- "You’re a high-powered bulimic. You make yourself throw up. You have to find the most efficient way to vomit without revealing the tell-tale signs of bulimia, which is all, eugh. Very unseemly, for a CEO. So, you found a common antidote for accidental poisoning to do the job: ipecac. Which is great, if your kid’s just swallowed a bottle of aspirin, but really, really bad if it’s a habit. It causes muscle damage. It caused the pain in your leg. And it destroyed your heart. How often do you do it?"
- ―House goes beyond the diagnosis
Unbeknownst to the medical staff, Carly was suffering from bulimia and was taking Ipecac, a drug that induces vomitting, three times a week. However, it is also clear that the patient has almost no leisure time and is working almost non-stop while she is awake. Her mother died of colon cancer. She does a lot of running to exercise.
- "I need a doctor. I can't move my leg!"
- ―Carly tells her assistant why she sent the text "I need help"
Carly was a young CEO of a cosmetics company who during a business meeting was having minor tremors in her right hand, had difficulty concentrating and realized she was unable to move her right leg due to severe pain. Her staff did research and determined that Dr. Gregory House had the best reputation as a diagnostician in the region and she came to Princeton-Plainsboro to be treated by him. Dr. Cameron immediately suggested a leg infarction, the exact condition that resulted in Dr. House's disability. Dr. Foreman suggested a disc herniation, but Dr. Cameron pointed out that she would have pain elsewhere if that were the case. She also got Dr. Chase to agree that a clot was the most life threatening possible diagnosis as a clot could lead to a stroke. House realized that she had been reading negotiating books, but agreed the patient needed blood thinners and an angiogram. If those were negative, Dr. Chase was ordered to do an MRI on the spine and perform a biopsy on the leg.
- Chase: "I'm gonna have to ask you for the cell phone?"
- Carly: "Do what you need to do, I'm okay."
- Chase: "Pretty sure my x-ray machine can take your phone in a fight. It'll fry it."
- — Chase treats a resistant Carly
Chase performed the angiogram of her leg with one of the residents from radiology. Dr. Foreman went to inform the patient that the initial tests were negative and the problem was probably a clot that broke up on its own, but soon found her screaming in severe pain. He ordered morphine stat. Dr. House asked what the patient's severe pain meant. Dr. Chase assured him the angiogram was clean. The biopsy showed no neurogenic or myopathic abnormalities. Dr. Foreman had ruled out trichonosis, toxoplasmosis and polyarteritis nedosa. Her sed rate was normal - 15, showing no inflammation or immunologic response. Dr. Cameron suggested her sed rate might be elevated for the particular patient, drawing a parallel |ith her aunt whose usual body temperature was 96.2F. Dr. House thought the idea was absurd, but agreed anyway, believing it was inflammation that indicated cancer. He asked Dr. Wilson for a consult, who believed it might be widespread bone cancer, requiring a bone scan. He agreed to perform it despite his busy schedule.
- "There are two Dr. Wilsons in the hospital. One in ophthalmology and one in cancer. My eyes are fine, so you’re here to tell me I have cancer."
- ―Carly tries her best Sherlock Holmes routine
Dr. Wilson met with Carly, who was meeting with her assistant. She knew he was an oncologist because apparently there are only two Dr. Wilsons in the hospital and the other one is an opthamologist. Wilson told her that she didn't have bone cancer, but she might have cancer elsewhere that was causing referred pain in her leg. Given her family history, he though that colon cancer was the most likely culprit - her mother had died from it. However, she refused a colonoscopy. Wilson suggests they do a virtual colonoscopy with a CT Scan instead - much more expensive, but less invasive. She agreed.
However, the virtual colonoscopy was clean, which seemed to rule out cancer. House wondered why the patient didn't have a regular colonoscopy, and Wilson put it down to her not wanting to have more tests. Dr. House realized Carly was only reluctant to have embarrassing tests.
The test results seemed to rule out any inflammatory process, clots or cancer. However, when Dr. House reviewed her angiogram, he saw that it was of her left leg, and he realized that Dr. Chase had X-rayed the wrong leg. He found out it was the resident who actually performed the angiogram. He assigned Dr. Foreman to do the angiogram.
While Foreman was performing the second angiogram, Carly complained that her chest hurt, but her vital signs were normal. However, she soon went into respiratory arrest. Dr. Foreman pulled out his stethoscope and realized her lungs had filled with fluid. He called a code blue.
The patient was revived and they were able to drain the fluid and stabilize her. The fluid was sent to the lab for testing. The second angiogram on the correct leg was also clean. House reviewed her physical symptoms, but soon erased his entire whiteboard and started writing down psychological symptoms: withholds pain, control, and shame. He examined the patient while she slept and found cuts on her thigh. He put her on the transplant list for a heart transplant. Dr. Chase and Dr. Cameron soon reported that the thoracentesis revealed a transudate. They performed an echocardiogram and it revealed she was suffering from severe congestive heart failure. Dr. House informed them she was already on the transplant list.
- Wilson: "Now, that’s good thinking, because I was going to go right to Cuddy and rat you out as soon as you were done talking."
