the patient to get an MRI.
The MRI is normal, though House imagines he can see a lesion in the central pons. He continues to believe that Lee has a tumor with an associated paraneoplastic syndrome. The hospital doctor disagrees and has diagnosed Lee with an infection of his central nervous system and so has him on antiviral medication (apparently suspecting a herpes, varicella, or CMV infection). The medications don’t work and Lee suffers a seizure. House reports that Lee needs plasmapheresis. Lee’s wife believes him and has Lee transferred to Princeton Plainsboro Hospital . Once there, the team discovers that he has blood in his urine. Thirteen suggests Marchiafava-Bignami Disease (a rare, progressive neurological disease seen in alcoholics). House decides that a brain biopsy is the key to discovering what the underlying disease is. In the middle of the biopsy, Lee loses his ability to blink — which was his only way of communicating. It’s not clear to the team why Lee can no longer blink — or even if he is still alive or brain dead. The worsening symptoms could be caused by a botched biopsy, brain swelling caused by the procedure, or it could be from an as of yet undetermined cause. The differential now includes Epstein-Barr virus, malaria, picornavirus or rotavirus.
Taub suggests using a brain computer interface to allow Lee to communicate. It takes some time and coaching (and pleading) by Taub, but Lee is eventually able to answer yes or no questions with the interface. While interviewing Lee about travel, his wife tells the team he had recently been in St Louis, but Lee tells House “no” to this. It turns out he lied to his wife, and was not out of town at all. At first, House thinks some hanky panky may have been going on (meaning that neurosyphilis would be a possible diagnosis), but he later learns that Lee was staying at a friend’s basement while he was cranking out resumes and applying for jobs because his roofing business was having financial troubles. The team also learns that he had been moonlighting as janitor for a local factory that made rechargeable batteries. Kutner and Taub search the factory and find cadmium dust, suggesting that Lee may have heavy metal poisoning. He is started on chelation therapy.
The chelation therapy does not seem to be working, and Lee has been frequently complaining (to himself, since no one else can hear him) of eye pain. Thirteen takes a close look with fluorescein dye (an orange dye that fluoresces green under black light if there is corneal damage) and diagnoses him with ulcerative keratitis. To House, this means that Lee either has an infection like varicella (the virus that causes chicken pox and shingles), or an autoimmune disease like Behçets Disease. Neither condition really fits well, so Cameron recommends that he perform a lumbar puncture (i.e. a spinal tap) and let the results guide his treatment. As the team is explaining the lumbar puncture procedure to Lee, he suffers a cardiac arrest. The team manages to successfully resuscitate him, but now he complains of an itching foot. To House, this mean that Lee has liver failure. When reminded that Lee’s liver enzymes are normal, he tells them that they had been high, but as the liver failure became worse and the liver died off, the levels dropped and now appear normal. He now believes that it is the liver failure which is causing the locked-in syndrome. Sclerosing Cholangitis (an autoimmune disease of the bile ducts and liver) is the team’s main diagnosis. They are preparing to perform a liver biopsy when Kutner realizes that Thirteen developed a rash where her skin had come in contact with Lee’s urine. Therefore there must be something infectious in his urine that caused her rash and Lee’s symptoms — and the likely cause is Leptospirosis. Sure enough, there were rats positive for leptospirosis in his friend’s basement. He caught the disease from them which caused his liver failure which then caused his locked in syndrome. Antibiotic treatment is started and Lee is able to move a finger again.
The concept of a patient who could only communicate with yes/no answers was clever, but the medicine was very sloppy this week.
As usual, major complaints are in red, minor in blue, nit-picking in green:
How did the liver failure affect just the one tiny portion of the brain to cause the locked-in syndrome? Why wouldn’t it affect the rest of the brain?
For the 1,732nd time: Don’t shock a flatline.
A recent study suggests bad habits learned from television medical dramas are a major reason medical students and residents are having trouble intubating patients correctly. I hate to think what that means for treating cardiac arrests…
Why was House suggesting that Lee needed plasmapherisis? It is used for treatment is certain cancers, but these are blood cancers, and nothing that fit Lee’s scenario.
It is true that in people with advanced liver failure the liver enzymes do seemingly return to normal levels. But by then, other symptoms of liver failure have been long evident. None of which Lee showed.
Liver failure can cause pruritius (itching) because of the elevated bilirubin. But it wouldn’t show up as just one foot — and the bilirubin level would be markedly elevated on the liver function test (but you notice the team only mentioned the “liver enzymes” were not elevated. Bilirubin in not a liver enzyme, though it part of the same common liver test).
Locked-In Syndrome takes a very long time to improve (not just a few days), and that’s even if the patient gets better and most don’t (actually, most die within 4 months of diagnosis).
Leptospirosis causes uveitis, not keratisis, which wouldn’t show up on fluoroscein staining.
Liver failure that advanced would probably require a liver transplant, not a few days of antibiotics.
The medical mystery was very clever, though it seemed a little too conveniently clever for its own good, still I’ll give it an A-. The final solution was an incredible stretch and earns a D. The medicine was scarcely better and earns a C-. The soap opera was only average. Taub was mildly interesting, and neither House nor Wilson seemed to have their heart in their scenes. C.
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A list of all prior House reviews
March 30th, 2009 at 11:56 pm
A cracking good episode, IMHO, even if the scenes on the beach were a little too reminiscent of the taco stand in “No Reason.”
I suppose if I’d seen a ton more medical dramas, the premise of a patient with locked-in syndrome wouldn’t seem that novel, although I was reminded of a really depressing 1971 movie called “Johnny Got His Gun,” in which Timothy Bottoms plays an American infantryman in World War I who gets caught in a shell explosion, and ends up deprived of his arms, legs, sight, hearing and speech, while his mind continues to function (”I don’t know whether I’m alive and dreaming or dead and remembering “).
And, thankfully, “Locked In” didn’t go in for the “clever” gimmick of staying with the patient’s POV for the entire episode – that would have been unbearable. (One “Blair Witch Project” is more than enough, thank you.)
One small groan was the whole atheism angle, once again. House was notably more restrained on the issue this time around, but then again, most of that was the patient’s imagination at work. The groan here is, I think we’re going to be hearing again from the predictable types who can’t stop crowing about how much smarter they are than people who believe in a deity. (If nothing else, they prove that self-righteousness isn’t limited to the faithful. And if you’re wondering where I’m coming from, let’s just say I used to be a sunny agnostic who isn’t as sunny anymore.)
One medically related question for Dr. Scott or whoever else cares to answer: All that talk about the patient’s liver having failed made me think he was a candidate for a liver transplant. Can the liver really bounce back like that?
March 31st, 2009 at 12:02 am
This episode didn’t have any House moments.
March 31st, 2009 at 12:25 am
What was more interesting than this week’s episode? The end credits teaser for next week, the edge-of-your-seat excitement of which has been stirring for quite some time now thanks to all the rumors online about the “shocking and completely unexpected death” about to occur on “House.” It’s funny how I have written this show off week after week and now thanks to the impending death, I can’t help but stay glued to my HDTV on Monday nights. Scott, wanna join us in guessing who bites the bullet?
House – If he dies, they might as well cancel the show.
Cuddy – Her death just wouldn’t make sense.
Wilson – Eerie & scary rumor about Amber appearing to him in a dream and when it’s over, he’s committed suicide to join her in the afterlife. That one freaks me out BIG TIME.
Foreman – Does he off himself after ruining his career with the whole Thirteen medical trial thing?
Chase – Rumored to have a huge role in Season 6 so count him out.
Cameron – Hardly used this season so her death wouldn’t be as shocking or have nearly as much an impact as it would have 2 seasons ago.
The new team (Taub, Kutner, Thirteen) – Any of the 3 can go, I never liked them anyway.
