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Paternity
House cutting big toe S01E02
Director(s)
Writer(s)
Airdate
November 23, 2004
Episode Number
1.2
TV.com Rating
8.8/10
Guest Star(s)
Zebra Factor
10/10


House (to Wilson): "All I know is he sued some doctors. Who am I to assume that they didn’t have it coming to them? (sees Cuddy) The cutest little tennis outfit! My god I thought I was going to have a heart attack! Oh my! I didn‘t see you there, that is so embarrassing!"
Cuddy: "How's your hooker doing?"
House (to Wilson): "How sweet of you to ask. Funny story, she was going to be hospital administrator, but just hated having to screw people like that."
— Paternity

Paternity is a 1st season episode of House which first aired on November 23, 2004. A 16-year-old boy comes to the hospital complaining of double vision and night terrors after being hit in the head by a lacrosse stick. House is dismissive until he notices a myoclonic jerk in the boy's foot. After a near-fatal hallucination and several faulty diagnoses, House is mystified until he learns the boy's true paternity.

The second episode of the series has both a short-term piece of character development and a hidden long-term piece of character development.

First, although we known from the Pilot that House avoids doing work, this episode shows just how far that goes. House avoids his last five minutes of clinic duty while Cameron catches up on his correspondence and Foreman and Chase cool their heels waiting for something to do. When a case presents itself that could make it at least look like House is working, he initially passes. However, we soon learn that when he's intrigued, his work ethic comes to the fore.

The second piece of character development is House's seeming distrust of the patient's parents, who he is certain aren't both his real parents (he suspects the father is not). He soon starts taking bets on the outcome and won't be satisfied until he misappropriates hospital equipment to satisfy his curiosity. He quotes statistics about true paternity.

However, he has a point. The parents admit they are keeping the truth from Dan. The irony is in the reveal - Dan has figured it out himself already and it doesn't matter to him.

Four years from now, when House's father dies, this episode suddenly snaps into high relevance. House's curiosity about Dan's paternity is not seated in his intense desire to be right, but in his own doubts about his family.

Recap

A lacrosse player, Dan, starts suffering from double vision while playing in a game. When he is checked by another player, he falls to the ground and there is blood all over his face. His trainer runs over to him, but Dan is unresponsive and the trainer calls for a doctor.

Gregory House is reading gossip magazines in the clinic when James Wilson finds him hiding in an exam room. House has five minutes until he can leave and doesn't want to treat someone who will take half an hour to pamper. Wilson asks him why he doesn’t just tell Cuddy he has an urgent case, but House replies he has no cases right now. Wilson is incredulous that House and his team have no cases. Meanwhile Allison Cameron is answering mail while Robert Chase does a crossword puzzle with help from Eric Foreman.

When House tries to leave the clinic, he finds a man and a woman with a letter, addressed from House, that says he would take his son's case. When House sees the letter, he confronts Cameron about forging his signature. She describes the case and House gets interested in the night terrors the patient is going through.

He agrees to see the family, against his usual procedure. He examines the patient, who has barely slept for three weeks. When the patient is asked to name animals starting with the letter B, he can only think of “baby elephant”. House thinks it is either post-traumatic stress disorder or sexual abuse. Dan denies abuse, but he admits he was hit in the head during lacrosse, but notes that he had double vision before he was hit. House chides Cameron for not knowing about the trauma. The parents object—the emergency room did a full set of scans on Dan and found no concussion, but House in unswayed and tells him to see an ophthalmologist. Cameron objects, but House says she's just objecting because she thinks his dismissive behavior is a reaction to how she brought him into the case. Based on her acting like everything is about her, he surmises that she's an only child, which she denies. House looks into the exam room and he notices a twitch in Dan's leg—a myoclonic jerk which only happens in people who are about to fall asleep. House is intrigued and orders him admitted.

They start a differential. Foreman is worried it is neurological, in which case it can't be treated. House rules out Chase's suggestion of infection. House also thinks that the patient's father isn't his biological father. Foreman bets $100 on the opposite. House orders a polysomnograph while the patient sleeps. That night, as they run the polysomnograph, the patient dreams that House is cutting off his toes. The EEG confirms the night terrors.

All the tests come back normal. They look at the patient's MRI scans. Chase thinks he has viral meningitis, but House knows he is only guessing. However, House has spotted something—an upwards arch in the corpus collosum, the junction between the two brain hemispheres. House orders a radioisotope examination to look for blockage. Foreman prepares Dan for the procedure, and looks at the facial structure of the patient and his father to see if he can prove they are blood relations. They find the blockage and schedule surgery to insert a shunt to drain cerebro-spinal fluid.

