House – episode 18
Yarr, mateys! Thar be spoilers below!
A pregnant woman has is admitted to the hospital for changes in her mental status. Dr. Chase suspects that this is pre-eclampsia (sometimes called “toxemia of pregnancy”) – but seems not to notice that she is missing the three cardinal signs: edema in the feet, high blood pressure and protein in the urine. Sure, she has some abnormal liver labs and that does happen with pre-eclampsia, so I’ll give him a pass on this one. Dr. Foreman thinks that she has some form of vasculitis. Dr. Cameron…isn’t around because she quit last week. Labs and radiology studies quickly show that both of these diagnoses are wrong.
When the patient develops trouble swallowing, House orders a CT scan of her chest which shows a prominent lung cancer. Her neurological symptoms were due to a paraneoplastic syndrome caused by this cancer. This is a very aggressive cancer and Dr. Wilson wants to start treatment as soon as possible. This would require an immediate caesarean section, but the patient refuses because she wants to carry the baby longer and give it a better chance at life. She confides to House that her first child died of Alexander’s Disease and she wants to give this second baby every chance. He reassures her that babies born at 28 weeks gestation (as opposed to the normal 40) have a high survival rate and ultimately she agrees to the c-section.
House enrolls her in an experimental study, but she is turned down abruptly once the researcher in charge is informed she is pregnant. Before any other action can be taken, the patient develops a pulmonary embolus. House presents her husband with a choice: his wife or the baby, because he states that a c-section will kill her “in her weakened condition”, but treating the pulmonary embolus will most likely kill the baby. The husband chooses his wife, but she hemorrhages during the procedure and as she dies a c-section is performed to save the baby.
A strong episode that was never going to have a happy ending. The medicine was pretty good. I’m disappointed in Dr. Chase’s call of pre-eclampsia (as I explained earlier), but Foreman’s theory made sense. The lung cancer and paraneoplastic syndrome diagnosis made for some good drama. House is right that the survival rate for a 28-week premature infant is decent, but he neglects to point out the key fact that most of these premature babies have severe problems both in the nurseyr and later on in life. The wife-or-baby choice seems a little forces and I can’t really see why they can’t try both (but then I’m not an obstetrician or a critical care physician).
Some nit-picks:
1) The doctors are once again doing their own ultrasounds (and how good is ultrasound at picking up a pulmonay embolus? There are much better options).
2) Isn’t it convenient that the MRI crash cart had terbutaline (a drug not normally — or ever! — included in a crash cart).
3) Finally, the infant, while small, was about twice the size of a 28-week premature baby (but I’ll admit it’s hard to find a premature baby actor).
4) The treatment of the patient’s flatline (asystole) was wrong.
The soap opera was excellent on both fronts. The patient and her husband had tough choices to make. More importanlty, Dr. House’s feud with Vogler came to a head this episode. Vogler called an executive committee meeting to revoke House’s tenure. He threatened to take back his 100-million-dollar “gift” if House remained on the faculty. This cowed everybody into siding with him except Dr. Wilson. Vogler then tried to revoke Wilson’s tenure – when that didn’t work he kicked him off the board so Dr. Wilson resigned from the hospital instead. The next night Vogler called another committee meeting. This time, Dr. Cutty stood up to Vogler and in the end House stayed and Vogler and his money walked. This was good drama.
This episode deserves a B+ for the mystery and an A- for the solution. The medicine this week only receives a C (due to Chase’s incorrect diagnosis and House withholding key facts from the patient). The soap opera aspects earn an A+.
December 6th, 2006 at 4:17 pm
Hey, i was wondering: How come they used ultrasound to diagnose pre-eclampsia? What were they looking for?
December 9th, 2006 at 7:09 pm
I would say that using an ultrasound to diagnose a pulmonary embolus is pretty unusual. There is no way to get a clear view of the pulmonary arteries through all the air in the lung. I had never before heard of this ever being done in clinical practice so I did do a search and did find a study regarding transthoracic ultrasound for peripheral P.E.’s but it is nowhere near standard of care.
Now, an echocardiogram may show right ventricular dilatation and doppler may show acute pulmonary hypertension, both which may suggest pulmonary embolism.
The idea that 2 fellows could do their own bedside ultrasound and diagnose a saddle-embolus is stretching credibility quite a bit.
December 13th, 2006 at 4:50 pm
I work at tornto general and I do all my scans bedside. I find it easier and i usualy have my team diagnose while i work away with my patient. I’ve been told that i act like house. srry no cane :(
June 19th, 2007 at 6:11 am
Good review, but Wilson didn’t resign. Vogler proposed a motion to *dismiss* (i.e. fire) Dr. James Wilson, which passed.