March 31st, 2009 at 12:26 am
This may not be medically relevant but I found this episode to be rip-off of the Julian Schnabel film Le Scaphandre et le Papillon (The Diving Bell and The Butterfly). I was very disappointed that the writers couldn’t come up with something more original.
P.S. Thanks for clearing up the shocking-a-flatline thing for me Scott. I posted a question two episodes back on the subject. My first-aid training kept conflicting with these medical dramas, we were taught that you can only shock V.Fib and V.Tach not asystole or PEA.
March 31st, 2009 at 12:37 am
As soon as I heard the flatline noise and saw them pull out the paddles, I told my wife, “I’ll be reading about that on Scott’s blog.”
I certainly can’t comment on the medicine, but just from a storytelling point of view, I loved this episode. It didn’t have a lot of the usual soap opera elements, but it was a great attempt at breaking up the House formula a little and presenting the story a different way.
Mos Def did get some of the best lines, but he delivered them perfectly.
And Kutner got the real “aha” moment – a first for the show?
March 31st, 2009 at 12:41 am
My big complaint: how is it possible to confuse locked-in syndrome with brain death?
I can see confusing locked-in syndrome with persistent vegetative state, but brain death? For one thing, the patient did not require any ventilatory support; right off the bat, a crucial criterion of brain death is not satisfied.
March 31st, 2009 at 12:49 am
The problem was the guest star. There is only room for one star on this show, and it is House.
March 31st, 2009 at 12:50 am
Am I the only one who thought of the “M*A*S*H” episode, “Point of View” while watching this ep of “House”? Both used the premise of providing the audience with a 1st view of the shows’ respective medical teams while they are being treated. Personally, I think “Locked In” was the better of the two. I think TPTB used the concept of the audience seeing things through the eye of the patient to better effect here than “Point of View” did.
March 31st, 2009 at 1:16 am
I have a toaster. It toasts bread. It can also toast various foods, but I prefer to use it to toast bread. I also have Nutella, wich is a kind of chocolate spread. It tastes good. It’s even better on toasted bread. I also like to eat that with a glass of milk while watching House. And I liked this episode even though I didn’t find it really great. But it’s like they’re saying House is getting Locked-In Syndrome by the end.
HA YOU DIDN’T THINK I’D BE ON TOPIC HEH?
March 31st, 2009 at 1:38 am
didnt the original doctor think it was infection?
March 31st, 2009 at 1:58 am
Matt C. you beat me of the mark – brain dead means no alpha waves, no brain waves at all to that matter at least none of those that means “Hey there is a person inside here” (I think we need a neurosurgeon to explain this actually). They checked in on that. I’m pretty sure that a guy can’t breath on its own in that state (brain dead). However there is a possible explanation – may be he was on a ventilator while in the other hospital (we never actually saw the patient until midway through the episode) and they could of ex-tubated him by then after figuring out that he is brain-alive. Having “explained” that really gigantic issue lets try and pick the bones of the other medical stuff
1. I think D-r Scott (as per usual) nailed the problem: How can liver failure cause Locked-in syndrome? The only explanation that I see for that is that since the syndrome is extremely rare and cannot be studied extensively (due to patients dieing pretty soon after getting it – 90% mortality rate after the first 6 months, the other 10% within an year or so). The inability to communicate is also a reason for not knowing much although they are researching it as much as possible. So may be it was that – we do not know much so it’s possible. It is a lame excuse for a show like House though…
2. How come a guy spend 3 days in a hospital with his liver not working (at all seemingly!) but have no symptoms at all (the symptoms I can think at the moment are jaundice, fever, cerebral oedema and encephalopathy, coagulopaty, systemic inflammatory syndrome and uhm death within about 36 hours.
3. Lepto is an infection right? So let’s once again start counting the MISSING symptoms of an infection – fever, increased white count (those are there for pretty much ALL infections). and for lepto in particular there is also a whole bunch more – headache, jaundice, vomit, diarrhea (both bloody) dark urine, muscle pain etc. Lepto is often misdiagnosed because of the wide range of symptoms – but those symptoms are there nonetheless. My explanation here is that the patient is between the two stages of lepto (however that means that his liver should be fine, cause liver failure happens during the second stage when all the nasty stuff is there too)
All the other minor stuff mentioned by D-r Scott is dead right too so I wouldn’t bother. I’ll have to re-watch the episode again with translation to have it all figured out. May be then some of the nitpick would be gone or new will emerge? Who knows…
Nobody even mentioning House was seeing a shrink? It is true that this entire subplot was not well played at all (and Wilson’s acting was atrocious – come on SPL can do way better than that!) but still – a shrink?!? Is Cuddy one lucky girl or what? He actually loves her enough to try something he abhors! I do think we’ll see some action there by the season finally. I was dissapointed however that House decided to jerk Taub around instead of molesting Foreteen. Boy are they annoying or what?!? well better luck next time. Overall I think it was an interesting episode but it left me with a feel of wasted potential – a locked in syndrome has way more possibility for fun than that. The fact that House used the patient to spy on his stuff was the only real funny part in the whole slightly funny enchilada. And since now Foreteen is officially busted lets hope fore some House/Foreman and House/13 action next week! Ta-ta!
March 31st, 2009 at 3:31 am
I really like it when they focus on Matt Lauer, oops i mean Taub (do they looks like twins, or what?). Kutner sees a rash on Thirteen’s wrist and thinks the pee must have caused it? I’d assume her bf got her some cheapo jewelry which caused contact dermatitis.
This episode would have been more awesome had the patient developed a Jarisch-Herxheimer reaction after starting the antibiotics. And why didn’t they start broad spectrum antibiotics earlier or do the LP as part of the differential?
Did they ever throw out the actual term for severe leptospirosis (since the writers love to name-drop every obscure thing)? It’s Weil’s Syndrome.
And is there such a thing as the brain computer interface used in the show? My area is pharmaceuticals so i have no idea, but I really hope it’s real!
-Pharmacy Student
March 31st, 2009 at 4:08 am
Like Megan said, the first half of this ep was 100% a play on/re-use of “The Diving Bell and the Butterfly”", including the locked-in POV/voiceover for long stretches, the blinking method of communication, the beach backdrop as a metaphor for the inner mind…House even paraphrases the movie when he jokes about the patient communicating “kill me”.
However, after adjusting to this fact, I enjoyed the episode. I almost always like how the various characters’ personal arcs are worked into eps in little bite-size pieces, and interact with the main story. The patient (Mos Def) reacting to Foreman’s necklace story in his mind was one really funny example.
Mos Def was good overall, as usual seeming both cool and vulnerable. Playing a patient on House seems to be the primo guest spot on TV, every actor/actress who does it is showcased, they’re never really shoved into the background.
March 31st, 2009 at 4:36 am
While I enjoyed the ep, at the end when they made the big revelation I was totally “are you kidding me?”
I mean, apart from the mentioned by you Scott, and D-r Bulgaria above, there’s the fact that if the patient was in the hospital for some time, they wouldn’t have missed the liver failure but aside from that – he’d be on some treatment.
Liver not working, means drugs are not properly metabolized, I mean, at least part of the drugs would have higher than normal levels in the blood (I know that the one we know he got – Acyclovir is primarily excreted through the kidneys), but most antipyretics and painkillers have hepatic metabolism. The drugs themselves would have killed him or caused symptoms that would have alerted the doctors that something is quite wrong.
I’ll admit that I didn’t enjoy the character interaction and drama between House and Taub. Found it a bit overboard at times.
March 31st, 2009 at 5:52 am
Is it actually possible to use that brain computer interface to make the patient answer yes or no questions?
March 31st, 2009 at 6:22 am
Medical stuff aside, I really liked the filming of the episode.
