Not a bad hour of medical drama, despite being an episode that hit pretty much every House cliche there is.
Jack is a thirty-something touring musician who is back in town for a few days to spend time with his family. While taking his daughter to the zoo, he sees a woman who has fallen, seizing, onto the subway tracks. Seeing that no one else is helping her, Jack jumps down onto the tracks in an attempt to save her. He is unable to get her to safety before a train arrives, but does manage to duck them both down beneath the passing train where they survive. However, after standing up, he collapses, unconscious. He is brought to Princeton-Plainsboro Hospital and admitted to House’s service mainly because M3 thinks it’s neat treating a “hero” (House himself just thinks the heroism shown by the patient is a symptom).
The initial diagnosis is that Jack has a neurological condition set off by the sympathetic nervous system (i.e. “fight or flight”) . House wants his limbic system tested, which apparently means the cerebral angiogram we see M3 and Chase performing next. During the procedure — as is too often the case on this show — a complication occurs and the patient develops a rising blood pressure and heart rate and ends in a cardiac arrest. He survives (because it’s only been 20 minutes), and House and the team meet again to discuss their new differential diagnosis. This time, the suspicions are vasovagal syncope (fainting spells, basically), drug use, and autonomic dysfunction. House prefers the latter and wants a biopsy of her pituitary gland. M3 intervenes, preferring blood tests instead as they’re less invasive. They’re also negative, so the patient goes for his brain biopsy. The complication during this test is that the patient’s O2 sats (the oxygen level in his blood) start dropping. Chase suctions Jack’s airways revealing a mucous plug (just what the name suggests: a chunk of mucous that had been blocking one of the airways in the lung) and fluid build up “in the lungs.”
Chase and the rest of the team now suspect that Jack has some form of pneumonitis (a general term for inflammation of the lungs), but the exact cause is unclear. Bacterial infection, parasites, and obstruction are all mentioned (conveniently neglecting to mention viruses). M3 suspects some kind of infection, but her suspicion seems to rest on a non-specific wide-ranging infection, not one just confined to the lungs. House still doubts Jack’s heroism and suspects that he only rescued the girl because he knew her — and furthermore, he was probably having an affair with her. Chase and Taub break into her apartment and the evidence seems to suggest she does know Jack: she has a CD of his obscure band. They also find roach spray and deduce that the toxins from the spray must be causing Jack’s symptoms. However, while talking to Jack at the hospital, the girl he rescued shows up to thank him and it is clear that they don’t know each other at all (it turns out the CD was a gift from one of her nurses).
A short time later, Jack develops severe bilateral ear pain. M3 suspects the infection has spread to his mastoid (the bony bump behind the ear) while House suspects an acoustic neuroma (a tumor of the hearing nerve). House orders evoked auditory potentials to test for the neuroma, but once again, the tests are negative. Meanwhile, M3 wants better samples to run tests for infection, so wants to get some ear drainage and perform a thoracentesis (stick a needle in the back to get some of the fluid around the lungs). When they numb the skin in Jack’s back prior to the procedure, his ear pain is suddenly resolved. This tells House that Jack has been having referred pain (paraphrasing House, during development some of his nerve connections got messed up so the pain in the ears was really pain he should have been feeling somewhere else. Now the problem is finding where that pain should have been pointing to). The new differential diagnosis now consists of hyperthyroidism (an overactive thyroid gland), liver disease, and M3 sticks by her infection suspicion. The thyroid tests are normal, but the liver biopsy shows diffuse inflammation which is interpreted as autoimmune hepatitis and Jack is started on steroids (which calm down inflammation).
So Jack’s better? Not by a long shot, because now he develops seizures and a fever. The team now suspects leptospirosis, an infection transmitted by the rat urine in the subway tunnel, but even they admit the evidence is flimsy. Jack is started on doxycycline, an antibiotic useful for leptospirosis. It’s not over yet, though. A chance comment by Cuddy’s mother (“Children are awful”) makes House suspect Jack is actually suffering from something he caught from his daughter. A conversation with Jack’s wife clinches it — Jack has varicella (infection by the Chicken pox virus), which can be a particularly nasty disease if caught as an adult. He is started on immune globulin and on his way to recovery.
For the second episode in a row (not counting the weeks off and the repeat episodes), I saw nothing I considered a major error. There were a bunch of mid-level errors, but nothing that had me screaming at the television. As usual, the team dilly-dallied, skipping the obvious tests that would have pinpointed the diagnosis earlier and hop-skip-and-jumped their way through the differential diagnoses.
