HOUSE: Kutner's Shocking Surprise

by Michael Smith, MD

SPOILER ALERT!

Dr. Kutner's suicide on last night's House left many of us shocked and surprised. And that's not so far from reality. It's always tough to imagine any loved one being miserable enough that they would actually take their own life. But the truth is that real-life suicide is often as unexpected as Kutner's.

If you have depression and are having thoughts of suicide, talk to someone. People care even though you may not feel they do. Don't have someone you feel comfortable talking to? Call a suicide hotline such as 800-SUICIDE (800-784-2433) or 800-273-TALK (800-273-8255) – or the deaf hotline at 800-799-4889.

Know someone who is depressed? First rule: never blow off even a brief mention of suicide in a loved one no matter how hard it is to imagine or deal with. Don't assume they're just trying to get attention. Talk to them. And explore. While it's a very tough thing to do, the best thing is to ask that person what he or she is planning. Let the person know you care and are listening.

Warning signs of suicide can be subtle, but oftentimes there are signs. And knowing what to say to a loved one is tough. See WebMD's "Recognizing the Warning Signs of Suicide" to learn more.

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• WebMD Depression Health Center
• WebMD Depression Support Group Message Board
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HOUSE: Miscarriage of Honesty

SPOILER ALERT!

Natalie is an unpopular, overweight teenager who concealed a full-term pregnancy, then discarded the products of her unattended delivery in a vacant crackhouse - or so she thought. Weeks later Natalie collapses, develops seizures, and spirals into multi-organ failure.

It was Cuddy, not House, who tumbled across the diagnosis: Natalie has eclampsia! (It is also called toxemia of pregnancy.)

Many of you know about eclampsia. This is a dangerous impairment of brain bloodflow usually associated with high blood pressure (most of the time but not always!) There are no effective preventive measures for eclampsia. If high blood pressure develops it can be treated and perhaps this eliminates many potential cases of eclampsis. Chronic headache and edema-related weight gain are important warning signs.

Eclampsia can be dangerous to both mother and fetus. Up to 5% of affected mothers succumb. Half the time eclampsia occurs prior to labor and another 20% encounter it in the delivery room. That leaves approximately 30% of eclampsia cases emerging postpartum (no harm to the neonate obviously!) Natalie's problems started one month after delivery, longer than the textbook timeline of 14 days. Who cares? When it comes to House I stopped arguing medical facts long ago!

The subject now switches to truth-telling. Episode 511 (Joy to the World) was loaded with lies, half-truths and deceptions. Nearly every character was dishonest at least once during the program: House, Cuddy, Wilson, Taub, Thirteen, Foreman, Natalie, her classmates, Kutner, and many more. For example, had Natalie confided in her doctors at the time of admission that she had recently delivered a baby, the diagnosis of eclampsia would have emerged far sooner - perhaps in time to spare her life. Of course, that is the most egregious example but Natalie and House's team were doomed by many other untruths that amused and entertained the audience.

Here's a bonus observation. Did you notice that House, the embodiment of ethical medical practice, never spoke to Natalie, not even once? That's how I knew she was a goner. I'll look for that behavior in future episodes and see if a trend develops. It's just as well he kept silent. He probably would have lied to her anyway, perhaps by wishing her a Merry Christmas.

Related Topics:

• WebMD Video: What Is Pre-Eclampsia?
• Preeclampsia and High Blood Pressure During Pregnancy

HOUSE: Compensatory Measures

This week's episode of House (#510: Let Them Eat Cake) offered a powerful lesson in human behavior in depicting the lengths an individual will go in order to preserve one's health - consciously and unconsciously.

Emmy is a weight-conscious fitness maven who keeps collapsing. As a result of her workup (and multiple incorrect diagnoses) the team discovers that Emmy had undergone previous gastric bypass surgery. In the past Emmy was obese and she loved sweets. She still does!

Late in Act II House declares that Emmy suffers from Hereditary Coproporphyria. This is a metabolic condition caused by a defective gene involved in blood protein synthesis. These patients can experience severe abdominal pain and such attacks can be reversed with a bolus (large dose) of glucose. Earlier in life Emmy managed her disease by overeating carbohydrate-rich foods.