While I appreciate that they eventually switched to a standard filming after awhile, the portion they did from the patients POV at the beginning really served to highlight the terror of being fully in your own mind but completely cut off from the rest of the world.
And to Noiviceman – The thematic point at the in (the fuzzy camera from House’s POV) WAS meant to show that House has his own, symbolic form of “Locked In” syndrome through his refusal to seek therapy.
It’s a point that’s a little hammered to death (as is House v God) but dramatically sound.
March 31st, 2009 at 6:33 am
I don’t think House was seeing a therapist about himself. I think he found something out about someone on his team and went to the therapist because they’re treating him/her.
If I’m right, you read it here first! (If not, you’ll forget about it anyway).
The kidney failure missed for 2+ days diagnosis was pretty bad though. I usually forgive them for the common slip-ups they have for the sake of drama, but liver failure causing only an itchy foot after multiple days?
March 31st, 2009 at 6:36 am
Benn, you are not; I was thinking of the M*A*S*H episode too.
Both House and ER are resorting to the kind of ‘gimmicky’ episodes that I remember from the last years of M*A*S*H and associate with writers running out of story *ideas*, so they mess with story *styles*. I can understand it with ER because it’s 15 years old, but House has only been on a few years.
March 31st, 2009 at 6:59 am
I really liked this episode. There were a few zingers (”When Dr. Idiot sees this, he’ll realize how appropriate his name is”) but more quiet emotion, I thought, in the interaction between House and the patient. Maybe that is not what people are watching to see (foobar, Silver above) but it is suggestive. This season House has been changing somewhat as a person, trying to change himself (e.g. with the methadone, maybe with the shrink) and I like the arc better than the arcs involving grotesquely nasty outsiders as in seasons 1 & 3. It’s a lot subtler and more various (his father’s death, Wilson’s mourning and brother situation, Cuddy’s baby angst and joy). That may be why they are going back to House vs. God, to clarify that this is an option others have but he does not. It’s been kind of House vs. House all season.
That said, I am sad that the medicine was not worked out better.
March 31st, 2009 at 7:01 am
PS I think the first major use of the patient’s-eyeball pov was in Powell and Pressburger’s film Stairway to Heaven….
March 31st, 2009 at 7:15 am
I enjoyed this episode. I enjoyed this episode when it appeared on “MASH” (I’m a little young to have watched MASH the first time around. I’ve seen the reruns.)
But, I thought it was interesting. I laughed when the patient thought “My doctor is on drugs?!” Hee!
And, I also thought that I’d be reading about shocking a flatline here on your blog, Scott. All medical students who are learning their medical skills through TV (and I’m a secretary in the Chemistry Department at a university. There are pre-med students taking chemistry classes that I deal with. I KNOW some of them think that medicine they see on TV is real) need to read your blog to find out that you don’t shock flatlines! I have nothing to do with the medicinal side, and I now know that, thanks to your blog.
Kat
March 31st, 2009 at 7:30 am
Just a minor nit… fluorescein is an orange dye that fluoresces green intensely, period. It make corneal damage visible because it sticks around in any crevasses or divots making them more visible, just like ink in an intaglio printing press.
March 31st, 2009 at 9:06 am
Ha, Dr. Idiot (John Kapelos) was Barry the Sniffing Accountant in Seinfeld.
March 31st, 2009 at 9:12 am
The brain computer interface is real. That might have even been a real one they are using. There have been a few computer games that use one. You get about 6 different signals out of it. None of them very strong. They all require training and work. That seemed to be a realistic part of the episode.
As for playing with episode format, House has doing that since season 1 with 3 Stories. I think this episode and parts of others have really been buildups for next week. There have been the persistent House v God themes, a decline in House’s health along with an improvement in his disposition.
March 31st, 2009 at 9:19 am
I think the drama created by the POV, especially with some of the internal dialogue by the patient (giving in to death, while staring at his children? Tissue please.) was awesome.
I think they sacrificed some medicine (I am no judge of it, though) for the cinematic..ness of the show. They were more interested in giving us a closed-in no way out feeling from Mos Def’s point of view.
I liked it.
March 31st, 2009 at 9:20 am
Oh, also. I too see the consistent House vs. God theme becoming more apparent in each episode.
I think they’ve got a showdown coming.
March 31st, 2009 at 9:27 am
For the first time ever, I had to change channels about 10 minutes into the show. The point of view choppy camera moves and out of focus shots were just too irritating to watch after a while.
I did come back to the program a bit later and was relieved to see the normal shots return.
As far as the brain to computer interface is concerned, I believe it is based on fact and is used for people who have ALS for example, that is people who have no muscle movement. With training, internal movement in the brain can apparently be used to move a cursor onscreen.
March 31st, 2009 at 9:46 am
So, how are the doctors supposed ti handle a flatline? And when should they use the paddles. Also, there was at least one episode where Chase had the “aha” moment instead of House. It was in the season 3 episode where the girl was allergic to sunlight.
March 31st, 2009 at 9:48 am
So, how are the doctors supposed to handle a flatline? And when should they use the paddles? Also, there was at least one episode where Chase had the “aha” moment instead of House. It was in the season 3 episode where the girl was allergic to sunlight.
March 31st, 2009 at 9:57 am
Like others have alluded to “The Diving Bell and The Butterfly” is a much better film than this episode was. The writing seemed confused during this episode as none of the symptoms matched all that well. I just hope this episode makes people go out and rent the above mentioned movie as it is fantastic.
March 31st, 2009 at 10:52 am
P: If I remember correctly, you would use the paddles to shock the heart back into a normal rhythm if it wasn’t beating correctly for some reason such as tachycardia. For a flat line you could try some kind of adrenaline type injection like Epinephrine.
March 31st, 2009 at 11:07 am
slightly related question – have you been watching sarah connor chronicles? in the last one i saw, sarah shocked herself on the breast to short out a transmitter, and was knocked out for maybe a minute. then she applied the paddles to either side of a man’s head to render him unconscious.
at least they weren’t shocking a flatline, but are the effects shown realistic?
March 31st, 2009 at 11:11 am
Just wanted to fill in what I said before about the Powell-Pressburger movie. Someone posted a clip on Youtube, at
http://www.youtube.com/watch?v=4aQ3bokPcXI
The operation sequence begins around minute 3 and the eyeball is around minute 4. It begins with a motorcycle crash in which the brilliant-diagnostician doctor dies (trying to avoid crashing into the ambulance). I presume the motorcycle crash in House is a coincidence, but it’s interesting….
The movie is from 1946, and the original British title is A Matter of Life and Death; it was released in the US as Stairway to Heaven (no Death in the titles, please). The idea is that a pilot who crashed on his way back to Britain survived by a fluke but with brain damage which produces illusions in which he discusses with the personnel of Heaven whether or not he should be allowed to live. Since he has fallen in love, he wants to live. The doctor who diagnoses him becomes, after death, his lawyer in heaven; in the meantime, on earth, the operation is continuing.
March 31st, 2009 at 11:13 am
As far as I’m aware a ‘flatline’ or asystole along with PEA (pulseless electrical activity) are treated with CPR 30 compressions to 2 breaths continueously until IV access is secured and adrenaline 1mg is given. For asystole atrophine 3mg is also given. The CPR continued and chest compressions are not stoped for rescue breaths. The patient should be on monitors so these are checked at 2mins. If rythmn remains un-shockable then continue CPR giving adrenaline 1mg ever 3-5 minutes.
Admitedly these are guidelines provided by the RESUS council in the UK, however, the priniciple will be the same throughout, you never shock asystole or PEA.
The emphysis with a flatline is to keep blood and oxygen pumping around the body to the brain and to try and discern if there are any reversable reasons for the condition in first place. TV not only portrays incorrect treatment of a flatline regularly the survival rate is extortionately higher than reality sadly.