As usual, major complaints are in red (none this week), more minor complaints are in blue, and nit-picking ones in green:
Though Chase said Jack had “fluid in the lungs,” it doesn’t fit with any of their differentials or procedures. So I don’t think it was supposed to be fluid in the lungs (pulmonary edema, which has an entirely different differential diagnosis starting with heart failure) as much as pulmonary effusion — fluid building up in the membrane surrounding the lungs. This fits better with their diagnoses and the procedure to drain and test this fluid (the thoracentesis)
House’s definition of referred pain is screwed up. The best definition I’ve found is the one I linked to earlier (here it is again), and while we don’t have a complete grasp on the subject, it’s not nearly as random as House suggests. It’s a moot point in some ways because (1) the procedure used to accidentally diagnose it was performed wrong, and (2) the source of the referred pain was never identified.
When performing a thoracentesis, you numb the skin on the side of the back over the location where the pulmonary effusion (fluid you’ll be draining) is – you don’t perform an epidural or spinal block. Screwing up the anesthesia is the only way that a shot in the back blocks referred ear pain makes any sense at all (and even then it’s very tenuous).
The time course is all screwed up. Jack’s only been home for 3 days (max) and he already has a rip-roaring infection? Infection doesn’t occur until 10-21 days after exposure, so he would have to have been exposed no more than 2 weeks before, when he was on the road. (and say he was home for brief visit then, it still doesn’t fit because Daisy is being kept home from school due to a current outbreak.)
It’s also too late to start VZIG, per the FDA anyway. It’s far from the first time House has gone for an off label use of a medication.
Surely they got a good chest x-ray or CT scan since the patient was having lung problems. Why didn’t that show the varicella pneumonia?
Despite what M3 suggests, a thoracentesis is not a super-simple no risk procedure. Complications, including pneumothorax, are not uncommon.
If you go with a diagnosis simply because there is “nothing else on the table” then your main problem is not putting more ideas on the table.
The medical mystery was mildly interesting this week, though fairly vague. I give it a B. The final solution fit the symptoms decently well, as long as you ignore the time course, and earns a B+. The medicine was slap dash, about average for the show this year, so earns a C. The soap opera was enjoyable, but needed more Candace Bergen. I give it a B+.
This show was particularly strong in House cliches this week. Worsening symptoms with procedures? Check. Cardiac arrest? Check. Unnecessary biopsies? Check. A diagnosis of an autoimmune disease? Check. A patient who promises to change their ways, but then doesn’t? Check. I think the only one missing was the artificial life or death choice (it’s either this or that, but if we choose the wrong treatment, the patient will die!).
The review of the previous episode of House
A list of all prior House reviews
This week’s House Challenge scores have been posted.
Here’s another Charlton PSA about 
Blood in the cerebrospinal fluid is extremely irritating to the tissues surrounding the brain and leads to an incredibly severe headache and a neck that is too stiff to bend, but it has nothing to do with the blood being absorbed. Blood is just very very irritating to the 
Best Depiction of Medicine:
Worst Depiction of Medicine:The treatment of Joker’s neurological disorder in The Brave and the Bold #31. Every facet of this was wrong from basic neurology to simple anatomy down to microbiology. 
Hellblazer: City of Demons #1 “Accidents Will Happen”
Hellblazer: City of Demons #2-5
I’m starting a new feature at Polite Dissent. Every Friday is now Nurse Day, where I’ll highlight a classic comic book story starring a nurse. Some of these will be super-hero comics, some will be war stories, but most will be Silver Age romance comics — so, sadly, you shouldn’t expect much in the way of progressive views on either women or nurses.
Apothecarius Argentum, Volume Six begins with Argent and his assistant Soda arriving at Castor, a nation that is purely capitalistic, in all its cut-throat glory. Argent and Soda win admittance to the city with the help a local girl, a destitute heiress named Popola. The trio tries a variety of businesses before finally running up against Lulu, an elderly doctor. She takes Argent and Soda as apprentices despite her views of medicine conflicting with Argent’s. In this city, apothecaries treat with medicine, while doctors use less medicine and more prevention and surgery. Honestly, this is quite similar to 
When you think of the classic sulfur smell, you’re probably thinking of 
This week, Friday Nurse Day takes a look at Sue and Sally Smith, Flying Nurses. Their first story was in My Secret Life #47 (discussed this week), and apparently they proved popular because starting the next issue, the comic was renamed after them. However, they couldn’t have been all that popular, because the title only lasted seven more issues before being canceled.
? How every piece had to fit together just right for the mouse to be caught? Tonight’s episode was like that, only there was an observer involved at every step of the way.
has been in print longer than Peter has been alive. But then, Peter always liked old books. (I notice the rest of the title “The Pilgrimage of Psychotherapy Patients” was left off Olivia’s copy.)
Despite the promise of the cover, this comic features neither hobos nor exploding medicine cups. Instead, it features Betsy Crane, a nurse who first appeared in the romance comic My Teen Diary #11. She proved popular and the comic was renamed Nurse Betsy Crane with the next issue and continued for sixteen more issues, and several volumes of reprints.
vibe from Brandon’s lie detector, which I suspect was intentional — hunting for shapefshifters can’t be all that different from hunting for replicants.
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