- I've told you in the past
that I take your comments seriously.
Well now I'm putting my money where my mouth is
and watching an episode that you asked me to watch.
Here we go, House M.D., episode "Three Stories."
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- [House] Three guys walk into a clinic.
Their legs hurt.
(film squeaking)
In less than two hours, one of these three
will be tossed out of the hospital
because they were faking it to score narcotics
and one will be very close to death.
(film squeaking)
Where is the pain localized?
- It started just above my ankle and it's radiating up.
- So, what should we do first?
- Family history?
- Indicative of leg pain?
That's a very short list.
Any history of bone cancer, osteogenesis imperfecta,
or multiple myeloma?
- It could be a blood issue.
We should run a CBC and a d-dimer.
- And get an MRI.
- MRI or a PET scan?
- They're asking him questions really out of order.
In medical school you're taught to go with the OPQRST model.
O being onset, P being provocative palliative
Q being the quality of the pain,
R radiation of the pain, S as the severity of the pain
and T timing which could mean like time of day
or if they've ever had this issue in the past.
You don't just randomly start asking
family history out of nowhere.
Because if you start asking that,
it could lead you down a line of questioning
where you're gonna spend a lot of time
and not get any valuable info.
You want the high-yield stuff up front.
- Sorry, thanks for playing.
Patient's dead.
You killed him.
- We had no time to run any tests,
there's nothing we could do.
- You had time to look at the leg.
(film squeaking)
Puncture.
- [Female doctor] Snakebite.
- That would be my guess.
- So a lot of times when you have an open wound
like this farmer's presenting with,
you have to think, obviously, about bug bites,
animal bites that sort of thing,
because we're in the northeast coast,
we always jump to Lyme disease, ticks.
*patient grunting*
- Too much pain to be a slipped disc,
could be herniated and appending the nerve root.
- Or it could be referred pain from his groin.
- Sir, are you getting pain anywhere?
- He's curling, it's not the back.
- Sir, where are you getting pain?
- Help me!
- Hey, he's not gonna tell us anything
if we don't get him out of pain.
Give him 50 milligrams of Demerol.
- We have no history.
He could be allergic.
- What do I do?
- We can't diagnose him while he screams.
- Better than killing him with painkillers that-
- There's ways you can distinguish whether
someone's actually in pain or not.
If someone's in horrendous pain,
their heart rate's gonna go up,
you can't fake that.
You can't make your heart rate go up
while you're faking pain.
Second of all, you can, when you're doing
your physical exam, there's ways to test if
someone's really having pain.
I do this all the time in the hospital.
I'll put pressure on the area while the
patient is looking at me and I'll ask if it hurts.
If they're screaming in pain,
I'll change the subject or I'll ask them
about something else that's going on,
but leave my hand on the area where
they're still having pain.
And while I'm talking to them,
I'll gently start increasing pressure on that area.
If they're not jumping in pain,
it's either not as bad as they say it is,
or they may be pain seeking,
exhibiting pain seeking behavior.
This example doesn't look like a person's faking pain.
- You did exactly what his attending did.
- [Male Doctor] And that was the proper way
to handle the case?
- Yeah.
- The guy used him as a dealer.
- You're gonna see a lot of drug seeking behavior
in your practice, and there's a reason- it works.
(film squeaking)
- [Dr. Cameron] This will start making you
feel better really fast.
(monitors beeping)
He's having an allergic reaction.
Bag.
Paddles and epi.
- His heart's fine.
- It's not gonna stay that way.
- The reason you give the epi is not because
his heart's about to about to stop,
it's because his airway's closing
from having an anaphylactic attack
to what looks like the snake anti-venom.
So you need to give epinephrine immediately,
usually to the upper thigh or some other muscular region
where it can get well absorbed very quickly.
- Let's say we take five.
Get some coffee, go pee.
- It's funny, like he's fine with the medical students
going out to do that.
Nowadays, all the medical students would be buried
in their phones, trying to Google what the answer is
or Google what the possibilities are.
What a good doctor means in medicine has changed
from those who know the most
to those who can get the best information
in the most efficient way possible.
Because there's so much information.
It's being updated so quickly.
It's almost impossible to be up-to-date
on every single study on every single subject.
I've heard that there was five studies
coming out per minute in the scientific field,
so it's impossible to stay up-to-date with
every piece of literature,
but if you're very good with internet research,
you're very good with verifying sources,
you're very good at reading journal articles
and understanding which one's the quality one versus not,
you can make a good decision and possibly
the best decision for your patient
from being able to research.
- [Patient] Oof.
- [Dr. Foreman] The patient responded to epinephrine
and the allergic reaction was arrested.
Unfortunately, the patient continues to deteriorate.
- [Dr. Chase] Maybe the snake wrangler
was wrong about the type he caught.
- He faxed us the venom tests
and confirmed it's a timber rattlesnake.
- No, it's not.
Notice the volume?
- I skimmed over that and the gender
and the coloring, jumped right to the name of the snake.