Paddles or pads used to provide a shock are used when the patient is in VF/puselessVT, ventricular fibrillation or puseless ventricular tachycardia only and CPR along with adrenaline is given between shocks.
Hope this helps :)
March 31st, 2009 at 11:32 am
I thought this was a great episode dramatically, and focused on the medicine, however poorly, instead of pandering to the soap addicts for once.
I had no problem with House recommending plasmapheresis to get the wife to release the patient to his care. He knew “Dr. Idiot” wouldn’t sus out the implausibility of the test and would be too arrogant to admit it. “Everybody lies” especially House whenever it suits his purpose.
The first instance of “locked-in syndrome” I saw on TV was a half-hour episode of “Alfred Hitchcock Presents” I viewed as a child. A man is speeding along a winding California mountain road and ignores a construction warning sign. He rounds a corner too fast to avoid a stalled buldozer. His 1950’s era convertible smashes head-on into the buldozer with no seatbelts, no air bags, and a hard non-collapsable steering column, crushing his chest and breaking his neck. He comes-to unable to move anything but a little finger. He frantically tries to signal the men from the construction crew who cut him out of the wreck, but to no avail. He wakes up again in an emergency room and finds to his horror that the duty physician is declaring him dead. As his head is being covered-up by the sheet, the doctor suddenly cries: “Tears! He’s alive!”
March 31st, 2009 at 11:36 am
If medical students are stupid enough to pay more attention to a
tv show in how to do medical procedures than the ones that are taugh in medical school they should change carriers. A tv medical drama has no obligation to be 100% since it’s not aired on the learnning channel. Sory for my my poor english.
March 31st, 2009 at 11:38 am
Yes, I’ve seen that “M-A-S-H” episode about the locked-in patient. But there was also an episode of “Alfred Hitchcock Presents” that originally aired in 1955 in which Joseph Cotten played a cold-hearted businessman who gets into a car accident and ends up in a small town hospital’s morgue, paralyzed yet cognizant. And basically, the ending of that episode (called “Breakdown” and directed by Hitchcock himself) was the same as the “M-A-S-H” episode.
As Fred Allen once observed: “Imitation is the sincerest form of television.” (Hitchcock and Fred Allen – do I sound old, or what?)
March 31st, 2009 at 11:52 am
Lacking sope opera this week (and the medicine appeared to be far fetched), but this episode made me extremely curious on what’s going to happen next. The patient suggests that cuddy still likes house. And what’s up with house’s vision being blurry at the end scene with wilson? Anyone else noticed that?
March 31st, 2009 at 11:55 am
I didn’t get why House was hospitalized for a scrape on his elbow?
I wish I hadn’t seen “The sea inside” well before this episode, I think I would have liked it a lot better then.
At least they didn’t do the stupid slow “a, b,c,d,e,f” spelling-words-out thing.
I never got why they didn’t write the letters in groups on a chart and then just first choose the row and then go down the letters..and write important words (pain/sick/tired etc) and often used sentences (I love you/ go away etc) on some other chart.
March 31st, 2009 at 12:08 pm
The paddles: It has been explained over and over a couple of times by both D-r Scott and others:
1. V-tach, V-fib, Arithmia, any kind of rhythm disorders – yes. And no not every time on max charge, 5 times in a row (like on TV). You combine with meds and choose a setting for each thing.
2. Flat line (asystoly), no rhythm at all – EPI, CPR, external pacemaker, internal pacemaker (both have been used on HOUSE btw – they just seemed to forget that (the writers) and decided it was easier and “way more dramatic” (10x House) to shock.
As for the “Eureka” moment not being House: please people there are plenty of examples that his team is not comprised of idiots in all seasons. Check those episodes: “Finding Judas” (Chase), “Airborne” (Chase), “Whatever it takes” (Foreman), “Emancipation” (Foreman), “Ugly” (Thirteen), “97 seconds” (Thirteen), “No more Mister Nice Guy” (Cutner) and finally this one “Locked-in” (Cutner). Interestingly enough although Foreman is credited of being the smartest and Chase the most stupid of the old team, it is Chase that usually hits the truth with one of his guesses or at least leads House to the truth while Foreman tends to just be: “You really think so HOUSE? I think you’re wrong!” and ends up being wrong or silly looking most of the time. He is also the easiest to be manipulated (not Cameron!) and his mistake killed a patient (and while Chase killed a patient as well his mistake was fixable and the woman died for reasons beyond his control.
March 31st, 2009 at 12:26 pm
I pay no attention to hip-hop culture and had never seen Mos Def before. I was pleasurably surprised by his aware, serious performance. I liked the way the POV shots allowed the writers to voice his keen observational skills and his ability to rapidly size-up the characters, relationships, and real motives of those around him. That the beach in his dream encounters was obviously southern California and not the Jersey Shore did little to detract from the freed-up interactions he was able to have with House and with his own family. I thoroughly enjoyed seeing another complex personality featured on the show for a change. Can’t anyone on this post remember “ensemble acting”?
March 31st, 2009 at 12:33 pm
Couple things. What was the deal with the very last scene when the camera changes to houses pov and gets all blurry? I think Joy is the one that is going to die. Save the cheerleader, save your world. Peace.
March 31st, 2009 at 12:35 pm
Sure the medicine on this show is often poor, but I would be interested in seeing another study: How many people went to medical school because of shows like House or ER?
March 31st, 2009 at 2:13 pm
Scott: great review as always
Izzy: The blurry vision was to show the similarity between House and the patient. House is somewhat “locked in” because of his unwillingness to change and seek help.
March 31st, 2009 at 2:17 pm
Shocking a flatline has been a great tradition of television and movie medical stories since time began, I wouldn’t look for any writers to try and change that, there’s no benefit to it except to confuse the millions of non-doctors out there who KNOW you bust out the paddles when the heart is stopped! :p
I liked this episode a lot, House is at its best when they disguise the fact that they are following the same old ‘get it wrong 5 times, making the patient worse until House gets his ‘Eureka!’ moment and saves the POTW from unnecessary brain surgery/amputation/etc. plotline with some clever filming or alternate reality aspects to the show. And SO glad that Foreteen is finally relagated to the background where it belongs.
March 31st, 2009 at 2:56 pm
Regarding “brain-computer interfaces”, my understanding is that most of the cheap ones (i.e. the ones marketed with games) read your brain in the same way a mentalist reads your mind, by physical tells. Many of them read either forehead tension or pulse rate of the temples. By thinking about something, you affect these physical tells and the device picks them up. The more you work with the devices, the more biofeedback allows you to talk in a way it understands. I honestly don’t know how well that would work with locked-in patients who lack conscious control over many of their facilities. That said, I also didn’t see the episode in question (I don’t get a chance to watch much TV) so I don’t know whether they had something more sophisticated monitoring actual brain waves (which would theoretically be controllable so long as you can think, as has been proven in multiple studies decades ago where they showed almost everyone can induce an Alpha state on command with practice and feedback) that would be plausible in such a case.
March 31st, 2009 at 3:06 pm
“Why was House suggesting that Lee needed plasmapherisis? It is used for treatment is certain cancers, but these are blood cancers, and nothing that fit Lee’s scenario.”
I assumed it was for the paraneoplastic syndrome (and I assumed that this meant a lot of nasty antibodies, which then would be cleared from the patient’s blood). What I couldn’t understand was why a paraneoplastic syndrome was needed, and how it was diagnosed, when there apparently already was a tumor that could explain the only symptom House could have discovered.
March 31st, 2009 at 3:25 pm
where do people get the spoilers about somebody dying on house
March 31st, 2009 at 5:03 pm
The medicine aside, I thought this was a decent episode of House. (Though not as great as it should have been.) My favorite sequence was when House and the patient were standing on a street, with the camera whirling around them. I have always admired the camera-work on this show.