Believe me, it's not worth nitpicking the rest of this episode. We already have enough with which to work!

Emmy discovered that sweets eliminated her pain. No medical degree was necessary. Intuitive patients learn on their own how to compensate for their symptoms:

• Young toddlers with cyanotic heart disease discover that they breathe easier when they squat


• Folks with acid reflux often swallow a spoonful of sugar after eating tomatoes


• Individuals with lactose intolerance shun dairy products


• Gentle rubbing of the eyes can lower the intraocular pressure during a glaucoma attack

The point to remember is whenever you observe someone exhibiting unusual habits, you have to ask yourself, "Are they trying to compensate for some kind of unsolved problem?"

Here's another great example. There may be 23 million diabetics in America but at least 8 million of them don't know it! All they know is that they are frequently thirsty, love to drink orange juice (quick source of glucose) and tend to urinate more often than others. From a medical perspective the classic symptoms of diabetes include: polydipsia (excess thirst), polyphagia (excess appetite) and polyuria (excess urination). Sure, it all makes sense, but the diabetic patient is unaware of these facts: they drink, they eat, they pee!

Emmy's situation was very similar. She compensated for her symptoms and bought herself some time. Then, when she weighted 300 pounds she again compensated by consenting to undergo gastric bypass surgery.

Okay, I lied! Here's one diagnostic nit to pick. Remember when House requested a stool sample from Emmy? Had House been thinking of Hereditary Coproporphyria at that point in the story the laboratory could've tested the feces for stool coproporphyrins. In affected individuals stool coproporphyrin levels are markedly elevated, usually 10-200 times greater than control samples.

House decided that the best treatment for Emmy was surgical reversal of her gastric bypass and plenty of carbohydrates. He also could have offered the patient some hematin. The key treatment of porphyria is stopping heme synthesis. Hematin provides negative feedback to the heme synthetic pathway and shuts down production of porphyrins and porphyrin precursors. I don't remember hearing anything about that treatment.

So, how do we compensate for the miserable way this case was managed?

No more House for Emmy and, come next September, no Emmy for House!

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HOUSE: Face the Facts

One-hour fictional dramas and 30-minute sitcoms are the staple of broadcast television. Granted, every once in a while NBC airs a string of 45-minute 'supersized' programs to lure viewers into staying tuned to their lineup. Following that theory, the viewer is trapped at 8:45pm after a supersized 'The Office' with nowhere else to go! Ever hear of TiVo?

Sometimes TV programmers air a full-hour program without commercial interruption. That requires re-editing when it comes time to repeat an airing of the show (or eternal syndication) so that space is available for commercials.

Another network TV gambit was the 'cold open' at 58 minutes after the hour immediately following the previously concluding program - and I mean immediately! No commercial break, no previews, no promos. Bang! New show begins. The strategy here is that the new show launches so quickly that the paralyzed viewer cannot react quickly enough to escape. Meet my little friend, the remote control!

Fox Television tried something a little different with Episode 509 of 'House' (Last Resort). They programmed the show to run 68 minutes in its entirety. Again, they create an automatic carryover audience but, nevertheless, they will need to trim the story when it comes time for recycling.

I can easily help House's editors chop 8 minutes from this week's extended episode. It all has to do with neurologic problems that affect the eyes, the eyelids, and the face.

A desparate gentleman named Jason takes hospital personnel from Princeton-Plainsboro hostage in order to recruit Dr. House's services. During the assessment House and Thirteen observe a subtle droop to the left corner of Jason's mouth. They suspect Bell's Palsy. This is the eponym for weakness of the seventh cranial nerve, the Facial Nerve. The Facial Nerve is responsible for chewing and facial expression: closing eyelids, raising eyebrows, lip and facial movement. It has nothing to do with facial sensation...that's the job of the fifth cranial nerve, the Trigeminal Nerve.