*Dr. Mike laughs*
- 200 milligrams.
Our guy got bit less than four hours ago.
There's no way a snake regenerates
that much venom that quickly.
- We're supposed to know how fast makes make the venom?
- Nope, unless you get a patient bit by one.
- Okay, that was just ridiculous.
I mean, I get that House has to know a lot,
but he doesn't know how fast snakes regenerate their venom.
That's just insane.
I don't know, I guess now I know that too,
but where does he get that?
Snake's venom, regeneration?
- It hurts again.
- [Female Doctor] He came back?
- On average, drug addicts are stupid.
(film squeaking)
- We're gonna put this hard rubber tube up
your urethra and into your bladder.
It may be a little uncomfortable.
- Will I be getting some sort of anesthetic?
- We're concerned about allergic reactions today.
*groaning*
- If the guy can handle a rod in his penis
for a half an hour, he's really sick.
- Okay, you don't just put a catheter in
because you want to see how serious someone
is about getting medications.
There are ways to check for people who are malingering.
Malingering is basically when a person
is trying to act sick in order to get some
sort of secondary gain like drugs,
like a day off work, like disability.
These things do happen and you need to consider them.
Not first and foremost in your mind,
but they do need to be in your thought
process, in your differential.
- Wrong snake?
- Tried every other antivenom we had.
- Or too late?
- Yep. He's dying.
(film squeaking)
- You're dying.
*Dr. Mike laughs*
In a few hours.
There's nothing we can do except deal with the pain.
- Well, I need to go home.
- You're not going home.
- But my dog.
What will happen to my dog?
(film squeaking)
Neighbors don't like him.
- So the Humane Society, take him in, find him a home.
- No, they won't.
Yeah, but maybe maybe my aunt.
- It wasn't a snake bite was it?
(film squeaking)
I assumed that Cujo bit one of your neighbors a while back.
You tell me that he bit you and I gotta report it.
Cujo's got a record, he gets the chair.
*Dr. Mike laughs*
- I don't know if that's how it works.
- The good news is, you might just live,
the bad news is your dog's gonna die.
- Why are the residents doing this?
Residents don't go to people's homes
and steal the dogs and swab the mouth.
This just doesn't happen.
They would call the local dog catcher,
I don't know the someone from the Humane Society,
to come and get the dog, bring it in,
test the mouth and then they'll deliver them the results.
Residents don't do this because
then their employment insurance would be through the roof,
because they're always undergoing these crazy risks.
It would be too nuts.
- What'd you call that?
- [Male Doctor] Ball of yarn.
(film squeaking)
- What color is your pee?
- Yellow.
- What color's your blood?
- Red.
- What colors did I use?
- Red, yellow and brown.
- And brown, what causes brown?
- Waste.
- Which means the kidneys are shutting down.
Why?
- Trauma.
- None that his history would indicate.
(film squeaking)
What are you missing?
- [Female Doctor] Muscle death.
- Rhabdomyolysis.
- Not your case.
- Nothing wrong with a consult.
- Dying muscle leaks myoglobin.
It's toxic to the kidneys.
- Medical students were saying that it was trauma
or damaged, they just weren't saying it the right way.
So he's being really mean to them.
I don't condone this kind of pimping.
- Dog's mouths are pretty filthy,
but they have natural antibodies to fight off
most of the stuff, we don't.
That's why dog bites can be so nasty.
- He's right, dog bites can be nasty,
but actually human bites are worse.
If you look at the infection rate from
an untreated human bite versus a dog bite,
human bites are actually more likely to get infected,
and that's because human mouths have a much
greater range of bacteria and viruses
that live in our human mouths as compared to dogs.
- We may need to remove the leg.
- I still don't know what this gentleman's problem is.
He has a muscle damage from what?
I don't, I'm not following.
And what did the MRI show?
- His MRI showed that the leg pain
was caused by the self-injection.
It wasn't caused by an infection.
- Compartment syndrome?
- It was an aneurysm that clotted, leading to an infarction.
- God, you were right.
It's House.
- [Female Doctor] We have to do the surgery.
- Now I get why you guys recommended this episode.
I was wondering what happened to House,
unless this is a whole thing is a farce.
It would probably take a few days to diagnose it
because it's such a unique and rare condition,
that it wouldn't appear at the top of your list.
If you're thinking of aneurysm at the top of your list,
you're gonna be doing a lot of unnecessary MRIs
and missing a lot of problems that are much more common.
So you need to think horses, not zebras.
But I know since this House M.D.,
zebras are usually the first thing they talk about.
- Do a bypass.
Restore the circulation.
- Amputation is safer.
- For you or me?
- The blockage of blood flow-
- Four day blockage.
- Yes.
It caused muscle cell death.
When those cells die, they release cytokines and potassium.
- To restore the blood flow instead of just lopping
it all off then all that crap gets washed back
into my system and cytokines can cause organ failure
and the potassium could cause cardiac arrest.
On the other hand, can we just get the use of my leg back?