March 31st, 2009 at 5:04 pm
Corien wrote:
“I didn’t get why House was hospitalized for a scrape on his elbow?”
He was hospitalized for being in a motorcycle wreck. Motorcycle wrecks have a nasty tendency to cause internal injuries.
When I wrecked my bike a couple years ago, I had no real visible signs of injury at all, unless you noticed me wincing in pain from my broken shoulder. But the shoulder was enough to prompt the ER doc to do a torso CT on me, due to concerns over internal injuries.
I think the real question is whether House would have consented to being taken to a hospital for apparently minor injuries. I lean heavily towards a “no” in that regard.
March 31st, 2009 at 5:17 pm
[...] Non-Medical Drama: B- — Not much really. Taub saving his job. Little hint that Cuddy likes House when she turns around while he’s walking away. One of the positive points of the 1st person camera. Medical Accuracy: C- (Click Link HERE) Medical Mystery: A — Hard to beat it, really. Can I (a future med student) believe the final solution?: B — Again, pending medical accuracy, it sure seems plausible.. although I would think it’d have to be a lot more urine than what they’re leading on to suggest but we shall see with a fan site favorite of mine that critiques the medical accuracy. [...]
March 31st, 2009 at 5:20 pm
and why did they post it here Tiffany !?
they could’ve at least put up a warning !
March 31st, 2009 at 6:22 pm
re: whether House would have consented to being taken to a hospital for apparently minor injuries…
He probably did it to get another pain med prescription. Being in an accident and sustaining injuries, he could get the E.R. doc to prescribe him something in addition to his usual prescriptions.
Remember one of Wilson’s brainstorm ideas as for why House was even in the area was that he was going to a pain clinic for more meds, so obviously he’s still seeking extra meds.
March 31st, 2009 at 6:22 pm
In case anyone reads down this far:
What’s the deal with the stupid wives? like, two or three episodes in a row??”OMG! you lied to me! ONE FARKING TIME!” how could you??” please. These women make me want to reach through the screen and slap the snot out of them.
Secondly, my husband kept mutter ‘meningitis’ halfway through the episode, and it sounded plausible to me. The utter failure of the ending ruined the whole episode for me. It’s not that hard to wrap up with a an actual semi-plausible explanation other than rat pee. It’s absurd that it caused locked-in syndrome, and like others have said, you don’t recover that fast. There were just so many holes, it was not enjoyable. meh.
March 31st, 2009 at 6:56 pm
I’m now a bit nervous about rat urine!
Papercuts and rat urine almost kills a patient on House.
Watching a tv program called “1,00 ways to die”, a golfer (rat peed on him) dies a week after his encounter. Golfer didn’t get medical help and had a bad liver (heavy drinker), so he was a goner.
I had no idea that rat urine could be so dang hazardous. I don’t think, I’d be willing to pet a tame rat. Will be forever thinking of tv programs House and “1,000 ways to die”.
I thought Bubonic plague was the only rat malady there really was. Looks like I was wrong.
March 31st, 2009 at 7:10 pm
“Liver not working, means drugs are not properly metabolized, …most antipyretics and painkillers have hepatic metabolism.” Doesn’t this mean anything they gave him would not be filtered out of his blood and Therefore would remain in his blood, doing their thing, at a much higher level? Someone mentioned that Lepto causes “fever, increased white count… headache, jaundice, vomit, diarrhea (both bloody) dark urine, muscle pain etc.” But what if the extra drugs knocked down his fever, and kept him relatively pain free. (Not that he could say ‘ouch’ anyway.) As for vomiting and diarrhea, that could be explained (bloody or not) by the accident. Jaundice might be hard to notice in a dark-skinned person (but doesn’t it turn the eyes yellow, too?)
March 31st, 2009 at 7:52 pm
I liked it when it was on MASH, and I like it here. I thought it was one of the better episodes in a while.
March 31st, 2009 at 8:17 pm
was it just me or was there something about the elevator scene in the end….it seemed as if house was going to go into “locked in mode”…..
March 31st, 2009 at 8:38 pm
To everyone saying this is a rip-off of The Diving Bell and the Butterfly: those were my first thoughts too. But pretty quickly I also thought that it made for a very interesting (both plot-wise and visually) device for keeping the show fresh. While the visual style of the POV was exactly the same, as was the use of voice-over to portray the patient’s thoughts, the show’s obviously got a different agenda to the film, and I think that it was valid and fair to use such a device because of the effect it had.
Diving Bell is a beautiful, inventive, clever and emotionally taut film in which Locked-in Syndrome takes on the role of a physical, mental and emotional torture chamber. House is a medical drama in which it takes on the role of a pretty unusual obstable to diagnosis, and I certainly felt it made the show exciting at the expense of possibly being seen as running out of ideas at best, and plagiarism at worst.
Now if they do an episode about someone with anterograde amnesia in which scenes play out in reverse chronological order, maybe there’s a case building for having a go at the House team. (Though I think that’d be pretty damn interesting)
PS Judy – A Matter of Life and Death is a superb film! I was lucky enough to see it on 35mm a few weeks ago as part of my university course, and The Archers’ (or more sepcifically Michael Powell’s) eye for colour and composition is unforgettably striking and intelligent. Plus, David Niven and Roger Livesey? What a cast!
March 31st, 2009 at 8:39 pm
And of course, by obstable I mean obstacle.
March 31st, 2009 at 9:08 pm
MrBuddWing, the “M*A*S*H” episode, “Point of View” wasn’t about a locked-in patient. The soldier suffered a throat wound and couldn’t speak for most of the episode. The similarity with the “House” ep, “Locked In” is that the “M*A*S*H” ep shows the audience the 4077th through the eyes of the patient, just as “Locked In” was mostly through the eyes of potw Lee. The closest “M*A*S*H” came to a locked in case was in the episode, “Trick or Treatment”. Near the end of that episode, Father Mulcahy performs last rites on a patient declared dead. As the Padre performs the rites, the soldier begins to cry, revealing he wasn’t dead afterall.
Joebeets, I’ve seen Mos Def in the Spike Lee movie, “Bamboozled”. He was okay in that. I thought he did a better job on “House”. At any rate, this isn’t the rapper’s first acting job.
Entertainment Weekly has an online email Top Story thing. Among the features are an “Ask Auseillo” column. I’m not sure about anyone else, but it was from one of his column that I heard that a character will die on “House” before the season was finished.
March 31st, 2009 at 9:10 pm
Just finished watching the episode, and the whole time I kept waiting for some nugget to be unearthed about a recent bout of Hyponatremia, knowing without a doubt he had Central Pontine Myelinolysis. My immediate diagnosis probably has a lot to do with my upcoming test this Friday, which includes a large section of Neuropath, so I couldn’t help but think of anything other than CPM.
Even though many of you have said you didn’t prefer the POV method of this week’s episode, I loved it. I thought to myself halfway through that this was probably going to be in my top 5 episodes, but the last 1/3 of the episode seemed to fall flat. I love Mos Def, and thought he did a great job, but was left feeling a little empty by the end. (probably because I wanted to nail the diagnosis, and really thought I had!)
March 31st, 2009 at 10:44 pm
Please, people, at least put a spoiler warning if you are compelled to spoil next week’s episode, sheesh. Not all of us read about the upcoming episodes.
April 1st, 2009 at 12:14 am
Benn: Thank you for the clarification. I stand gratefully corrected.
But has no one else heard of that Hitchcock episode I referenced? You can watch it on Hulu (you can easily access the site through the Internet Movie Database – when searching, use the pulldown menu for “TV Episodes” and enter “Breakdown”).