July 8th, 2007 at 7:55 pm
Wilson did resign. He tells House later that the motion to dismiss him was defeated because four people voted to keep him, but Vogler still kicked him off the Board. Vogler then offered Wilson the chance to resign, which Wilson accepted.
July 16th, 2007 at 7:34 am
I didn’t notice that part. I’ll have to rewatch it again.
December 28th, 2007 at 12:35 am
Focusing on the soap-opera aspects, I didn’t understand why Wilson prefered to resign so fast, he could have resisted a bit. But I guess it wasn’t so strange, he wouldn’t have liked to stay there working under those conditions. And I guess having him out of the hospital because of Vogler helped the rest of the board to vote against the ugly millonaire.
January 14th, 2008 at 4:55 am
I’m a bit disappointed you don’t mention the ptosis (eyelid droop) that suggested the cancer diagnosis. I recently learned the etiology for this and it’s pretty interesting. It’s not unheard of for a lung cancer tumor in an upper lobe to put pressure on the sympathetic chain, paralyzing the sympathetic nervous system supply to the face. This causes the Horner’s syndrome, which is what I think the writers were going for. Symptoms would include ptosis, anhidrosis of the face, and miosis (constricted pupil), on the ipsilateral side.
January 15th, 2008 at 3:55 am
I’ve been watching this episode along with medicine student and she was disapointed by the fact that small-cell lung cancer was diagnosed solely by chest x-ray examination. “You need a pathologist with a microscope to determine the histology” she said; I don’t know much about medicine, but I was wandering… maybe they figured that out by other clues (couldn’t LEMS give them a hint?) – is it possible?
February 13th, 2008 at 3:29 pm
I was so pissed at Vogler in this. He claims that House is everything wrong with the health care system, while in fact he and people like him are. House and other doctors save lives, while people like Vogler make millions by ripping off sick people. Really, Cuddy made the right call. It was the thing to do for anyone with principle.
What about Chase, Dr. Scott? I have always wondered if what he did was okay. It seemed downright betrayal to me but then what I really know about medicine? I was quite mad at him in the end hen he shared drinks in the celebration though, as if he wasn’t Boss’ boy.
March 28th, 2008 at 3:49 am
Kardelen, I assume that Dr. Chase was worried about his job since he liked working in the hospital, so he tried that method. It wasn’t an honest method but House was a risky party to side with during this as was shown by Dr. Wilson’s dismissal. Vogler is what is wrong with healthcare and seemed quite the dictator. It was clear from the second episode that he was in, if not before then, that the only reason he was there was to make himself more money than the 100 million he invested.
April 7th, 2008 at 7:16 am
Don’t they mix up Lambert-Eaton syndrome with Horner’s syndrome when House notices the eyelid ptosis?
May 9th, 2008 at 3:37 pm
There is no way that a 28-weeker comes out of the womb kicking and screaming with what must have been Apgars of 9. I didn’t hear anyone during the episode mention the mom being dosed with steroids to hasten his lung function, either.
May 24th, 2008 at 4:00 am
I just watched this episode – I’m not a medical professional but my son was born at 27 weeks gestation late last year. Having been through his birth by emergency C-section and his subsequent 10-week hospitalization, I found the handling of the premature baby issues to be some much-needed comic relief in a rather emotionally heavy episode.
The errors in the portrayal of the medicine, even from my layman’s point of view, were hilarious. The baby’s condition at delivery was, as has been pointed out, ridiculous, and a 28-weeker is a skinny, scrawny little thing, as no significant fat has accumulated yet. And where were the neonatologists who would have been all over the place, resuscitating and assessing him?
Scott, or any other actual medical practitioner who is still reading this 3-year-old post: it’s mentioned above that “House is right that the survival rate for a 28-week premature infant is decent, but he neglects to point out the key fact that most of these premature babies have severe problems both in the nursery and later on in life.” I was told that this actually depends more on the cause of the prematurity than the gestational age at delivery: a 28-weeker with no congenital abnormalities and no placental problems will usually have a better long-term prognosis than a 33-weeker with a birth defect or a low weight for gestational age – even without the benefit of the steroid shots for the lungs. They’ll require respiratory support for weeks or even months (may go home with oxygen) and could have digestive issues that might take a while and some surgeries and tubes to manage, but my impression was that most of these problems resolve with little permanent damage before the end of infancy.
