House – Episode 1 (Season 2): “Acceptance”
A discussion of the medicine in this week’s season premiere of House is below — but be warned — there are spoilers for the episode as well.
A death row inmate is exercising when he starts to hallucinate. When he goes on to develop a rapid heart rate and respiratory distress, a doctor is called to see him. Upon examining the inmate, Dr. House believes that his breathing is bad enough to require intubation and mechanical ventilation, so he admits him to the hospital.
The team’s initial diagnosis is a drug overdose, but the tests all come back negative for drugs. However, the patient’s blood chemistries show a widened anion gap and a metabolic acidosis. Isoniazid (INH) poisoning is a possibility, but House deduces that the patient has tried to kill himself with an overdose of copier fluid. This copier fluid is 90% methanol, so essentially the patient tried to kill himself with wood alcohol. House sits at his bedside and does shots of high-proof rum with him until the poisoning is cured. Strange but true: Grain alcohol (ethanol) is the cure for methanol poisoning, as well as ethylene glycol (antifreeze) poisoning.
House is convinced that the methanol poisoning is not the only diagnosis the patient has. As Dr. Cuddy tries to dicharge the patient, he develops bleeding from some dead bowel which must be surgically removed. Finally, House realizes that this patient has the zebra-of-all-zebras, a pheochromocytoma (a tumor that releases high levels of adrenalin and similar compunds), and this is to blame for his symptoms. The tumor is removed and the patient returned to prison.
Meanwhile, Dr. Cameron has a young patient with lung cancer. Cameron refuses to admit that it’s lung cancer and runs test after test trying to prove it isn’t. Ultimately, after being lectured by both Dr. House and Dr. Wilson, she must tell the patient the truth: she has inoperable cancer and only six months to live.
The medicine in this episode is mostly sound and while I have a few nit-picks, I have no major complaints.
In terms of nit-picks:
- I’m surprised the inmate didn’t have a severely elevated blood pressure with the pheochromocytoma, and I’m equally surprised that his abdominal surgery went so well since pressure on the abdomen is enough to cause the tumor to release a large amount of adrenalin. This sends the blood pressure rocketing dangerously high.
- The patient got over his respiratory depression remarkably quickly — one minute he’s sick enough to require intubation, and the rest of the time he’s fine. (And why wasn’t the endotracheal tube taped in place?)
- It takes a great deal more alcohol than a few shots to clear that much methanol from the body, and that’s why IV ethanol is generally used.
- I can’t believe they used the tattoo-ink-in-the-MRI urban legend; don’t they watch Mythbusters?
- A chest x-ray is not typically obtained for an anemia work-up. Sure the patient had a persistant cough, but she was in clinic to follow up on her anemia.
- As usual, the Young Guns perform every test themselves and the patients recover remarkably quickly.
Drs. House and Wilson were absolutely right to get on Dr. Cameron’s case for the way she handled her patient. She should have been upfront with her from the start. The tests Cameron was ordering were useless anyway — they could only confirm the patient had cancer, not prove she didn’t. Cameron should have gone for the biopsy at the beginning.
This episode earns a B for the mystery and another B for the solution. The medicine receives an A-. The soap opera aspects, which were virtually absent, earn a C.
September 14th, 2005 at 1:28 pm
At my hospital a doctor drinking on duty,and obviously intoxicated,
would be summarily dismissed form our staff.Also he would be referred to our state medical practice board for appropriate sanctions.
Physicians should protest the shoddy depiction of medical ethics
in this episode.
September 14th, 2005 at 6:10 pm
Not to make light of drinking on duty, but really, you don’t want to complain about this episode. (Did they make hte point he was drinking on duty, and remained on duty afterwards? What am I thinking, this is “House”.) The whole point of the character is that, while he may have very high moral standards, his medical ethics are close to zero, if not actively negative. And he is taking all the Young Turks with him. (Only Dr. Wilson seems to be immune, in his role as ineffectual Greek Chorus/Jimmny Cricket.)
Protest the entire show if you must (and maybe someone should), but this episode is hardly the worst of the lot.
