House – Episode 3 (Season 2): “Humpty Dumpty”
House spoilers and review below.
A good episode of House this week. One of the better episodes of the series, actually.
Alfredo, a young handyman working on Dr. Cuddy’s house suddenly falls off the roof. In the ambulance on the way to the hospital Cuddy notices that several fingers on his right hand are turning dark and dusky. When prompted, Alfredo mentions decreased sensation in these fingers. These are new symptoms; he’s never had them before. The medical team’s first thought is that the patient has Disseminated Intravascular Coagulation (DIC), a condition where the clotting system in the body goes haywire. Cuddy decides to start him on Activated Protein C (brand name Xigris), a new drug with some serious side effects. Sure enough, the drug causes Alfredo to develop a bleed in the brain that needs surgery to correct.
The chest x-ray come back and show that Alfredo has some sort of pneumonia. The basic tests and blood cultures are all negative. Drs. Cuddy and Cameron search Alfredo’s house. They find a dead rat and decide that Alfredo must be suffering from rat bite fever. Meanwhile, Drs. House, Chase and Foreman search Cuddy’s house and find some mold growing in the bathroom that House suspects is the cause of Alfredo’s pneumonia. Cuddy starts him on Amphotericin B believing that he has Aspergillosis. Amphotericin also has some potent side effects and Alfredo starts to develop kidney damage.
Since the pneumonia did not respond to the Amphotericin, House decides that it must not be Aspergillosis. The gang goes over a variety of causes of atypical pneumonia, but none of them fit the case. House checks on Alfredo’s temperature and notices that his left right hand is turning gangrenous. The hand is amputated before the infection can spread, but then Chase notices that the fingers on the other hand are starting to look a little dusky as well. Belatedly, House realizes that Alfredo has developed Psittacosis from his Saturday night job — working with the roosters at the neighborhood cock fights. Doxycycline is started and the Psittacosis clears up (and presumably the DIC along with it).
My major medical complaint was Dr. Cuddy’s use of Xigris. This drug is only designed for use in patients in sepsis (an overwhelming infection of the body), and Alfredo was not septic. It is a risky drug and her incorrect use of it is both medically and legally indefensible.
Nit-picks? I have a few: Psittacosis isn’t that far-fetched a diagnosis and the team should have figured it out sooner. The surgery team wasn’t wearing proper eye protection. Finally, I would have liked to see more attention paid to the DIC diagnosis, particularly since that was a large part of Alfredo’s problem.
I was glad to see the return of some of the soap opera. There was more interaction between the main characters this episode than the previous two combined. The scene between Foreman and House about the treatment of black patients was particularly well done. On the flip side, I thought the touchy-feely scene at the end with House and Cuddy didn’t fit well with House’s character at all.
The mystery earns an A with the ultimate solution getting a A- (they should have pegged the Psittacosis sooner). The medicine earns a B+. The soap opera earns an A-.
The absolutely worst thing about House? We have to wait a month to see another new episode.
UPDATE (25 Sept 05):
FYI, according to the CDC and this week’s MMWR, there have been 15 cases of Psittacosis reported so far in 2005. However, it should be noted that not every state requires that Psittacosis be reported.
September 28th, 2005 at 8:22 am
Random Amphotericin antecdote. The mother of a man that I used to go to church with discovered Amphotericin. I’m surprised that you didn’t mention its nickname, “Amphoterrible.”
September 28th, 2005 at 4:27 pm
How does Foreman’s reaction to his patient seeking a second (and threatening to find a third) opinion differ from Cameron’s attachment to the cancer patient in the first episode this season? In both cases it seems like you’ve got a doctor going out of their way to help someone when a diagnosis has been given, is there difference I’m missing?
September 28th, 2005 at 4:42 pm
Official Comment
I think the main difference is that Cameron’s attachment was inhibiting her from practicing good medicine — she could not tell the patient the unpleasant truth. Foreman, on the other hand, wanted his patient to have the best medicine and wanted him to have the truth (though the medicine in question is really not any better than much cheaper alternatives).
Patients seek second opinions all the time. It can be a blow to the ego sometimes, but it’s something you learn to live with.
September 28th, 2005 at 4:52 pm
If they had figured out that it was Psittacosis shortly after he was admitted, could they have save the hand?
Also, it does seem to me that Chase should have recognized the claw marks on his hand and known that they weren’t construction related.
September 28th, 2005 at 5:11 pm
Official Comment
If they had recognized the Psittacosis sooner, the docs would have had a better chance of saving the hand, though it would still be touch and go. The blockage leading to the hand dying was from the DIC which was from the Psittacosis. The best treatment for DIC is to correct the underlying problem, though it’s not an instantaneous fix. Blood thinners have some effect in DIC too, and they did intially started Alfredo on Heparin (a blood thinner)– though that had to be stopped when he had the bleed around his brain.
I think Chase should have recognized they weren’t construction injuries too, but maybe Alfredo was building chicken coops. Chase probably should have asked what he was constructing.
September 29th, 2005 at 5:59 pm
Wasn’t it his right hand that was amputated due to gangrene?