Indeed, my son and the majority of 26-30 week premies we met during his hospitalization are all developing normally for their corrected ages. Out of 10 babies I’m thinking of, one 26-weeker is still tube-fed at 4 months corrected – no other known medical or developmental problems. That’s by no means a rigorous study, but are all these babies just lucky, or have treatments improved that much in 3 years? I know a lot of the therapies in use now are very recent.
July 3rd, 2008 at 10:54 pm
@Jamie and @Mouse:
My son Paddy was delivered by Caesarian at 26 weeks, (due to Pre-Eclampsia), & he had a near-perfect APGAR score. He also had a full head of hair & was yelling his tiny lungs out. :^)
The operating room was standing-room only, with around 8 medical personnel.
Paddy’s now 7 years old & is developmentally maybe a year or two behind full-term kids of the same age, but otherwise very normal.
It’s true that the premmie in the show would be tiny & skinny, but it’s obviously not possible to put a newborn premmie in a TV show!
August 25th, 2008 at 10:02 am
Bad explanation of the mechanism of paraneoplastic syndrome. Not for the first time in this series.
December 1st, 2008 at 11:02 pm
Saw this one for the first time tonight and the part that bugs me is this: how can Vogler “take back” his $100 donation? I wasn’t aware the charitable donations were refundable. Now, I could see him threatening to resign and thus take away his future support, but I don’t get how he could take back money he’s already given to the hospital.
December 21st, 2008 at 11:37 am
Re: taking back the gift.
I assume that Vogler had promissed donations of up to 100-million over a period of time (possibly through a foundation or something similar).
His angle was clearly to trade money for influence, so I don’t think he would have donated the money all in one go with no strings attached…
March 3rd, 2009 at 10:07 pm
How was the medicine for the second child in the episode? The vegan’s baby diagnosed with DiGeorge’s syndrome?
(Saw this episode 3 years late!)
March 25th, 2009 at 6:00 pm
As an ICU nurse that has to transport patients for CTPA all the time I only WISH it could be done by ultrasound!!!
October 3rd, 2009 at 9:33 am
They might have set the terbutaline out ahead of time, knowing she was pregent and had miscarried three times before. In fact, I can’t imagine that they would’nt have prepares a crashcart specfically for someone who was pregant.
October 3rd, 2009 at 9:35 am
pregnant* etc ..Forgive us our typos as we forgive those who typo against us ;/ (I blame 3 hours sleep however ;p )
November 8th, 2009 at 9:06 pm
I know I’m missing something, so please help me out: whats so funny about Olive Kaplan’s name?
November 9th, 2009 at 2:17 pm
Is it possible for so serious lung cancer to be discovered SO suddenly?!
Was it really no symptoms (like blood cough. etc.) before?
September 18th, 2010 at 8:43 pm
Olive Kaplan is a funny name for a baby of vegan parents, because those are both names for very non-vegan violin strings. Olive and Kaplan strings are made from tissue from the lining of an animals intestines (catgut).
November 17th, 2010 at 10:16 am
Hey there! I need to know what’s the relation between the name of the episode and what happens in it… I still don’t get the bathwater part…Thanks!
December 3rd, 2010 at 1:16 am
Bathwater is Vogler, what needs to be thrown away.
Actually if I were Cuddy or Wilson I will say at the board “This is how Vogler treat anyone who disagree with him. Anyone may be the next one.”
January 11th, 2011 at 4:14 am
I didn’t get, why the pregnant lady was taking oxybutinin and House blamed her for that saying she wanted to kill herself. Can somebody explain this to me?
January 14th, 2011 at 10:06 am
Very bad choice for small lung cancer, as it happens only to old people who heavy smokers, I don’t think it ever happens to someone young and not a smoker, they should used adenocarcinoma instead.
Lambert-Eaton syndrome causes ptosis, so this is right.
They did an X-ray to diagnose small cell lung cancer in a pregnant woman!!! Get me out of this!! They simply should have done an MRI of her chest
January 14th, 2011 at 10:50 am
Official Comment
Small cell lung cancer, though much more common in smokers, can rarely appear in non-smokers as well. The best known recent case is probably Dana Reeve, wife of Superman actor Christopher Reeve.
June 2nd, 2011 at 8:20 am
Hi Scott, I’m really enjoying the commentary on house here. I have one small comment. In the scene where they are shocking the woman at the end the sound effect is the asystole tone but the screen shows v – fib so your comment about the wrong treatment for a flatline is only half a criticism. :)
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