September 14th, 2005 at 6:22 pm
My chief problem with the episode is the shoddy teaching practices of House. Cameron wanted was 5 minutes of his time to brain storm and rule out alternative diagnoses, which is what he had been teaching them to do all along. If he had taken the time to discuss the case with her instead of repeatedly shutting her down, they could have worked out a pattern of tests to confirm the diagnosis, Cameron would have been satisfied that it was an untreatable cancer and she could have told the patient much sooner. All the power plays around ordering tests would have been avoided.
September 14th, 2005 at 6:29 pm
Isn’t the description House gives of the effect of the ethanol wrong? I remember him saying something like, “The ethanol is now binding all of that nasty formic acid.” The ethanol is actually keeping the alcohol dehydrogenase from converting methanol to formaldehyde.
September 14th, 2005 at 9:52 pm
Official Comment
Good call, Jeff, I missed that one (though give them a little credit, Formic Acid is close).
Here’s more information on alcohol dehydrogenase — they mention methanol and formaldehyde in the last paragraph.
September 15th, 2005 at 1:22 am
links for 2005-09-15
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September 15th, 2005 at 8:31 am
Frankly I thought Cameron was doing a terrible thing just stringing her patient along like that.
You know, if someone does have six months to live, maybe the polite thing to do is to give them as much of that six months as possible!
September 15th, 2005 at 11:06 pm
–The ethanol is actually keeping the alcohol dehydrogenase from converting methanol to formaldehyde.–
Thanks, I was wondering how ethanol would help with those forms of poisoning.
September 18th, 2005 at 12:26 am
Well I haven’t seen the Mythbuster’s episode that you’re referring to, but I’m pretty sure that anything containing iron could potentially be dangerous. If a tattoo contained enough iron particles I believe it is possible for RF pulses of the MRI machine to heat a tattoo to an uncomfortable level. Please correct me if I’m wrong.
September 18th, 2005 at 9:24 am
I’m a phlebot, and I was disheartened to see Dr. Minion Played By Omar Epps do such a crappy, crappy job of an femoral arterial stick. If the producers didn’t want to deal with a ‘nads camera hot, why not get a phlebot (or a respiratory therapist, even) to do a radial art stick? Frankly, it wouldn’t hurt the patient as badly, and there are fewer risks associated with it.
Oh, wait. This is “House.” The same show where every doctor does their own venipunctures, too.
December 7th, 2005 at 11:23 am
So you’re not accepting further comments on the first-season episodes of HOUSE? Because they did address the issue of clotting and blood thinning at the same time in “The Socratic Method”:
HOUSE: Without Vitamin K, protein C doesn’t work. Without protein C, she clots. Clotting and thinning, all at the same time.
I’m not qualified to judge how realistic this pronouncement is, but they did address the seeming paradox onscreen.
December 28th, 2005 at 8:38 pm
I was just wondering if anyone has an idea of how much $ House might make. Since he’s been fired by 4 administrators, I doubt Cuddy pays him top dollar, but after the transplant surgeon quoted $600K for his salary, I was curious about the head of diagnostic med department at a teaching hospital.
Thanks.
April 26th, 2006 at 10:00 pm
great show, wish you could keep more of such shows on t.v.
May 8th, 2006 at 11:27 pm
When it comes to the methanol poisoning, I guess that you would assume that the patient already had a considerable amount of formic acid in his system due to the metabolization of the methanol. Maybe what is meant by “binding” the formic acid is that no more is formed and what is already there can be excreted. Also, doesn’t methanol poisoning normally progress much faster?
December 14th, 2006 at 11:02 pm
The anion gap link seems to be down.
December 29th, 2006 at 3:17 pm
The tattoo ink in the MRI test on Mythbusters was with a regular, run-of-the-mill tattoo, as far as I know. The concern with MRI machines and tattoo inks involves home-made (prison) or cheaply produced inks which contain a much greater concentration of ferromagnetic elements.
Last time I went with a friend to get a tattoo this whole issue was addressed because my friend had similar concerns. Most high-end tattoo parlours (whatever that means!) use inks which are apparently screened against their contents, some even being hypoallergenic, apparently!
In any case, much thanks for the reviews–I enjoy them immensely (almost more than the eps themselves)!
December 29th, 2006 at 10:25 pm
Official Comment
In one scene on the Mythbusters in question, the team made their own tattoo ink which was basically iron filings with just enough water so it would flow a little. That didn’t heat up in the MRI either.