My real reason for posting, though, is to say thank you for these write-ups. I started watching the show over the summer because of them.
September 29th, 2005 at 10:43 pm
Official Comment
Johanna, glad you like the show (and my write-ups). And you’re right, I did have the hands backwards.
October 24th, 2005 at 1:05 pm
Another nitpick, from a friend of mine who’s an EMT: the neck brace that they had him in during the ambulance ride was installed all wrong.
Question: I was under the impression that doctors would give antibiotics when they don’t completely understand. House is a diagnostician, but had they just randomly given the guy an antibiotic on the off chance it was a bacterial infection, how much harm would it have been done? Had they done it on day 1, they might even have saved the guy’s hand. I know there are downsides to antibiotics, but can you elaborate?
I am, BTW, immensely grateful for your reviews.
April 23rd, 2006 at 7:34 pm
it is wierd to me that there wasn´t anything to see in the Ecocardio in the clamidia pshitashi endocarditis episode..(humpty dumpty i guess ). they should performence a trans esofagial Echo to rule out a vegetation or a clot in this heart.. anyway . . the show is the best..
December 15th, 2006 at 12:34 am
As a EMT myself…. along with the neck brace not being the right size and being off center, and ummm NO head blocks… or no staps that go with the spinal board that he is strapped to… right? LOL My husband and I are vivid fans, but like anyone else we nit pick things. I know its not a medical show but come on some things are just plain COMMON SENSE. If your going to use the every day things like an ambulance and the equipment we are properly trained on… do a lil research and show the viewers that you are a lil up to date with the workings of the emergency end that gets your patients to you….
December 15th, 2006 at 12:47 am
Generally, as an EMT, when I show up on scene (especially to a trauma scene) I am not going to just take a bystander’s word that they are a doctor and then take backseat to them. If a person can properly convince me that they are indeed a doctor, then I may allow them to give me advice, where appropriate. But, doctors for the the most part are not trained in field medicine and do not have the proper qualifications to stabalize and transport a patient to the ED. Case-in-point is how Cuddy starts doing a spinal exam in the back of a moving ambulance after the patient has already been given full spinal precautions (well, sorta… see above). Any field personnel can tell you that all of that would have been thoroughly performed on an otherwise stable patient long before, during, and after the back boarding evolution and definately not in the back of a moving ambulance!
Whew! I feel better now! Finally something that a lowly EMT can nit-pik with all the doctors around! He he…
July 29th, 2007 at 5:14 pm
I’m not a doctor or even a medical student, but I understood that, according to the show, DIC actually didn’t cause his fingers to drop off. It was endocarditis which was concealed somehow by psittacosis. Whether this endocarditis was actually from psittacosis or some other bacterium remained unclear.
December 11th, 2007 at 3:15 pm
The infection causing the endocarditis caused the DIC.
Also, there is one other major GLARING error. Chlamydia pssitaci grows extremely readily in culture (contrary to House’s clue for Chase), so readily as a matter fact, that it’s a safety hazard to culture it in a normal lab, as it might be inhaled by someone and further spread.
Also, I’m going out on a limb on this one…but I feel like his asthma medication would have made him more susceptible to the infection…not the actual asthma.
February 2nd, 2008 at 12:40 am
Just curious, but with this episode playing now on USA, I’m revisiting some questions I had…
Would EMT’s/Paramedics have actually allowed Cuddy on the ambulance? I thought that was extremely limited. Unless the ambulance was for her hospital only and she was their superior?
When she checks for a broken rib, why not just wait for an x-ray instead of risking puncturing a lung or his heart?
It also really pisses me off how quickly they prescribe a medicine. Why risk it before you’ve even seen all the tests? Like assuming DIC and starting him on Activated Protein C. I hope an actual diagnostician doesn’t do the same.
April 18th, 2008 at 10:54 pm
I just wonder how did dr.house think that it is psittacosis,???I mean there are other bugs that can cause same lesion(culture-negative endocarditis+pneumonia) such as bartonella and coxiella …..he just went for psittacosis ,ignoring other bugs,although when he diagnosed it like that he did no nothing about the guy’s job with birds….
June 11th, 2008 at 8:11 pm
@Aaron:
“I’m surprised that you didn’t mention its nickname, ‘Amphoterrible.’ ”
House himself did in the episode.
June 11th, 2008 at 8:43 pm
@MBS: I’m pretty sure that bartonella, which varies widely according to strain, also presents with more than those two symptoms.
And coxiella, if what I read about it a few months ago was correct, also presents with headaches, respiratory symptoms, and chills.
But I’m not a doctor, so I could be wrong.
July 5th, 2008 at 11:17 pm
how does Psittacosis cause gangrene..these 2 dont seem to go together
September 5th, 2008 at 7:04 pm
Having been an EMT for some time, I just wanted to point out one technical note on Alfredo’s transport to the hospital. They have him on the backboard, and a cervical collar on his neck, which was the correct thing to do given the mechanism of injury. However for full spinal immobilization he should have had the CID blocks on either side of his head to further prevent it from moving.
My guess is that they were intentionally left out so they wouldn’t get in the way of the camera’s view.