However, the buildup of CSF turns out only to be a symptom. After testing the fluid, they think it might be multiple sclerosis, but here are no lesions and if it is progressing this quickly, it will most likely kill him within five years. They break the news to Dan but tell him it will take months to confirm the diagnosis as it is in its early stages, but warn him that the symptoms will get worse. They recommend medication to ease the symptoms and advise him that they are looking for a specialist.

The patient goes missing from his room and the team searches for him. They are worried because he had a lumbar puncture to prepare him for the radiological procedure and he should not be moved. They call House at home. House shows up at the hospital and tells Foreman to keep looking and that he's going home. He tells Foreman to check the roof because the orderlies sometimes prop the door open. Chase, Cameron and Foreman run to the roof and find Dan there. The patient seems to be dazed and Chase reassures him, but the patient doesn't know where he is. The doctors realize that Dan believes he's on the lacrosse field. Foreman keeps talking to him as Chase tackles him to keep him from walking off the roof.

Foreman tells House that the patient thought he was on the lacrosse field. House thinks that this shows he doesn't have multiple sclerosis. It also means that he probably had a brain infection. Cameron thinks it might be syphilis. House wants to use a dose of penicillin, injected directly into the brain using the existing shunt from the surgery to allow any excess fluid to drain. They start the treatment, but the father doesn't think the patient has ever had sex.

Cuddy finds out about the paternity bet. Thinking the father is Dan’s biological father, she bets House's attendance at a symposium against a week of clinic duty.

They continue the injections on the patient while Chase tries to distract him by directing his attention to Cameron's low-cut blouse. Dan starts having tremors, auditory hallucinations and double vision.

They realize the penicillin isn't working. They eliminate just about everything it could be from the mnemonic "MIDNIT". House focuses on the night terrors. He orders an EEG, with microphones along his esophagus.

House tells Wilson he's missing something. The parents confront House about doing nothing, not even meeting the patient. House tells them he is continuously informed of the patient's condition. He tells the parents to go comfort their son. House plans on using DNA from the parents' coffee cups to test paternity. He bets Wilson double or nothing he is right. House checks in with his team and gives them the DNA to test.

The tests are negative, except the paternity test—neither the father nor mother are biologically related to the patient. House confronts the parents. They admit the patient was adopted. House admits he tested their DNA. The parents say the medical history they gave him was for the biological mother. House asks if the biological mother was ever vaccinated, but they don't know and say that the patient was. House dismisses them—he needs to know what happened in the first six months of the patient's life when he was relying on his mother's antibodies like all newborns. The parents don't know.

House explains the problem: an infant gets exposed to measles, has symptoms, but in rare cases the measles hides in the brain—subacute sclerosing panencephalitis. It only happens in babies whose mothers haven't had measles. Dan will need interferon injected directly into his brain, but it will kill him if they are wrong. They need a biopsy, but the only way to do it safely is to go in through the eye and biopsy the retina. They do it and the test confirms the diagnosis.

Foreman starts to explain the interferon treatment, but stops the technical explanation and simply tells the parents it's dangerous, it could kill him, but they should do it. They agree to proceed and they start the procedure by drilling a hole in Dan’s skull.

Cuddy and House argue about the cost of the DNA test. They settle it by having House get to take a week off clinic if he pays for the test. House uses the money he won off the team and Wilson.

They test the patient and he easily names several animals that start with the letter "O". The patient also says he has known he was adopted for six years—neither of his parents have a cleft chin like he does.

House makes a trip to the lacrosse field, where he imagines watching a game.

Clinic Patient

A baby has a swollen face, but no fever. The mother has not had the baby vaccinated because she thinks they are a conspiracy of the pharmaceutical companies. House starts talking about another conspiracy: the market for "teeny, tiny baby coffins" and tells the mother a baby's immunity from breast milk only lasts six months and that her not immunizing her baby will force companies to bring down their prices. When the mother gets worried about what is wrong with her baby, House tells her the baby only has a cold.

The next patient has inserted a nail file into his leg to relieve the pressure of a boil. It has become infected. House gives him some Vicodin. House wonders why the patient drove 70 miles to Princeton-Plainsboro, passing more than one hospital and several doctor's offices along the way, and figures that the patient has sued all the doctors between here and where he lives. House treats him anyway.

The patient comes back with a lawsuit and offers to settle it. House tells him he has gonorrhea. The patient doesn't believe him. House says he will have to inform the health authorities, who will contact his wife. They bluff each other. House tells him to have it checked out himself—if he can find a doctor.