April 1st, 2009 at 2:25 am
To fk: Jaundice would be noticed mainly on the scleras (white part) of the eyes also on the gums, long before the one on the skin. That along with the other symptoms would have been there BEFORE the accident (if we assume that Liver failure cause the Locked-in Syndrome!). Remember they asked his wife for symptoms existing BEFORE the crash? Never mentioned anything. And while we are there I seriously doubt that a person with Weil’s syndrome would go around biking so happy and nonchalant. Basically my main complaint here is not so much about liver failure causing locked in (I gave an possible “explanation” about that) it is the time line – what happened after what and when and why did it happen without anyone noticing? Cutner’s logic was: rat bite (OK rat pee) caused Weil’s, which caused liver failure, which caused locked-in. Then the progression of symptoms would have been – Lepto symptoms (two stages – mild one with flu like symptoms still noticeable, short break than severe symptoms: the ones I listed, including Liver failure (but liver failure that you can very well notice because of the other stuff), than Liver failure (biking anyone?) than locked-in. So you see why I am bugged. There would have been plenty of symptoms before he even got to the hospital and than while there there would have been even more (well at least liver toxicity with all the symptoms of acute liver failure and believe me jaundice would have been the least of the problems (or the itching for that matter!)
April 1st, 2009 at 2:32 am
I just read a summary: it appears “Diving Bell” and “Johnny Got His Gun” are quite similar films. I’ve seen “Johnny” and it is relentlessly depressing; if you ever get the urge, do yourself a favour and watch the extended video for “One” by Metallica; ot uses footage from the movie, tells the basic story in the song, and is five minutes long rather than two hours.
April 1st, 2009 at 2:33 am
Yes, this episode of House was indeed not the most original, and I’m sure most people can connect it with another film or show. But, isn’t cool to have a House version of those, I really enjoyed it!!
P.S.
Another show that it remainded me E.R. with the episode that had a mom in the same state because of a stroke.
April 1st, 2009 at 6:45 am
Worst episode ever. I kept hoping for the guy to die so that the inner monologue and the beach scenes would stop.
April 1st, 2009 at 8:27 am
House was crying. His brief POV shot was the same as when they put artificial tears in the patient’s eyes.
April 1st, 2009 at 11:29 am
Late(ish) reply to Matt above – I think this is Kutner’s second ‘aha’ moment – can’t remember exactly when but it was just after the new team was formed.
I remember the diagnosis was Chagas Disease – although I can’t picture the patient.
I’m sure someone will remember.
April 1st, 2009 at 12:12 pm
Not to get on the religion discussion, but just for the sake of argument, is there going to be one episode where the patient who loses his faith has his faith STAY lost? It’s actually an interesting dynamic — House is happy that his atheism is supported but pissed that he didn’t figure out the puzzle.
April 1st, 2009 at 12:27 pm
Maybe House will die. But as he flatlines they will pull out the paddles and zap him back into existence!
Even with no medical training at all, I could tell that Mos Def was awful healthy looking for someone with a dead liver, didn’t buy that bit at all.
As far as the psych goes, I was guessing he did it to get his hands on some prescription or another. But that doesn’t seem to be where they are taking it.
Kudos to Wilson for getting the upper hand on House for once, with the cell phone.
April 1st, 2009 at 12:30 pm
Good episode. Final solution didn’t really seem that clever though. Rats piss would be one of the first things on my list of ’sourcs of infection’ once I saw that shitty basement, personally. And I have zero medical knowledge.
Thanks to whoever noted the suggestiong that House has ‘locked in’ syndrome at the end, I thought Wilson looked suspiciously out of focus.
Anyway, we all know it’s Kutner who dies.
April 1st, 2009 at 12:34 pm
Just if you didn’t know : “The Diving Bell and the butterfly” is based on an autobiography written by a locked-in patient. To write it, he would look at a computer which showed letters one at a time and he would blink when he saw the letter he wanted.
April 1st, 2009 at 3:45 pm
I’m working as a graduate student in a lab that is developing brain-machine interfaces (in Freiburg, Germany), and I guess I should comment on that part of the plot, because nobody here seems to have realized the simple thing: what was shown in this episode is absolutely, utterly and completely IMPOSSIBLE with present-day technology. There’s no discussion about that.
1. In one comment here (by Sean Duggan) it’s correctly written that all “cheap” commercial BCIs now are fake.
2. It’s true that one can have one-dimensional (up-down) control with EEG-based BCI in healthy subjects. I guess it was EEG that Taub was using, though I haven’t actually seen EEG electrodes.
3. Usually what the subjects are to imagine is something like moving their left arm for moving cursor up and moving their right leg for moving cursor down. This works with something like 80% accuracy, slowly and needs quite a lot of training. Training here means that first you actually do move your left arm and right leg, and the EEG signal is recorded. Then you can go on imagining it. The “training” as it was shown in the episode (try, try, try harder) just doesn’t make any sense.
4. And why the cursor was staying in the middle anyway? There’s a lot of noise in the EEG signals, cursor must have jittered a lot.
5. There was never ever a case of successful BCI with a person in a completely locked-in state. Not a single one. Though people are trying hard (for example, in Tubingen in Germany).
April 1st, 2009 at 5:01 pm
Just two questions — do things like the machine Lee was hooked up to (with the cursor) actually exist? If they do, do they work like that? It seemed rather… Unrealistic, I waned to see if that could actually happen…
And if you’re not supposed to shock a flatline, what do you do?
April 1st, 2009 at 5:21 pm
“The blurry vision was to show the similarity between House and the patient. House is somewhat “locked in” because of his unwillingness to change and seek help.” –
comment:
House is “locked in” because his high intelligence. Higher IQ – higher level of loneliness. He gets everything but cannot express himself because “average” people cannot understand him and his world. Failure to communicate.
April 1st, 2009 at 8:11 pm
D-r Bulgaria; I’m not disputing any of what you said. It makes sense. But, isn’t it a theme in ‘House’ that things can present themselves differently than normal? Wasn’t there a scene where the wife says he “doesn’t complain” about medical issues? How fact can the liver fail? In a day? What if he was skipping lunch (to save $ while looking for a job) and put off any abdominal pain to that? What if he did itch, but thought it was the fact he worked at a battery factory (chemicals, etc)? It certainly doesn’t cover all of the ‘missing’ symptoms, but it might account for a few.
April 1st, 2009 at 11:16 pm
To fk:Well if you put it that way: Yes it is possible for some of the stuff. A liver failure however is a serious condition (they did mention that about 20 times in HOUSE already – for example as early as in season one). A person with a dead liver dies within 24-36 hours from liver toxicity alone so it is unrealistic to think 3 days and no signs at all exept an itchy foot (who started itching on the third day!).
April 2nd, 2009 at 12:26 am
@ Philip – thank you! Makes sense :)
And, slight correction, movie I meant was NOT “The sea inside” but “The diving bell and the butterfly”.
Which in my defense has a lot of sea in it…
April 2nd, 2009 at 2:28 am
Just curious: what’s happened to the House Challenge? (The fact I have Leptospirosis on my list has nothing to do with my curiosity…)
April 2nd, 2009 at 6:43 am
Mos Def also played Ford Prefect in the “Hitchhiker’s Guide to the Galaxy” movie.
I read a terrifying short story by Stephen King about locked-in syndrome recently. I can’t remember the name of the short story, but it’s first person POV. In it, an attorney wakes up on an autopsy table after he got bit by a snake on the golf course, and the toxins put him into a locked-in mode. He can’t do anything to signal that he’s alive.
A fascinating but terrifying short story. I highly recommend it.
Kat
April 2nd, 2009 at 9:02 am
I had a friend who was once shocked by defibrillators…his comment was:
“The one thing they never tell you on TV is how much it freaking hurts!”
April 2nd, 2009 at 9:21 am
On the question about the brain-computer interface, I’m not sure if it’s possible in the way they described (as in, the computer pretty much reads your mind); however, a member on a forum I frequent was in a car accident a couple of years ago and suffered a stroke while in the hospital, resulting in locked-in syndrome. We wondered for months where she’d disappeared, until one day a site member discovered a blog by her mother. Since then, we have been tracking her progress.