September 5th, 2008 at 7:19 pm
@ Paul:
I don’t know about New Jersey where this is based, but I know that in PA, yes she could hop in the back of the ambulance. However, any doctor on the scene that wants to take charge of the patient’s care MUST do so until care has been properly transfered to the receiving facility. Failure to do so constitutes abandonment.
This is to prevent doctors who are on scene from saying “give medicine X, do this procedure” and interfering with the medics or EMTs who are actually giving the prehospital care.
September 27th, 2008 at 3:07 pm
I loved this line: “Aren’t pinkies pink? I mean… they don’t call them gray-ies” haha!
January 8th, 2009 at 2:51 pm
I thought Foreman’s comparison of House to a slaveowner was a little much… I mean, if the patient was tricked that easily, he wasn’t really paying attention. And House didn’t say he was giving the black patient the same medicine they give white people, he said it was the same medicine they give republicans. It would be different if the patient had said he felt the medication was too expensive and wanted a generic prescription, but he just insinuated that the doctors didn’t have his best interests at heart rather than having any problem with the medication itself.
April 10th, 2009 at 10:50 pm
@ Beth:
The republican thing was a joke; later on Foreman says the patient himself said House gave him “the white stuff”. But I too think Foreman’s comparison was too much, what was House supposed to do if the man was irreductible? I guess he should have let the idiot die drowned in his own hypocrisis after all, aparently he didn’t want the “black stuff” because he thought that’s what white people wanted to give him to NOT cure him but at the same time he trusted more a white doctor than a black one. The sad thing is that there are people like that.
And I didn’t think the House and Cuddy’s scene at the end was out of character. Stacy had already asked House to cut Cuddy some slack and in the end Stacy gives House a look as for him to say something to make her feel better, and as we have now seen in 4th’s season finale, House Is capable of doing things for people he cares about(especially because there are so few of those).
June 28th, 2009 at 11:52 pm
Hi, thanks again for these follow ups -as we say in medicine- for the show, but I had a not regarding the renal damage due to the Amphotericin, I think the damage was a little bit fast, no drug can cause renal failure that much fast, unless it is a real poison! And they should have monitored his renal function (Urea and Creatinine), not waiting until his family tell about the anuria!!!
September 17th, 2009 at 6:39 pm
When Cuddy mentions Xigris, House proclaims it “borderline irresponsible”, which got a chuckle out of me; I was thinking it was fully irresponsible. The drug is basically only used when people are so sick that they’ll probably die of sepsis anyways. Literally: when used in patients at lower risk of death it has no benefit and increases serious bleeds.
Also, I’m not a doctor but I would expect that falling off a roof might count as “trauma with an increased risk of life-threatening bleed”, another contraindication to its use.
November 5th, 2009 at 12:53 am
Cuddy (sp?) is the head of the hospital..she lives in a …middle class house… O.O
December 22nd, 2009 at 12:26 am
Anyone noticed that Cameron was using the stethoscope backwards? I mean with the olives pointing to her face!! And also with the Littman symbol upwards?? i know with a littman classic ii you have double diaphagm, but is not really the best for listening to the chest
December 22nd, 2009 at 12:27 am
sorry i meant olives pointing to her neck !:P
January 28th, 2010 at 7:53 pm
It was pretty obvious for me that Cuddy called her own hospital to get an ambulance. And that’s why they let her care about the patient – they knew her.
Further, the team brought up psittacosis earlier. But they excluded it based on the interview: “he does not have any birds”, nor is he working with birds (they didn’t know about cockfights).
March 9th, 2010 at 1:37 am
I found the “black” medication to be both interesting and odd — but not all because of the show itself. They had to be referring to BiDil, a heart medication that was approved by the FDA in 2005 for use in African Americans.
Here’s the thing: there are lots of drugs to treat high blood pressure. Some work in the renin-angiotensin system, a hormone system used by the kidneys to regular blood pressure. This includes ACE inhibitors and angiotensin-receptor blockers. There are studies showing a racial difference in the response to these drugs — blacks don’t respond as well as whites. This is still under discussion, because there are other studies where the difference disappears with dosage adjustments or combination therapy.
Blacks respond better to other drugs that treat blood pressure, such as diuretics, vasodilators, and calcium channel blockers. There are many well-established drugs used in whites and blacks alike. One is hydralazine; it’s been around for decades. There is also a heart medication (vasodilator) called isosorbide dinitrate… also been around for decades. They’re as “white” as anything. BiDil is simply a combination of hydralazine and isosorbide dinitrate in one pill. Why is it approved for black people? Because its manufacturer did successful clinical trials in (self-identified) African Americans. This is primarily a marketing strategy. It doesn’t mean that the combination wouldn’t work well in whites, or that the same result couldn’t be less expensively achieved in two pills (one hydralazine, one isosorbide dinitrate).
The issue of race/genes is complicated by the fact that in this country there is a lot of mixed heritage. Just because someone is black doesn’t mean that they’ll necessarily be worst off with ACE inhibitor monotherapy and best off with BiDil. When all else is equal, it may be a good starting point, but only time will tell.
In the future we may have far better predictors of how a given patient will respond than superficial race.
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