Major Events

  • House reveals that he only takes cases that he considers to be interesting.
  • House starts a bet with Wilson, Cuddy and his team on the grounds that Dan, their current patient, isn't related to his father.
  • After learning Dan is adopted, House wins the bets and gets a week off clinic duty from Cuddy as a result.

Title

  • The title of the episode comes from the running bet on the main patient's paternity.
  • Also on the Region 2 DVDs, a new theme tune is used in place of "Teardrop" by Massive Attack as the European distributor could not obtain the rights to use the song.

Zebra Factor 10/10

Subacute sclerosing panencephalitis is very rare. It only appears in one out of every 1,000,000 cases of measles, and with measles being such an uncommon disease now thanks to vaccination, there have been less than 30 cases in the United States during the past 20 years. Even an infectious disease specialist like House would be unlikely to see a case in his lifetime.

Trivia & Cultural References

  • Lacrosse is a stick and ball game that is one of the few modern sports that is native to the Americas, having been played by native Americans in pre-Columbian times. It was first described by European priests in the 17th century.
  • The colors worn by Dan's team and Dan's parents, as well as the team mascot, appear to be the maroon and white of Carnegie Mellon University
  • A shot at Chase - he’s doing a crossword puzzle and has to ask for a nine letter word describing iodine deficiency in children. Foreman gives the correct response, cretinism.
  • Maplewood, New Jersey is in the north-eastern part of the state. However, it it only about a 40 mile drive from Princeton, not 70.
  • Laurie's accent slips back into a more British pronunciation on the words "diapers" and "wheelchair" where he fails to insert the final "R" sound. He also pronounces "diploma" with a terminal "R".
  • Sound engineers Barbara Isaak, Craig T. Rosevear and Bradley L. North were nominated for a Golden Reel Award for their work on this episode.
  • The George Washington Bridge spans the Hudson River between Fort Lee, NJ and Manhattan.
  • The scene with Foreman, Chase and the crossword puzzle was actually shot for the episode Pilot and appears in the extra footage version of that episode.

Goofs

  • An eye biopsy would never be performed in the manner shown. The central cornea is a poor target as scarring of the cornea could lead to permanently impaired vision. Similarly, the pupil contains crystalline structures which would be permanently damaged by the needle. Finally, the center of the retina, the fovea, would be the worst place to take the biopsy as it has the most densely concentrated area of light sensitive cells and is the most sensitive part of the retina. Permanent loss of vision in the area would be almost certain.The needle should be inserted through the white of the eye, which doesn't have any effect on vision.
  • A closeup of the crossword puzzle already shows that CRETINISM is filled in before Chase asks Foreman.
  • House should not have put the parent's DNA samples in a plastic container as the plastic can affect the DNA. Paper would be a much better choice.
  • When Chase looks at the corpus callosum on the scan, the scan doesn't actually show this feature.
  • "Radionucliatide" is a malapropism. The word is "radionuclide"
  • You can tell that many of the fans at the lacrosse game are merely dummies dressed up with wigs to cut down on the costs of extras.
  • In one of the shots of the lacrosse game, the word "TARTANS" is clearly reversed, showing the shot has been reversed.
  • When House examines Dan in the clinic, he is wearing a different pair of shoes than he was the moment before when Wilson found him hiding in an examination room.

Reviews

  • IMDB users rated the episode an 8.3 with 36.3% of users rating it an 8. The episode did best with females (8.6) and worst with people under 18 (7.7)
  • TV.com users rated the episode an 8.8. They chose Hugh Laurie as their most valuable performer.

Medical Ethics

DNA Testing

First and foremost, yes it was unethical for House to test the DNA of Dan's parents without their consent. There are instances where you don't need consent to perform a test, but they generally don't apply to doctors. A good reason would be to diagnose a genetic condition, but even in that case the patient's consent should be obtained.

This issue arises in a few other episodes for the same reason - paternity testing. In the previous episode, Maternity, Jill tricks her husband into undergoing a paternity test because she's not sure he's the father of the baby she's carrying. Similarly, in Joy to the World, Whitney's fiance demands a paternity test when she gets pregnant because they've never had sex. Finally, in both Birthmarks and Love is Blind, House tests people to try to determine his own paternity.

On a larger scale, there are genuine privacy concerns about routine genetic testing and security of results. Given that many genetic conditions and predispositions may never manifest into a disease, patients fear that employers or insurance companies may use such information against them. For example, genetic tests are now becoming more common to detect a predisposition towards breast cancer, which is something a patient would want to keep private if such a test was positive.