So, what caused the Facial Nerve weakness? House suggests postherpetic neuralgia (PHN). This is a chronic pain condition following a bout of shingles (Herpes varicella zoster infection). Next, House wants to test his hypothesis by injecting capsasin. I got lost here because capsasin is usually prescribed as a topical pain reliever - you rub it on. It is used to treat PHN by temporarily overriding the pain signals from the PHN-irritated sensory nerves. With capsasin PHN sufferers feel heat instead of pain. Then, to top it all off, when Jason reacts to the pain of the capsasin injection House hastily eliminates "Peripheral nerve paralysis" off his list of possibilities.

I may have missed something, but House appears to have criss-crossed his wires and his nerves. The facial droop and PHN consideration only involved cranial nerves that come directly from the brain. Cranial nerves are very different from peripheral nerves that connect to the spinal cord. (There is nothing 'peripheral' about either the Facial or Trigeminal Nerves). Next, since PHN affects sensory nerves, there is no 'paralysis' involved. Injured sensory nerves experience impaired sensation (too much is hyperesthesia, altered is paresthesia, too little is hypesthesia, none at all is anesthesia.)

Let's summarize. The lid droop reflected a possible problem with the Facial Nerve. House suspected PHN involving the Trigeminal Nerve. Whereas both of these problems involved cranial nerves, House performed a test of peripheral sensation and ruled-out paralysis. Yikes! Get the scissors out and we can get this extended episode back to 60-minutes in no time!

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HOUSE: Flawed Identity

** SPOILER ALERT **

Sophia is a factory supervisor who collapses at work and ends up at Princeton-Plainsboro Medical Center. Hmmm...she looks kinda young. Sophia is actually 16 and living on her own - she is a legally emancipated teenager. With both parents deceased the courts recognized her as an adult, giving her personal responsibility and legal authority to make her own decisions. Sophia is found to have acute promyelocytic leukemia and needs a bone marrow transplant from a sibling or parent in order to have the best chance for survival.

There are just a few unresolved problems:

• Sophia's parents are not dead
• Sophia is responsible for her sole sibling's death
• Sophia is not who she says she is, she is an identity thief

It seems 'Sophia' ran away from home out of guilt for her brother's accidental death. She fabricated (embezzled) a new identity and wanted to start over with a clean slate. (Funny...we never learn her real name?!?)

By now most of you are familiar with the serious identity theft problem that threatens every person in this country.

[A quick digression: I love watching the commercials with that CEO blurting out his social security number to boast about his anti-hacker software. How long before he gets burned?]

Anyway, do you know about Medical Identity Theft (MIT)? It is an enormous, underpublicized crisis that is compromising our entire health care system. MIT occurs when someone ineligible for health insurance uses another person's health card for doctor's visits, hospitalizations, prescription drugs, and other medical benefits.

Sophia may have been involved in MIT. Her factory job may not have provided comprehensive health care benefits. The 'real' Sophia's parents [still alive!] would probably need emergency hospitalization when they received the 'Explanation of Benefits' (EOB) from their health insurer - including a $250,000 bill for bone marrow transplantation. Fortunately, Sophia confessed by the end of the program and her real mother and father (still alive!) arrived at her bedside - hopefully with photo IDs.

According to the most recent government statistics approximately 3% of all identity theft cases involve MIT. That's over 250,000 victims per year and countless millions in illegal claims. With traditional identity theft stolen credit cards eventually get canceled and bogus charges are forgiven. Your credit rating remains bruised for awhile as you try to reconcile your accounts. When MIT happens the consequences are far more severe and far more enduring! Huge costs are quickly incurred and everybody ends up paying for the fraudulent claim (insurance premiums, local taxes, higher copays, etc.) Even worse, the victim's computerized medical records are permanently corrupted. Depending on circumstances, it would be very hard to acquire life insurance if your records say you have acute promyelocytic leukemia!

Just like a erroneous credit card charge, if you discover an incorrect billing statement regarding a family member you should fight it, fight it, and fight some more! If you know that the EOB is wrong alert your insurer to the possibility of Medical Identity Theft.

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• WebMD Video: A Less Toxic Bone Marrow Transplant
• The Identity Theft You Haven't Heard of...Yet

HOUSE: Simulated Surgery, Real Deceit

A young man named Nozick ("no sick"... get it?) suffers from agoraphobia (fear of public places) and collapses at home. He resists emergency responders who want to transport him to the hospital for evaluation. House's former fellow, Cameron, knows the patient and she recruits the team to help establish a diagnosis right inside Nozick's bedroom.