January 5th, 2007 at 2:46 pm
I’m wondering why they missed an adrenal mass on the MRI if the pheo is treu. When a patient is moving around during a MRI the pictures will be inadequate for interpretation. The diagnosis of a pheo is based on the finding of certain metabolites in the urine. Surgery will be performed after the patient is premedicated with certain anti – hypertensive medication. Has anyone noticed that dr Wilson held the X-ray up side down of the patient with lung cancer. Also I didn’t see any tumor on the X-ray used in the show. In a patient this young with probably lung cancer, one should be sure about the diagnosis and chemotherapy should be thought of.
February 21st, 2007 at 9:13 pm
From wikipedia tattoo article
“There has been concern expressed about the interaction between magnetic resonance imaging (MRI) procedures and tattoo inks, some of which contain trace metals. … The television show MythBusters tested the theory, and found no interaction between tattoo inks and MRI.
…According to the American Chemical society, home-made tattoos, in which metallic inks have been used in larger quantities, cause these reactions.”
House did mention that he bet he got the tats in prison.
April 27th, 2007 at 1:06 pm
AGAIN; Putting iron filings ( in so high levels as sufficeint to kill if used in a tattoo) in an NMR scanner will not heat it up by a single degree.
September 11th, 2007 at 11:33 pm
Yeah – the thing with Mythbusters is that first they test the circumstances, then if that fails, they try to duplicate the result.
The circumstances: tatoos obtained from normal tattoo parlors use ink that contain trace amounts of metals – nowhere near enough to cause a problem in the MRI machine. Myth busted.
The results: that some form of tattoo (say, prison-made or home-made) which can be worn safely by a human (or pig/human analog as seen in the Mythbusters episode), could feasibly contain enough metal to make the MRI machine go hay-wire.
To test this “result,”, they over-did the experiment, hoping for an explosive result. They had to, as Scott said above, use “iron fillings with just enough water” – in other words, pure iron ore floating in solution, and it did nothing to the MRI. Myth completely busted.
If the prison tats seen in House contained even that much metal, they would have killed the wearer. Ergo, the medical advisors look like idiots for further perpetrating a complete myth on the unsuspecting and gullible American public.
November 8th, 2007 at 4:28 pm
How come nobody takes issue with House drinking a half a fifth of Bacardi 151? The guy’s popping, what, twelve to twenty Vicodin a day, and the pills as depicted are always oblong, not round, meaning there’s acetaminophen added. (Note: they always say “Vicodin,” never “hydrocodone.”) Wouldn’t that much ethanol, combined with that much acetaminophen, just about guarantee liver failure?
November 27th, 2007 at 1:08 am
Chris- According to the show, he’s had that leg pain for a good five or six years now. I’d imagine he’d have one hell of a tollerence to Vicodin by this time. Drinking all that 151 along with the pills would most likely just give him a nasty hangover, like the one he walks into work with the next day.
December 29th, 2007 at 3:32 am
Jason- Chris’ issue was with the potential liver damage of the alcohol-acetaminophen combination (acetaminophen- or APAP- is one of the drugs in vicodin, the other being the narcotic analgesic (or opioid) hydrocodone).
In a season 1 episode of House, Cuddy says that when House was hired he took 40mg a day and that he was presently up to 80mg. I think its safe to assume that he takes more than that at the time of this episode, but I’m not sure how much. If he is taking 10mg pills (House is smart, why would he take 5mg pills when he’d be taking 1000mg APAP for every 10mg of hydrocodone instead of 660 if he is taking the 10mg vicodin HP pills?) then if he took 100mgs in a day that would 6600… 400mg short of the 7000mg the below website reports as toxic.
I have chronic pain in my leg as well and I take norco which is the same drug combination as vicodin but 325mgs of APAP for the 5, 7 and 10mg amounts of hydrocodone (vicodin’s 5,7 and 10mg pills contain 500, 750 and 660mg of APAP respectively). I imagine that House would be taking norco to reduce his APAP consumption if it had the same name-recognition that vicodin does. The FDA allows 4 grams of APAP to be consumed daily, or 8 regular vicodin, 5 of the 7.5’s and 6 of 10’s as opposed to 12 of any of the norco strengths.