- This is really interesting.
So, whenever you have a part of the body
that doesn't have blood going through it
for a very long period of time,
that body, the part of the body, dies.
Becomes necrotic, that's medical term for it.
Because of ischemia, lack of oxygen, it dies,
because blood is bringing oxygen to those areas.
When a muscle dies, for example,
it releases these inflammatory cells called cytokines.
It also releases potassium because when a cell ruptures,
the first thing that releases or the most
important thing that it releases, is potassium.
And having too high of a potassium
in your bloodstream is very dangerous.
It can be lethal.
And having too much of inflammatory cells
can also be lethal and cause organ damage.
So you have that problem going on
because his muscles have been without blood
for a long period of time in his leg,
but then as you restore blood flow
you have reperfusion of that area.
You can also get even more inflammation going
and inflammatory markers going,
because he's bringing healthy blood into damaged blood,
and that sparks to even more inflammation.
And that's why Dr. Cuddy's actually
encouraging him to go for the amputation,
to leave all those cytokines and
inflammatory cells and potassium in the leg
and not cause even more inflammation and pain.
But I also understand what he's coming from,
where he doesn't want to lose his leg.
It's risky what he's saying.
It's not advisable, what he's saying.
And I could see a lot of surgeons
turning down this procedure because
they don't see that this is ideal for him.
As a doctor, you always want to do
what's best for the patient and
let the patient decide what's best for their bodies,
but if they're telling you to do a procedure
that you think is very risky and unnecessary,
you're well within your means to try
and convince them otherwise.
- If you were right, the pain would be subsiding.
You'd be getting better.
- It's just taking longer.
- No, it's not.
We've got to let them cut the leg off.
- It's my leg.
It's my life.
(film squeaking)
- The middle ground you were talking about -
- We go in, take out the dead muscle.
There's still some risk of reperfusion injury, but-
- Give me the forms you need signed.
- If I were House, I'd be pretty mad about that.
But then again, this is why the bioethics committee
comes into play because you're technically
doing something the patient doesn't want,
it is explicitly said he doesn't want,
but you know it's better for them.
It's such a thin line.
I'm not sure what the right call here is.
But as medical proxy, she does have say over
what happens to his body right now.
- Because of the extent the muscle removed,
utility of the patient's leg was severely compromised.
Because of the time delay in making the diagnosis,
the patient continues to experience chronic pain.
- A lot of people don't realize this,
but when you're on chronic opioid medications,
which is just essentially it's a masking agent for the pain,
it's not treating your pain, just hiding the pain.
When you're on that for a long period of time,
it changes the chemistry of your brain,
and actually makes you feel something known as hyperalgesia,
where you feel more pain and are more sensitive to pain,
so that sometimes in a patient who has chronic pain,
you have to reduce the amount of pain medications they take
for them over time to feel less pain.
It's a paradoxical, complicated concept,
but I've actually had a patient that,
he was 81 years old, 30 years of back pain,
he's been on opiate medications for two years,
he's taken morphine and when he came to me said,
"Dr. Varshavski, you're my last hope".
And when I talked to him about it,
I said that I know this is gonna sound crazy,
but I have to lower your dose
and eventually get you off of your narcotic medications
if you want to improve this pain.
And actually, right now we're at a point
where he's not taking any narcotic medications for his pain.
He's going to the gym, he's golfing,
he's felt better than ever.
Narcotics aren't always the right answer.
They have a place, there's definitely a role for them,
but they're not always the right answer.
They definitely have harms and sometimes
those harms outweigh the benefits
and we need not lie about that.
- [Female Doctor] She had no right to do that.
- She had the proxy.
- She knew he didn't want the surgery.
- She saved his life!
- We don't know that, maybe he would have been fine.
- It doesn't matter, it's the patients call.
- The patient's an idiot.
*Dr. Mike laughs*
- Little do they know!
- They usually are.
(film squeaking)
- It wasn't clear to me in the episode
if they understand that it's him,
because they were still talking smack
at the end of that episode.
I do think that sometimes he crosses the line
and is a little rude, but that's Dr. House.
He's just got this personality that's like angry
and wants everyone to see him as the bad guy,
when in reality, he wants to do the right thing
and he wants to help people,
but he comes off harsh at times.
I feel like whenever he says a patient is dumb
or doesn't do the right thing,
he's essentially thinking that because
he's thinking about the mistake he made
of not amputating his leg and going through all those
surgeries and procedures and having this chronic pain issue,
when if he just would have gotten an amputation,
got a replacement, you know, there's so many ways
to get a prosthetic nowadays.
If you have another episode in the later seasons,
season two maybe season three,
drop it down below in the comments.
I'll watch that episode.
I want to watch more of this series.
I like watching House.
It refreshes a lot of my knowledge
that I know I studied back in the day,
but I haven't really utilized.
This is a great way for me to learn
and for you guys to learn at home.
So keep those comments coming.
Subscribe if you like my content,
and most importantly, as always,
stay happy and healthy.
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