Vaccination

Back in 2004 when this episode was produced, vaccination avoidance was a relatively minor problem. However, in today's world, it is increasingly becoming a major health concern. Many pediatricians now refuse to see patients who won't undergo routine vaccinations.

However, here House uses tactics that are somewhat underhanded. Instead of discussing the issue rationally with the patient, he appeals to her emotional side by intimating that her baby may have caught something that is potentially fatal. Patient, including parents of infants, are still permitted to exercise informed consent.

But "Young Mom" isn't totally out of bounds with her concerns about vaccine costs. In many countries with universal or single-payer health care, most routine vaccinations are free of charge. In the United States, not only will patients be charged for vaccines, they often have to pay for the privilege of being vaccinated. For school age children, schools provide a good venue to do mass immunization, and many medical facilities set up specialty clinics for annual vaccinations (like for influenza) to keep patient costs down. However, it isn't unusual for a vaccine to cost in the range of $40, and many require multiple doses at a regular interval to become effective.

Withholding medical records

As a rule, medical records belong to the patient, not the hospital or the physician. In lawsuits, it is common for lawyers on both sides to request copies. This includes situations where the patient has been injured otherwise and the opposing lawyer wants to ensure that current conditions were not present at the time the plaintiff last saw a doctor, or to confirm the patient reported consistent symptoms to their physician.

However, when a lawsuit is even threatened, hospitals and physicians also have a duty to preserve records pending review for litigation. House is really pulling a fast one here though. He should have offered to make copies of the originals for the patient which would meet both his obligation to preserve records and to provide them to the patient.

Quotes

Dr. Gregory House: [examining a baby whose mother isn't vaccinating him because she feels it's a scam; House takes the child's stuffed frog] All natural, no dyes. It's a good business - all-natural children's toys. Those toy companies, they don't arbitrarily mark up their frogs. They don't lie about how much they spend on research and development. And the worst that a toy company can be accused of is making a really boring frog. Gribbit, gribbit, gribbit. You know another really good business? Teeny tiny baby coffins. You can get 'em in frog green, fire engine red. Really. The antibodies in yummy mummy only protect the kid for six months, which is why these companies think they can gouge you. They think that you'll spend whatever they ask to keep your kid alive. Want to change things? Prove 'em wrong. A few hundred parents like you decide they'd rather let their kid die then cough up forty bucks for a vaccination, believe me, prices will drop REALLY fast. Gribbit, gribbit, gribbit, gribbit, gribbit, gribbit.
Young Mom: Please, tell me what he has.
House: A cold.

Dr. Gregory House: Thirty percent of all dads out there don't realize they're raising someone else's kid.
Dr. Eric Foreman: From what I've read, false paternity is more like ten percent.
Dr. Gregory House: That's what our moms would LIKE us to believe.

John Funsten: You've caused me considerable mental distress.
Dr. Gregory House: I certainly hope so.

Dr. Eric Foreman: He probably just moved. Nobody stays perfectly still for their entire MRI.
Dr. Gregory House: Yeah, probably got restless and shifted one hemisphere of his brain to a more comfortable position.

Dr. Gregory House: Dr. Foreman. I assume you found the kid.
Dr. Eric Foreman: He almost walked off the roof.
Dr. Gregory House: Suicidal?
Dr. Eric Foreman: No, he thought he was on his lacrosse field. Look... look, I was just gonna run home, shower, change...
Dr. Gregory House: Conscious?
Dr. Eric Foreman: Yeah.
Dr. Gregory House: How'd you talk him down?
Dr. Eric Foreman: Actually. Chase tackled him.
Dr. Gregory House: How come YOU didn't do it?
Dr. Eric Foreman: Right, well, I am black, but he was closer.

Dr. Gregory House: Perseverance does not equal worthiness. Next time you want to get my attention, wear something fun. Low-rider jeans are hot.

Dan's Father: No! No, we took him to the ER after the game, he was scanned, they tested him, said he was fine. No concussions - it's gotta be something else.
Dr. Gregory House: You hound me for my opinion and then you question my diagnosis. Cool.

Dr. Gregory House: It's ironic, isn't it? Sort of like the boy who *sued* wolf. You know, I bet we have a doctor here named Wolf. How perfect would that be? I'm gonna page him.

Dr. James Wilson: Yes, concerned parents can be so annoying.

Dr. Gregory House: Oh, crap. Another reason I don't like meeting patients - they don't know what you look like, they can't yell at you.

Dr. Gregory House: Listen, when we were taking his medical history, were you confused? Did you think we were looking for a genetic clue to his condition or did you think we were trying to ascertain who loves him the most in the whole, wide world?