Back to the issue of House, alcohol and APAP… the below site says that the major concerns for alcohol-APAP are accidental overdose of APAP in alcoholics and intentional overdose. I don’t think House would qualify as an alcoholic and obviously the latter doesn’t matter however if he is taking close to 7000mg and then drinking on top of that, I could see that as potentially very problematic.
http://www.straightdope.com/columns/000929.html
February 23rd, 2008 at 5:02 pm
what is the point of adding so much acetaminophen to hydrocodone pills anyways?
March 14th, 2008 at 2:23 pm
I am the farthest thing from a doctor (I only passed chem in high school- I think) but I did stay at a Holiday Inn Express last night.
Anyways, wiki says this: “Combining an opioid such as hydrocodone with another analgesic can increase the effectiveness of the drug without increasing opioid-related side effects (e.g., nausea, constipation, sedation). Another argument for combining hydrocodone with acetaminophen is that it limits the potential for abuse. In tolerant users, hydrocodone can be taken in large doses relatively safely, but acetaminophen is fatally toxic to the liver in large quantities.”
When I had my wisdom teeth out the doctor told me to take a vicodin and 5 advil twice a day for as long as the pain kept up. I was pretty afraid for my liver, but I stopped needing the vicodin after 3 days.
May 7th, 2008 at 12:43 pm
Zack, Advil is ibuprofen, not acetaminophen; the risk of an overdose is far lower and damage would likely be to your stomach or kidneys, not your liver. Ibuprofen doesn’t “stack” with alcohol the way acetaminophen does, so it’s safe(r) to take when drinking.
Mind you I also am not a doctor; but I’ve done my research on NSAIDs. I was a stressed-out kid.
My understanding of the acetaminophen-in-Vicodin thing is more the latter; to prevent (or lessen, anyway) hydrocodone abuse. Acetaminophen carries a higher danger from overdose than almost all other NSAIDS – though at safe doses it does have fewer side effects. There are hydrocodone pills available that are cut with ibuprofen instead, or with lower doses of acetaminophen (as Brad mentions) but they consistently use the brand name “Vicodin” on House. Perhaps they have a sponsorship from Abbot labs. Heh.
May 21st, 2008 at 12:58 pm
The reason they call it Vicodin on the show is pretty simple. Everyone knows what Vicodin is.
May 22nd, 2008 at 11:17 pm
On the tattoo thing:
I found 4 articles in Medline on Tattoos causing burns in MRI.
2 are available as free full text.
http://www.ajronline.org/cgi/content/full/174/6/1795
and
http://www.ajronline.org/cgi/content/full/183/2/541
Mythbusters may not have been able to do it, and the literature seems to indicate that it is very rare, and more pronounced if the tattoo has circles or coils, but the published literature does lend credence to the hypothesis that burns at tattoo sites can happen.
The remaining two are:
http://www.ncbi.nlm.nih.gov/pubmed/10663745?dopt=Abstract
and
http://www.ncbi.nlm.nih.gov/pubmed/9145144?dopt=Abstract
September 24th, 2008 at 4:52 pm
I don’t get why it matters if Foreman testifies or not- wouldn’t the defense need an expert in the field?
October 2nd, 2008 at 6:48 pm
I was actually thinking of Mythbusters during that scene. Honestly, they need to start doing a little more research for this show.
But, oh well, it’s a medical DRAMA not a MEDICAL drama, so the medicine doesn’t necessarily have to be 100% accurate (although it would be nice).
October 4th, 2008 at 2:37 am
I’m not sure what effect the ratio of alcohol to acetaminophin has, but I have definitely had 7-8 Vicodin–don’t remember if it was 5mg or 7.5mg–and about half of a handle, or a bit more than a full fifth, of 80 proof alcohol in a day, with nothing worse than a brutal hangover to show for it.
I abused alcohol for years, and on the rare occasions when I was prescribed Vicodin–removal of my wisdom teeth, having my knee scoped, etc.–it didn’t stop me from drinking. I also did tend to take the Vicodin in a slightly different manner than prescribed (2 first thing in the morning, then 1 every 3 hours or so, depending on the pain, instead of a simple one every 4 hours). So, that’s basically 4000-7500mg of APAP plus the equivalent of a bit more than half of a fifth of 151-proof rum. I’m not recommending it, just saying it is well within the realm of possibility without any significant short-term health effects. Also, I have about zero tolerance for hydrocodone, though I do, or at least did, have a high alcohol tolerance.