As usual, the guest star patient quickly decompensates and emergency surgery is needed. Anxious Nozick adamantly refuses to leave his bedroom. House announces a clever scheme: Let the patient consent to surgery that will be performed in his own house but, once asleep, transfer the anesthetized patient to Princeton-Plainsboro Medical Center for the exploratory procedure. Following surgery, drag Nozick back to his own bed before he wakes up.

You got a problem with that?

It is a different twist on sham surgery. Yeah, you read right - sham surgery. It's real medical terminology. Tell the patient you are going to perform a procedure on them, take them to the O.R., put them to sleep, apply a dressing and take them back to recovery.

Sham surgery and other sham treatments populate the medical literature. They demonstrate the power of placebo therapy to gauge treatment efficacy in randomized clinical research. For example, does removal of frayed knee cartilage improve long-term knee comfort? A study is designed where half of the patients receive knee arthroscopy with damaged cartilage removal while the other half merely receive peek-a-boo arthroscopy. The patients themselves are blinded as to which procedure(s) they received, and both have stitches and swelling after surgery. Six months later, surprise, both groups share similar statistics regarding comfort and function.

Just a thought; would phony 'gastric banding' lead to progressive weight loss simply because the patient believed their stomach was 50 percent smaller and thereafter were satisfied with smaller portions?

Faking surgery is more complex and more risky than swallowing a sugar pill.

Many medical ethicists claim that the routine use of invasive sham procedures is unethical and should only be reserved for special occasions where no alternative exists. They claim that research volunteers cannot render a valid consent because if they knew beforehand that they were going to receive the sham procedure they would never agree to undergo the procedure. The ethics of medical practice can also be applied to fictional medical dramas. As seen in House Episode 507 - 'Itch', there is no way Nozick would agree to undergo exploratory surgery if it meant leaving his home. That is where House's approach went astray and nobody intervened. Things went badly for the patient up until the end of the show when House opened Nozick's abdomen without anesthesia to remove some old bullet fragments.

Once again, I ask myself in horror, "Does anybody ever sign consent forms on House? Does it really matter?"

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• What is a Phobia?
• WebMD Video: How Do Placebos Work?

HOUSE: Asleep at the Wheel

Ready for a surprise? I actually enjoyed watching most of this week's House [Episode 506 "Joy"] because it taught me several things I had not previously known.

Jerry is a busy single father who experiences unusual neurologic attacks wherein extended periods of his day disappear as if they never happened. Time warp. Jerry and his single daughter live a spartan, isolated life: work and school. They do not socialize. In fact, they hardly relate to each other.

It doesn't take the team at Princeton-Plainsboro to establish that Jerry is a narcoleptic sleep walker. During attacks Jerry is a cocaine abuser, which only further aggravates his sleep disorder.

Chicken meets egg: Did the cocaine cause the narcolepsy that led to the sleepwalking (to buy more cocaine)? Much of the program tries to unravel that mystery until Jerry begins to perspire blood and goes into renal failure. House puts the pieces together and diagnoses Familial Mediterranean Fever (FMF). Jerry and his daughter are from the Middle East, a region where FMF cases congregate. The responsible genetic defect in FMF resides in chromosome 16 and it is passed along in an autosomal recessive inheritance pattern. Parents can be affected or carriers. Jerry is a widower and the cause of his wife's death was not mentioned. Jerry's only daughter apparently inherited the disease as well.

Now for the good part. House recognized that Jerry and his daughter exhibited anhedonia. Ever hear that word before? See the letters 'hedo' as in hedonism? These two bland, boring people found no joy is life whatsoever. Anhedonia is linked to various chemical imbalances in the brain as seen in depression, schizophrenia and drug addiction. Aha! The cocaine! Wait, don't take the bait! Jerry's daughter was not abusing cocaine. In their particular circumstance it was their Familial Mediterranean Fever that was responsible for their flattened mood.

House prescribed colchicine and melphalan to delay disease progression and inhibit additional complications that await FMF patients down the road. At the end of the program everyone was smiling - not really. Remember, this is House - not Full House!

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