Despite the presence of John Larroquette, this is a confused mish-mash of an episode with poorly thought out medicine and unexciting soap opera. Still, it was better than an episode of Manimal. There are spoilers in the medical review of House below, so consider yourself warned.
House is eating lunch and watching television in a ward dedicated to patients in a persistent vegetative state when Kyle, the son of one of the patients, comes in to visit his father. House has noticed that Kyle has akinetopsia, an inability to detect objects in motion. House mentions that people with intermittent akinetopsia like Kyle often have seizures as well, and he flicks the lights on and off to see if he can induce a seizure. He does — Kyle has a generalized seizure and ends up admitted to House’s service. The team discovers that he’s had seizures before, and has had them worked-up but the tests have always been negative. They also discover that he’s an alcoholic.
The initial differential diagnosis of Kyle’s seizures includes infection, brain tumor, or trauma. House suspects Kyle might have an inherited disease. He has the team test for adrenomyeloneuropathy, but the tests come back negative. He then wants to test for Unverricht-Lundborg Disease and Late-Onset Lafora’s. These are all rare inherited diseases that have seizures as symptoms.
While being interviewed, Kyle complains of nausea. On exam, he shows right upper quadrant abdominal tenderness and begins to cough up blood. Foreman order an immediate transfusion. He is noted to be slipping into a coma and is a “4 on the RLAS scale” (The Rancho Los Amigos Scale is a scale used to assess the severity of head trauma and coma patients. By the way, you’ll notice the S stands for “scale” so “RLAS scale” is redundant, but the characters said it that way so I’ll stick with it.). His kidneys are soon failing as well and he is started on dialysis.
House decides the only way to get information about Kyle is to wake up his father who has been in the persistent vegetative state for ten years. Using a combination of L-dopa (the drug used by the doctor in Awakenings), amphetamines, a secret South American African drug, and eleven herbs and spices, House manages to wake Kyle’s father Gabriel.
Gabriel understands the medications are only temporary, and in twenty-four hours or so he will slip back into his vegetative state for good. He lets House know that he’ll only answer his questions if House will take him to get a hoagie at his favorite sandwich shop in Atlantic City. House, Gabriel, and Wilson all pile into Wilson’s car and take a road trip to Atlantic City. When they can’t find the sub shop, they end up sharing a hotel room at a casino. Gabriel tells House know that for each question he answers for House, House has to answer one for him. What follows is an exchange of personal and family history — medical and otherwise — with occasional interjections from Wilson.
Back at the hospital, Kyle is getting worse; he’s now a 3 on the RLAS scale. After talking with his father, House decides that Kyle may have mercury poisoning from exposures at his father’s factory years ago. He is started on chelation therapy to remove the mercury, but his labs show no evidence of mercury so that diagnosis is wrong. Kyle’s blood pressure and oxygen saturation drop. His heart rhythm is abnormally fast so he is given an injection of epinephrine. An echocardiogram is attempted, but he has another seizure while undergoing the procedure. He then has another episode of an irregular heart rhythm and requires defibrillation. House calls Foreman and announces that he has diagnosed Kyle with Red Ragged Fiber disease. (Red Ragged Fiber disease is a mitochondrial disease; these are inherited maternally because the abnormal mitochondria are passed from the mother to her offspring by the mitochondria in the mother’s eggs.) Foreman tells House that it’s too late; Kyle has severe alcoholic cardiomyopathy and a transplant is his only hope of survival, but none are available.
Gabriel offers Kyle his heart, but Cuddy refuses pointing out that Gabriel is still alive. House asks Wilson to leave the room. After a brief discussion with Gabriel, he too steps out of the room. They hear a loud thud from within the hotel room. Gabriel has committed suicide so that his son can have his heart.
The medicine was poor and scattershot this week. I know this was intended as a “chew the scenery” episode and not a medical episode, but I still expected better. First, why was Kyle admitted to House’s service? He had a seizure — nothing too mysterious about that (and it takes more flickering than that to induce a seizure in people who have
photosensitive epilepsy). Then this young patient instantly goes into severe liver and kidney failure. Sure, he’s an alcoholic, but that’s still mighty fast. Then we’re told “forget the liver and kidneys, it’s his heart.” He might have alcoholic cardiomyopathy, but clearly he also has kidney disease or he wouldn’t have been placed on dialysis. And the right upper quadrant pain and vomiting blood are vastly more consistent with liver disease than cardiomyopathy. This raises the question whether he would be candidate at all for heart transplant since his kidneys and liver are still in such bad shape. Finally, the
Myoclonic Epilepsy with Ragged-Red Fibers diagnosis doesn’t really fit the situation well, and even if it did, it has a generally poor outcome and would be another reason not to perform the transplant.
In terms of Gabriel, it was convenient a mysterious “South American African paper” led House to his wake-up-the-vegetative-patient medication. They refer to Awakenings in the episode, both by name and action, but despite what the writers imply, it’s apples and oranges. Oliver Sacks was dealing with patients with a rare neurological condition, whereas Gabriel has brain damage brought on by lack of oxygen. Two completely different situations and no wonder drug is going to wake up a brain damaged patient. It was amazing Gabriel had such great muscle tone and no problems speaking after ten years in a vegetative state, wasn’t it? And I sure hope he has a compatible blood type with his son, or that heart he killed himself for is going to go to waste.
The sad part is that with all the bad medicine, the soap opera was only fair. Despite the best efforts of John Larroquette and Hugh Laurie, the hotel room scenes just didn’t seem believable. Wilson did better with his scenes, but he didn’t get all that much. Meanwhile the cop talked up all three of the Young Guns back at the hospital. All three acted as you’d expect, so no surprise there, except that all three told House about it, which was more than I expected.
This episode earns a C for the mystery (and its a mystery why it’s a mystery) and a B for the solution (the use of a mitochondrial disease is clever). The medicine, however, gets a dismal D, and the soap opera only receives a C- (partially salvaged by Wilson and the Young Guns).
The previous House review
A list of all prior House reviews
Tags: television medicine house alcoholism persistent vegetative state
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