November 3rd, 2008 at 12:11 am
Regarding the very old question from Nancy about House’s salary:
Depends on what you would consider a “crappy salary” for his Fellows. Using the math from one of the Vogler episodes:
A 17% cut on all four salaries would equal 100% of one of the Fellows’ salaries, and my impression is that they all make the same salary. 17 x 3 = 51. Which means House’s 17% is worth about 3 times as much as the other 3.
A quick check online shows an average Neurologist (the only of the three specialties I could find numbers for) at $228k, with the lowest reported at $180k. I doubt anyone would put up with House for a dead minimum salary, so assume about $200k for each Fellow, and House is probably making about $600k, same as the transplant surgeon. Given that House is the head of a department and the other doc was “the worst transplant surgeon in the hospital”, I’d say he’s getting a lot less due to those firings. :-J
November 24th, 2008 at 11:57 pm
I’m no doctor, but I HAD a pheo-Actually it was a Carotid Body Paraganglioma (It was in my neck). Almost 6cm mass that gave me REALLY high BP (210/180) when touched, and it never sent me into a rage and my adrenilin level was like 10X the norm. In fact it made me shut-down from the mind-numbing headache the HBP caused. Since mine was not on my adrenilin gland, I can’t say for sure, but I think the effect of this tumor was VASTLY exagerated in this episode.
February 11th, 2009 at 1:37 pm
I self-diagnosed my own pheochromocytoma in ‘02 and had it removed at Mayo.
I’m no doctor, either.
I agree with Jim. You’re WAY to sick to be flying into rages. My numers were 14x above the norm.
Where was the hugely elevated BP, the headaches, the cardiac irregularities, etc.
Perhaps more importantly, where was the alpha blockade prior to surgery?
Surpised that House didn’t kill the guy by not administering it.
June 8th, 2009 at 10:07 pm
Guys with the Pheo, you’re right about not having the rage in your symptoms, but that does not mean it would not occur with any other patient….. cause it is really one of the symptoms of the tumor…
July 22nd, 2009 at 1:24 am
anybody else notice that stacy is wearing a lab coat when house comes in hung over? Why would a lawyer wear a lab coat.
July 31st, 2009 at 1:52 pm
Stacy might be wearing a lab coat if she was talking to patients or staff in a patient area. She might cover up so that all the ‘bugs’ from the outside weren’t contaminating the patients. It’s a bit of a stretch, but if she regularly works in a hospital it’s a possibility at least. Maybe?
As for the Vicodin and alcohol – both are metabolized by the cytochrome P450 pathway in the liver. If house has been banging back the Vicodin AND he’s a drinker (which he seems to be) then he’s a P450 pathway that could metabolize paint. So yeah, he could probably take it.
Incidentally, it’s a clinically useful question to ask patients how many drinks it takes for them to get drunk before you give narcotics because it gives you an idea of what their P450 pathway strength is and therefore how much narcotic you need to give.
October 3rd, 2009 at 1:42 am
I have a nose piercing, stainless steel, and abdominal MRIs with it in were no problem. My ring was difficult to remove so the tech let me keep it in so long as it didn’t hurt.
My real issue with this show is that everyone magically heals. No terrible chronic diseases, slow deaths or lasting pain. As a chronic pain sufferer this is frustrating and reinforces the idea that illness is quickly and easily fixed.
October 6th, 2009 at 1:15 pm
Summer: Umm… no lasting pain? Are we watching the same show? Maybe House pops Vicodins because he likes the taste? :)
October 11th, 2009 at 2:08 am
Are those true-to-life rates of pay? I’m just surprised because I expected American doctors to be making much more than Canadian ones, who are being paid by the government. While these are rates for the more prosperous areas of the country, I know of a hospital doctor who makes CAD500k and a neurosurgeon who makes CAD800k. I suppose if you convert (depending on the month, these days) and add the large income tax, it evens out.
December 13th, 2009 at 7:04 pm
Dyvid,
I thought it was a lab coat, but closer inspection suggests (to me, anyway) that it was just a coat of similar (but different) cut.
December 31st, 2009 at 9:20 pm
where are you guys getting these numbers from? i thought doctors only made about 100k a year.
January 1st, 2010 at 6:19 am
Official Comment
Here’s a fairly recent list of average physician salaries in the US
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