Dr. Gregory House: General Hospital is on channel 6.
Dr. Eric Foreman: Dan's brain's not showing channel 6 right now, only mush.

Dr. Lisa Cuddy: And is there a paternity bet on the father of the patient?
Dr. Gregory House: Doesn't sound like me.
Dr. James Wilson: Well it does, actually, but it doesn't mean you're guilty.

Dan's Mother: How can you just sit there?
Dr. Gregory House: If I eat standing up, I spill.

Dr. Lisa Cuddy: You can't order a thirty-two hundred dollar DNA test to win a bet!

Cameron: McDonald criteria requires six months to make a definitive diagnosis.
House: Oh, who cares about MacPhearson? I hear he tortured kittens.
Foreman: McDonald.
House: Oh, McDonald! Wonderful doctor. Loved kittens.

Foreman: Look, I'm sorry. I-I-I can explain this as best I can, but the notion that you're gonna fully understand your son's treatment and make an informed decision is... is kind of insane. Here's what you need to know: It's dangerous. It could kill him. You should do it.

Dr. Chase: It doesn't necessarily have to be that bad. If we exclude the night terrors it could be something systemic: his liver, kidneys, something outside the brain.
House: Yes, feel free to exclude any symptom if it makes your job easier.

House: Another reason I don't like meeting patients. If they don't know what you look like, they can't yell at you.

Dr. Wilson: Just tell Cuddy you have an urgent case.
House: That would be lying.
Dr. Wilson: And that would be... wrong?

House: Can we get off my screw-ups and focus on theirs? Theirs is bigger.

House: Who thinks there's a third option? (Chase raises his hand) Very good. What's the third choice?
Dr. Chase: No idea. You just asked if I thought there was one.

Dr. Cameron: What about sex?
House: Well, it might get complicated. I mean, we work together. I'm older, certainly, but maybe you like that.
Dr. Cameron: I meant maybe he has neurosyphilis.
House: Huh. Nice cover.

House: Dr. Cuddy. Great outfit.
Dr. Cuddy: What are you doing back here? Patient?
House: No. Hooker. Went to my office instead of my home.

House: Are you guessing?
Dr. Chase: Yes.
House: Too bad. You're right.

House: He knew that I saw something on the MRI, so he figured that I saw something and took a guess. Clever... but pathetic.

House: When did my signature get so girly?
Dr. Cameron: I can explain.
House: See that "G"? See how it makes a big loop on top? Doesn't even look like my handwriting. Think I have something? What's the differential diagnosis for writing G's like a junior high school girl?

House: Close the door. Close the door!'
Wilson: Is Cuddy down the hall counting to fifty?

House: If it's not trauma, the other cause is...sexual abuse. So who is it? Teacher? Especially friendly neighbor? I'd say it was one of you two, but you'd deny it.
Father: It's not us.
House: I say it here and it comes out there.

House: This might be kind of controversial, but...sexual abuse is a BAD thing. I just wanted to make sure he wasn't being diddled by father or mother.

House: This is going to hurt, Dan.

Foreman: So when you say, 'Call me when you need something,' you mean don't call you?
House: No, I mean call me if I can actually do something.

Dan: This is where I dropped the ball.
Chase: Dan, we're on top of a roof.

House: I never said I wasn't going to treat you. We'll just drain the pus out of your knee and fix you right up.
Funsten: Why would you do that?
House: I'm a people person.

House: If I don't keep myself busy with trivial things like these, I'm afraid I might cry.
Wilson: You're an ass.

Dan: You're sure this won't hurt?
Foreman: I'm sure. It's just scary as hell to look at.


Cast

Music

  • On Saturday Afternoons in 1963 by Rickie Lee Jones - in the final scene
  • Years May Go By by Jayme Kelly Curtis

Release Dates

  • United States - November 23, 2004 on Fox
  • Canada - November 23, 2004 on Global
  • Estonia - December 23, 2005
  • Hungary - March 29, 2006
  • Germany - May 16, 2006
  • Finland - September 28, 2006
  • Mexico - January 17, 2007

In Other Languages

  • Spanish - Paternidad (Direct translation)
  • French - Test de paternité (Eng. Paternity Test)

Heavy foreshadowing

In this episode, House correctly questions Dan's paternity and it turns out that Dan is adopted. He talks about the number of men raising another man's child without knowing about it, which varies widely by culture and social standing. We learn in Season 5 that House doubts that John House is his biological father, and that suspicion turns out to be correct.

Links

This article is also available in Spanish at es.dr-house.wikia [1]


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Pilot

Paternity
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Occam's Razor
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