- House: " I’m not saying you want to, I’m saying you’d be obligated to."
- Wilson: "Because of my position on the Board?... Because of my position on the transplant committee! Hey, you brought this up for a reason. You need to talk to me."
- — Wilson realizes something serious is up
Dr. House talked to Carly. He told her she needed a heart transplant, as he had realized along with cutting herself, she was bulimic and had been swallowing Ipecac to induce vomiting to keep thin and hide the other symptoms of bulimia. However, the Ipecac she had been taking had resulted in severe damage to her heart and had also caused muscle damage in her leg. She admitted to taking the drug three times a week. Because of her cutting and bulimia, she was too high risk for a heart transplant, which meant that House had to lie to the transplant committee about her mental state. If he did so, he could lose his medical license. He asked the patient if she wanted to live and if her life was important to her. She broke down and told Dr. House she didn't want to die.
- Carly: "What do you want me to do? Cry?"
- House: "Yes! I want you to tell me that your life is important to you, because I don’t know!... Because that’s what’s on the table right now: your life. "
- Carly: "I don’t want to die. I don’t."
- — House decides to put his medical license on the line
Dr. House appeared before the transplant committee and told them that apart from her heart, she was in good health. Lisa Cuddy was suspicious, as House had Carly put on the waiting list for a heart transplant an hour before he started the tests to confirm the CHF. She asked Dr. House how he knew about the CHF before he did the tests, and he said it was just a hunch and he had no foreknowledge of the diagnosis before the tests came back. He denied there were any exclusion criteria, including no drug use or mental illness. Dr. Cuddy reminded him that he would be disciplined if he misled the committee, but he still denied there were any exclusion criteria.
- House: "Dr. Cuddy, do you have any reason to think that I would lie?"
- Cuddy: "I simply want you to answer the question! Is there anything on the recipient exclusion criteria that would disqualify your patient from getting a heart?"
- House: "No"
- — Everybody lies
A heart soon became available and surgery was started. Carly’s surgery went well, finishing in just under five and a half hours.
Dr. Chase was afraid of losing his job after messing up the angiogram. He also wondered why Dr. House had not mocked the team after he determined what the patient's diagnosis was. He decided to search Carly’s room. He discovered the bottle of Ipecac in her purse.
House waited with the patient in the recovery area and gave her a fried chicken dinner. She asked why he fought for her when he hardly knew her. House just said that what he did for patients, and not to screw it up.
- Carly: "Why did you fight for me? You risked so much, and you hardly know me."
- House: "You're my patient. Don't screw it up."
- — House reveals what he's willing to lie for
Dr. Chase took the Ipecac to Edward Vogler the new chairman of the board of directors and the hospital's primary donor. He confronted Dr. House about the Ipecac, and Dr. House denied he knew anything about it, feigning surprise and saying if he had known he would not have fought for the patient, and the transplant committee would have had to turn her down.
A Reflection of House
The patient is a quick thinking, intelligent driven individual who achieved success and fame in her field at an early age. However, she abuses drugs and has deep seated psychological issues she refuses to address. Although she has family, she is not close to them and is reluctant to reach out to them when she's ill. She is not in a relationship.
Reaching the Diagnosis
Paralysis and severe pain in the upper right leg pointed to the possibility of an infarction. A disc herniation was a stretch as the pain would most likely be more widespread.Since a clot could quickly cause a stroke, and the treatment of blood thinners and confirmation with an angiogram posed little risk, it was a good first step. However, House didn't want to rely entirely on it being an infarction and ordered an MRI of the spine in the event it was a disc herniation, and, if that was clear, a biopsy was more invasive, but still a good next step.
A clot seems likely when her pain improves, but when it suddenly gets much worse the team is at a loss, particularly when the MRI is clean and the biopsy discloses no problems with the nerves or muscles in her leg. The team has also run tests for common conditions that cause leg pain; the parasites trichinosis and toxoplasmosis, and polyarteritis nodosa a form of vasculitis. A normal sed rate which would appear to rule out inflammatory condition, but Cameron argues that her base sed rate might be lower. Since cancer could cause intense leg pain, House turns to Wilson for a consult. Wilson feels that primary bone cancer would be the only thing that could cause pain that intense, and suggests a bone scan. He also agrees to perform it.
However, when the bone scan is clean, Wilson believes she may be suffering from referred pain from cancer in another part of her body. Given her age and the fact her mother died from it, colon cancer would be most likely. The patient refuses a colonoscopy to confirm, but agrees to a virtual procedure using a CT Scan - the only difference is the expense involved and the radiation exposure.
Wilson reports to House that the virtual colonoscopy was clean. House wonders why the patient would refuse a colonoscopy when she's already had so many tests. He figures she was too embarrassed to have one.
When it turns out Chase did an angiogram on the wrong leg, a clot is back on the table. However, when the patient starts to go into respiratory arrest during the procedure, it appears to rule out the clot once and for all.
