S8E11: Nobody's Fault

This is a preserved copy of "Nobody's Fault", originally published at politedissent.com. Wayback capture: 2012-10-07. Original URL: http://politedissent.com/archives/8621.

An interesting set-up on this week’s episode of House, but, alas, it led to a poorly execute denouement. And the medicine could have been better, too.

⚠️ Spoiler warning — plot details for this episode follow.

The episode begins with House and his team being questioned individually by Dr. Cofield, a doctor from another hospital, as part of a disciplinary hearing.

It all started with a patient named Bill, who is a thirty-two year-old high school chemistry professor who collapsed while jogging and is now in a coma and “paralyzed in all four extremities.” There was no history of trauma, and CT scans of the brain show no evidence of stroke or structural lesions. Reviewing the case, House initially suggests transverse myelitis, but admits it doesn’t really fit the situation. He then presents the patient to his team, who suggest the diagnoses of hepatic encephalopathy or normal pressure hydrocephalus. Chase points out that Bill is hypokalemic (low in potassium), which House takes as a sign that he has thyrotoxic paralysis (a temporary paralysis associated with an overactive thyroid). House starts bill on a regimen of steroids, PTU (an anti-thyroid medication), and beta-blockers (a class of drugs, that among other things, blocks the effects of too much thyroid hormones).

Bill improves and wakes up from his coma. His wife and some of his students visit, and they make a comment about a lab explosion he was in earlier that day. After this key fact is mentioned, Bill starts coughing up some blood. The team learns that during the explosion, conveniently uploaded to the internet, Bill was caught in a burst of hydrofluoric acid and hit his head fairly hard against the wall. The team now suspects that Bill is coughing up blood because of the inhaled chemical, and the rest of his symptoms can be explained by the trauma of hitting his head. House wants to treat Bill with aerosolized (inhaled) Heparin (a blood thinner), a treatment not yet approved, or apparently even tested, in humans.

Everything seems to be going well and Bill is getting ready for discharge. He is being given a bath to remove the remaining chemical on his skin when Adams notices a rash. While she is trying to get a good look at it, the patient freaks out. Adams thinks the rash is invasive Strep, while Park thinks the rash is nothing special but thinks the patient’s freak out was because of the steroids they had put him on. Taub feels the rash, together with the other symptoms like the lung problems, is a sign of Wegener’s granulomatosis. House decides to put Bill on steroids again. If he has Wegener’s, the steroids will cure the condition. In the other two cases, it will worsen the condition enough so the right diagnosis can be made.

Chase agrees with Adams and decides a biopsy of Bill’s rash is the best way to get a diagnosis. Unfortunately, Adams was wrong and Park was right — the patient is having steroid-induced psychosis. Thus, when Bill sees the needle Chase plans on using, he has a psychotic break which requires an injection of Haldol to bring to an end. In the scuffle, Chase was stabbed in the heart with a scalpel. He is rushed off to surgery. The hole in his heart is patched, but Chase later discovers that he can’t feel his legs. The concern is whether Chase has a post-traumatic syringomyelia (a cyst in the spinal canal), or a clot of a radicular artery (vessels which supply the spinal nerves with blood). It ends up being the clot, which is good news because its removal should allow Chase to regain some use of his legs. While all this is going on, House keeps popping in updating the team on Bill, even though they are no longer on the case. First, he suggests that is autonomic dysregulation, then he reports kidney failure which rules out his last diagnosis. Finally, after having w Eureka! moment with a pranked bottle of Vicodin, House diagnoses Bill with tumor lysis syndrome, caused when he he struck the wall after the explosion and ripped open the tumor he didn’t even know he had, spilling its contents into the bloodstream.

The news of Bill’s survival reaches the team just as the results of the disciplinary hearing are to be announced. Learning the patient survived, Cofield lets House of the hook (yet again), a decision that even House is upset with.

As usual, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

The first step in treating thyrotoxic paralysis is supplementing to low potassium, which House failed to do.
Steroids are not indicated for the treatment of thyrotoxic paralysis.

The primary sign of tumor lysis syndromeis is hyperkalemia (high potassium) — the exact opposite of what the patient had.
Bill wasn’t showing any of the myriad other symptoms of tumor lysis syndrome.

Syringomyelias can occur post-traumatically — when there is trauma to the spinal region. A scalpel to the heart is not going to cause a cyst formation in the spinal cord.

Hydroflouric acid is a very nasty chemical. They should have decontaminated the patient much earlier and I’m surprised he didn’t have any acid burns or other damage. Was he even wearing goggles when performing the experiment? (I also find it hard to believe that he’s use HF for a classroom demonstration with a risk of explosion).

Why biopsy a lesion you suspect is bacterially infected? I can understand performing a biopsy on an unknown lesion, but Chase specifically said that he agreed with Adams, and a biopsy is not how you prove a Strep infection.

I’m a bit confused how a clot in a single radicular artery (caused by what exactly?) could cause paralysis in both legs.

Swelling in the brainstem, like Park suggested, would have shown up on the initial head CT.

What was the rash from?

House carefully scrubs into surgery and gets gowned and gloved – and then grabs an unsterile surgical mask and holds it against his face. Masks are put on before scrubbing.

A disciplinary hearing before the patient’s disposition is even known? No bureaucracy moves that fast.

I found the medical mystery to be moderately interesting this week. It earns a B-. The final solution directly contradicted some of the earlier patient history and left several symptoms unexplained. It earns a C-. The medicine was sloppy and perfunctory this week. When the anatomy is wrong, why would we expect better from the medicine? I give it another C-. The soap opera had some good drama, but the ending was rather anticlimactic — and virtually a deus ex machina (or in this case, patient’s wife ex machina). It earns a B.