Sorry, I had to give a bit of backstory for this to make sense. Anyway, at first she was only able to communicate through blinks. However, she now has a computer program that tracks her eye movement and allows her to communicate by looking at letters. It looks like she is moving on to another program called Brainfingers. It tracks electronic signals from eye movement, facial muscles, and brain waves.
http://www.brainfingers.com/ <<<< Link, if anyone wants to see it.
So, yes, such a software program does exist.
The one thing that got me though was how easily the patient recovered from locked-in syndrome. While it was a nice happy ending, when I first saw the finger movement I thought ‘hey, they’re actually doing this somewhat realistically!’. When he was moving and talking by the end of the episode, that was thrown out the window.
The girl I know with the syndrome has regained a bit of movement, but only such things like the small finger movements. To have the patient recover that quickly seemed to be a slap in the face.
Nonetheless, I enjoyed it.
April 2nd, 2009 at 9:29 am
However, I will admit that a patient who even lost his ability to blink probably wouldn’t be able to use such a computer program. The girl I know has a small degree of movement, making such a thing a lot easier.
April 2nd, 2009 at 9:32 am
Official Comment
The House Challenge is still on, I’m just at my in-law’s and don’t have access to my score spreadsheet. Everything should be updated and posted by this weekend when I get back home.
April 2nd, 2009 at 11:03 am
Thanks, Scott. Right after I posted that comment I thought to myself, “D’uh, new baby!”. Sorry for the impatience.
April 2nd, 2009 at 11:29 am
I LOVED the patient’s inner commentary on House and his team. Very clever and funny!
April 2nd, 2009 at 12:31 pm
I’ll admit that I’m not familiar with Brain-computer interfaces, but this episode really made me interested. Upon reading some of the comments, it is indeed possible. Amazing!
My only question is how long would it take the pt to learn how to communicate in this manner? If someone with locked in syndrome was hooked up to this machine, how long would it take before they were able to move a cursor around? (Like our PotW.)
April 2nd, 2009 at 5:32 pm
@Marc Mielke – April 1st, 2009 at 2:32 am
Do yourself even more of a favor and read the book: “Johnny Got His Gun”. A great read.
We own a recently reproduced copy with a prologue… it’s actually been banned from sale multiple times since its writing (all during times of war not surprisingly).
http://en.wikipedia.org/wiki/Johnny_Got_His_Gun
April 2nd, 2009 at 8:03 pm
The brain interface used in this episode is different from the Brainfingers thing (although that does sound extremely fascinating) because the patient was unable to move at all after the biopsy.
The brain interface featured in this episode seems to be related to an experiment (you can probably find it on youtube) teaching monkeys to move a robotic arm/joystick (that controlled an object on a screen) with their minds.
The monkeys first did the task themselves with the joystick, learning how it worked, and the electrical activity in their brains was recorded during this time. In the later stage of the experiment the monkeys were unable to use the joystick themselves and instead “thought” about the movements they were making before to move the joystick. These “thoughts” were interpreted by the computer (I’m assuming they use the electrical activity from the earlier stage of the experiment as a template of sorts for the computer program) and the cursor moved on the screen. The experiment was advertised as a breakthrough in “reading minds” or something of the like.
This would not have been possible in the scenario presented on house, at least not to the same extent. The electrical activity would likely have to be detected using electrodes (as with the monkeys) and not an electroencephelogram, and I’m sure they would not have risked using electrodes on someone who they already believe has brain damage (or virtually anyone for that matter). Also, even if there was a way to safely read the electrical activity with enough accuracy, the patient would have had to first learn how to control the mouse movements manually, like the monkey did. It’s an interesting concept, and I’m 98% sure they borrowed it from this experiment, but we’re a long way from being able to do anything like that with humans.
April 3rd, 2009 at 4:22 am
Concerning brain-computer interfaces; some Japanese company developed a brain scanning method based on laser technology some years ago. The workings are somewhat comparable to sonar if I remember correctly; you measure the echo of laser beams and from this infer blood flow. This method is therefore comparable to fMRI but somewhat more invasive since the lasers will in fact affect brain temperature. On the other hand it will require less equipment and the Japanese claim they have been able to communicate with locked in patients with this method.
Still, the manner of training BCI in this episode of House is just sloppy TV.
April 3rd, 2009 at 4:38 am
Any reason House, who lives near Philadelphia and New York City would go to a shrink in nowheresville (Apologies to Middletown) a small exburb of New York. It is about 160 miles away just for starters and I can’t imagine to many, if any shrinks, there.
April 3rd, 2009 at 6:29 am
And in case anyone missed the “House” April Fool’s moment:
http://www.youtube.com/watch?v=bryk4_KoO6Y
April 3rd, 2009 at 6:38 am
Hm, I didn´t really get this ep, but maybe because my father was talking on Skype right next to me.
1. In US you get painkillers for scrapes and bruising? And for every bandage change? Wish I lived there!
2. The asymptomatic liver failure kinda puzzled me, too. The guy could ride a bike? And it caused only locking-in with no other lovey side effects?
3. The spoiler warning is a good idea. I´ve done reading spoilers cause I realized I wanna the surprise from the ep. I´m unhappy I know someone´s gonna die etc.
4. I´m curious about the challenge though I know I score 0 again:-)
5. I don´t buy House is seeng a psychiatrist. He surely went to New York for a different reason.
6. Happy we saw Cameron again, though just doing the nurses´s stuff.
April 3rd, 2009 at 7:55 am
House quoted Heroes!!! ‘’save the cheerleader, save the world”
I quite liked the episode this week actually
April 3rd, 2009 at 12:04 pm
The fact that most people with locked-in syndrome die seems like a huge thing to miss…
April 3rd, 2009 at 3:31 pm
Michael, you suck!
April 4th, 2009 at 4:15 pm
It was definitely influenced by The Diving Bell and the Butterfly, but I don’t think that’s a bad thing. It was a great episode and still the most innovative show on TV right now. They actually try new things in a cinematic way, not like most shows. Pablo Picasso said “Good artists copy. Great artists steal.”
April 5th, 2009 at 1:53 pm
I’m noticing a certain diagnosis joining lupus and sarcoidosis as always-suggested-but-never-the-case.
Sadly, “It’s not paraneoplastic syndrome” isn’t so catchy.
April 5th, 2009 at 7:30 pm
Shocked that the elevated bilirubin didn’t show up anywhere considering they spent so much time on the patient’s liver.
It’s routine tests like this that the writers ignore that really throw me out of episodes of House lately, especially this season where the soap opera is definitely not making up for it.
April 6th, 2009 at 2:31 am
In anticipation of tonight’s episode I re-watched this one with some decent translation too. Nothing much to add to the medical nitpicks, I was right the first time and D-r Scott covered it up pretty nicely. On the account of the Lepto one thing puzzled me – at the very beginning of the episode the other doctors (not House or his team) were discussing him as a possible candidate for a heart transplant. Now I am not familiar with transplant protocols (organ transplant that is and heart transplant to be more specific) but don’t they check for infections in that case beforehand? Don’t they do blood cultures or therapy with broad spectrum antibiotics to prevent an infection in the recipient? The recipient is receiving immune-suppression therapy so he is susseptible to infections right? They need to make sure there aren’t infections BEFORE using the heart? D-r Scott I will really be thankful if you clear this issue for me 10x in advance.
April 6th, 2009 at 12:33 pm
Ava — he would go to shrink in the middle of nowhere precisely because he wasn’t likely to see anybody he knew there.
April 6th, 2009 at 6:13 pm
Mos Def is a terrific actor. It’s a shame his talents were wasted playing a vegetable.