They take a sample of the fluid from her lungs for testing and complete the angiogram, which shows no clot. Given the confusing constellation of physical symptoms, House decides to examine the patient's psychological condition. He notes that she always feels the need to be in control of a situation, that she suppresses pain instead of expressing it, and that despite her confidence and position she's ashamed of exposing her body. He performs a physical examination and finds cut marks on the patient's thigh.
When the team looks at the lung fluid they find a transudate. They do an echocardiogram and find the patient has severe congestive heart failure. However, House has already figured this out and that his patient suffers from bulimia complicated by use of ipecac which, when used long term, can damage muscles, in this case, those in her heart and thigh..
Explaining the Medicine
- Herniated disc is actually a pretty good guess. A herniated disc in the lower back will present with pain, numbness and weakness in the thigh.
- Trichinosis is a bad guess. Although it can cause muscle pain, that's one of the later symptoms. Carly would have fatigue and digestive tract symptoms as well.
- Toxoplasmosis is also a poor fit. It can cause muscle aches, but not intense pain. The same can also be said of polyarteritis nodosa.
- Bone cancer can cause bone pain, but not muscle pain. In addition, with pain that intense, it is likely that a tumor would be well along.
- Pulmonary edema puts congestive heart failure at the top of the list - it's the leading cause of the symptom. As the heart loses power, pressure backs up in the lungs, leading the small blood vessels to leak fluid from plasma into the lungs.
- Self injury and eating disorders often occur together, as in this case, and self-cutting is the most common harmful behavior among bulimics. Carly's exercise may also be a self-harming behavior if she does it to excess and is also common in persons with eating disorders. So is shame about exposing the body, even with doctors. There are several reasons why a patient might develop these disorders, but it is almost always due to an inability to deal with emotional responses in a healthy way.
- Transudate is fluid that has been filtered through a membrane, meaning it is usually virtually free of any protein. In a person with heart failure, increased blood pressure in the blood vessels forces fluid through the wall of the vessel. It is a classic sign of congestive heart failure. If the fluid was exudate, it would have come from an inflammation and would have contained blood proteins.That would indicate bleeding, infection or inflammation instead.
- A mutigated acquisition scan or "MUGA" is a form of nuclear angiography that is used to determine if the lower chambers of the heart are pumping blood properly. The test lasts about thirty minutes and contains moving images of the heart.
- The main active chemical in ipecac is emetine, an alkaloid toxin. It is only slowly eliminated by the body, so it tends to collect in the body's organs. Although it does not accumulate in the heart, it appears that the heart is most susceptible to its toxic effects. It's exact mechanism is not well understood, but it appears it interferes with protein synthesis and can kill mitochondria. It doesn't have a severely toxic effect on most cells, but does have a very toxic effect on muscle cells, particularly those in the heart. The toxic effect does not appear with a single dose, only with regular use.
- Different transplants have different exclusion criteria. Here are the ones for an adult heart transplant in Ontario . There are several psychological considerations, one of which is that patients who abuse drugs must have abstained for a minimum of three months.Later, House rattles off a long list of exclusionary factors he has ruled out to avoid giving a straight answer to the question as to whether Carly has any exclusionary criteria.
- Patients with congestive heart failure will be given pressors and vasodilators to try to reduce the load on their heart. However, their effectiveness is being questioned.
- "FVC" is "forced vital capacity" - a measurement of the total volume of air that the patient can force out of their lungs after taking a full breath. "FEV-1" or "forced expiratory volume in 1 second" is how much air the patient can expel from their lungs in 1 second after taking a full breath. The "expected FEV-1" is calculated using either a specialized calculator app or by referring to a chart and depends on the patient's age, sex, body mass, height and ethnicity. This is expressed as a ratio, FEV1/FVC.Dlco measures the capacity of the lung to deliver gases to the blood, ironically using carbon monoxide to measure this ability. Translation: "her heart may be in trouble, but her lungs are just fine."
- The MUGA ejection fraction is a measurement of how much blood in the heart is pumped out with each beat. In a normal patient, this can be anywhere from 50 to 75 percent. Carly's measurement of 19 percent shows her heart is beating inefficiently, essentially having to pump three times as often to deliver the same amount of blood
- A new heart wouldn't do Carly much good if her cardiac arteries were obstructed, so House gives the results of a heart catheterization that indicated they were clear.
- In most cases, congestive heart failure is caused by a lack of blood flow to the heart. However, there are also treatable forms of congestive heart failure. To ensure a full diagnosis, a heart biopsy is usually performed. As with most cases, Carly's biopsy probably showed the damage was permanent and untreatable.
- Unseen father
- Unseen brother
- Mother (deceased)
|July 2018||August 2018||September 2018|
|House's car||Carly Forlano||Need to Know|
|#02||"Paternity"||#10||"Histories"||#18||"Babies & Bathwater"|
|#04||"Maternity"||#12||"Sports Medicine"||#20||"Love Hurts"|
|#05||"Damned If You Do"||#13||"Cursed"||#21||"Three Stories"|
|#06||"The Socratic Method"||#14||"Control"||#22||"Honeymoon"|
This article was the featured article for August, 2018