April 6th, 2009 at 7:17 pm
Holy heck! Simple explanation.
April 7th, 2009 at 4:50 am
This episode had the two most common — and trite — themes in House — One — House’s reson vs. the patients faith in God, and Two — a patient hiding something from his/her spouse.
April 7th, 2009 at 7:55 pm
The episode didn’t show an interface that “reads your mind”. It seems like what they were saying is that it was based on the pattern that corresponded to the user thinking a specific word. Our school has a wheelchair that operates on a similar principle, except the cues are different (thinking about moving your left hand is the cue, I believe – not necessarily actually moving it).
April 7th, 2009 at 8:57 pm
scott, plasmapheresis can be used for paraneoplastic illnesses, though it is more commonly used for peripheral neurologic Sx (lambert eaton, etc) than central. and no one’s taken issue with house’s dismissal of rotavirus on the basis that the pt didn’t have *bloody* diarrhea? i’m really getting sick of house’s brand of medicine….don’t order *any* tests, jump to conclusions based on next to no info, ignore the complete absence of corroborating symptoms, and dramatically declare that any treatment you give him “could kill him.” house seemed to think it was veritable genius to do an LP and look for PMNs or lymphs. uhhhhhh…standard practice anyone? oh my goodness! what will we geniuses be doing next? getting a white count to corroborate infection? getting coags to confirm a coagulopathy? getting a bmp to confirm electrolyte disturbances? mavericks we are!
this episode sucked. they really need to spend more money on md consultants. there’s no reason it can’t go back to being a little more true to the medicine and still be steeped with drama. right now it’s just a slap in the face to anyone with *any* medical knowledge (and believe me, i’m normally pretty willing to suspend disbelief). i’m not looking for totally credible or complete ddx (how about rapid correction of hyponatremia as one really obvious but omitted explanation?), but for the differential they generate to make *some* sense. the points have already been made by previous posters, but almost every item on their differential was ludicrously at odds with the clinical facts.
April 8th, 2009 at 7:08 am
It seemed to me that the description of training to use the computer interface was grossly oversimplified. There’s no point in telling the patient to keep thinking up – the software would have no way of correlating brain activity when the desired response. It seems more likely to me that the program would prompt for either up or down, and then examine the brain wave responses. Eventually then it could realise that one occurs after a prompt for up, and the other appears after a prompt for down.
April 8th, 2009 at 9:12 am
1) I find it fascinating that so many people here have bumped into “locked-in” syndrome in their entertainment and yet I haven’t. It makes me wonder what the cultural common denominator is with this group. (Hmm, I hated MASH. The past two years have been a pretty amazing drama movie crop, so I passed on Schnabel. And the “Johnny Got His Gun” flick strikes me as obscure as well…)
2) Having said that, I find I really liked this episode a lot. It struck me as the opposite of predictable or hackneyed. I know I’m in for a really bad episode when I see a lot of soap opera (e.g. – Fourteen), and little medical mystery. Not just have the previous episodes been excellent and true to form (medical mystery driving the show), but this one went out in left field as well; the storytelling format was out of the style for the show (patient 1st person, rather than the normal omnipotent spectator). The key is how to get all the House-ism in while in the patient POV. And we saw it in poor Taub, and House/Wilson inter-sniping.
3) Weird. Taub’s the least gifted in all areas (from looks, to brains, to entertaining situations), and I personally tend to have no compassion for the also rans, yet he’s my favorite new character in House merely because he gets the least contrived storylines and personality, and he’s a good enough actor to not drop the ball. (Of course, they wrote out Cutthroat Bitch and Big Love too early.) It also makes me feel bad that I suspect he’ll get the heave-ho sooner than some characters. He’s not the great idea guy for the group. He’d normally be useful as the guy best able to “challenge” House, being the experienced doctor and most professionally centered. But with Foreman around, Taub’s is definitely outclassed and redundant in that role.
4) So, to recap, I don’t get why so many of you are so negative about this episode. It seems to me that the medicine must be incredibly cringeworthy to you guys; enough to ruin your episode enjoyment. But other than that, HOW is it such a hackneyed or substandard episode?
April 10th, 2009 at 4:10 pm
pet peeve of mine:
don’t use Wood’s lamp with fluorescein dye. Use the Cobalt blue filter on the ophthalmoscope.
1. UV light not good for retina.
2. Flourescein absorbs blue and gives off yellow/green. Does not absorb UV.
now if i can convince all the other IM, peds, and ER docs.
April 13th, 2009 at 10:01 am
Hey Scott, I just have a question. I know from reading your reviews that you don’t shock a flatline, so how do you revive a flatline?
On a semi-related note, my badly-translated medical video game appears more medically accurate than House; they’ve never shocked a flatline.
Thanks in advance!
April 13th, 2009 at 10:16 pm
As at least one other commenter posted, this was a direct rip from “The Diving Bell and the Butterfly,” an outstanding movie. I guess for those who didn’t see that, this seemed fresh.
May 15th, 2009 at 10:16 am
If anyone working at a hospital can tell me that it is hard to diagnose that the liver has so completely hit bottom that even the enzymes are not elevated anymore I would be very interested.
June 2nd, 2009 at 7:50 am
best house quote ever : “oh damn! flatline!”
June 30th, 2009 at 8:36 pm
“How did the liver failure affect just the one tiny portion of the brain to cause the locked-in syndrome? Why wouldn’t it affect the rest of the brain?”
Because that’s what the writers wanted to happen. :)
A vegetable or stiff is realistic but it isn’t a reason for them to use this plot device. I liked this plot device btw. I thought the brain computer was a bit contrived even though I know for a fact they exist.
I’ve become accustomed to anticipating to them shocking flatlines. If medical students would simply read this blog the damage would be undone or at least minimise.
June 30th, 2009 at 8:57 pm
This review is depressing. I’m quite happy that I know next to nothing about medicine because I greatly enjoyed this episode. Ignorance is bliss, because it must suck to be unable to enjoy a simple TV show because you can identify all the flaws in it.
Not suggesting you guys are all pompous elitists, but sometimes you have to realize perfect medicine isn’t possible when the writers want to develop drama, which they did quite well in this episode. Just enjoy it rather than whining about a small procedural or factual mistake that ultimately didn’t diminish the entertainment value of the show.
October 15th, 2009 at 4:21 pm
The original doctor at the beginning of the movie says that Lee’s brain wave activity is below the EEG’s noise level – then later in the episode, Lee communicates through a BCI, which essentially works by interpreting brain waves (and thus needs higher brain wave activity than a simple EEG)… WTF? Was the EEG machine broken or something? Maybe it is to further show the stupidity of the original doc – he can’t even use an EEG…
Also, for the 1743rd time (I actually counted the references to it in the comments to make that accurate): Don’t, repeat, do NOT shock a flatline!
December 29th, 2009 at 10:25 am
I really didn’t enjoy this episode at all. I watch House because of House and we got to see so little of him…. I didn’t really care about the patient, so seeing everything from his point of view wasn’t particularly interesting. They did the same POV thing on ER with Cynthia Nixon from Sex and the City and it wasn’t particularly interesting there either.
February 15th, 2010 at 6:05 pm
Of course filming from the POV of a person who can’t speak is not an original idea, but then very little in fiction is totally original. You could consider it a tribute to the predecessors, but better than that, as something like a genre. (I know it’s not, the plot content is too narrow for that.) There was a first time for everything we see on TV (or elsewhere, or read, or listen to, for that matter), but that does not make every subsequent occurence of a similar thing a piece of shameless plagiarism. Artists will experiment with other artists’ ideas, sometimes for worse, sometimes for better, and that’s a good thing. It’s explicitly stated that House was based on Holmes, after all, and that doesn’t seem to bother anybody.
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