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Mid 30s man is one of the three case studies in the episode Three Stories. The patient's name is hidden by calling him Carmen Electra who portrays the patient at some points in the narrative. During most of the narrative, he is represented by actor James Saxenmeyer. However, once the patient is revealed to the audience to be a recollection of the incident that led to House's disability, he is portrayed by Hugh Laurie.
Medical History Edit
Mid 30s man is a man in good health for his age who enjoys physical activities such as golf and running. However, several days before his admission to the hospital as described in the case study, he came to the emergency room crying out in extreme pain that appeared to be eminating from his right thigh. He did have a decreased reflex in his Patellar Tendon, which might indicate a slipped disc. He demanded relief from the pain and started yelling loudly. That much pain seemed to rule out a slipped disc, but could indicate a herniated disc which was impinging on the nerve root or referred pain from his groin. However, the patient was able to curl his body, which appeared to rule out any problem with his back. When the attending physician grabbed a syringe of demerol to decide whether to inject the patient, the patient grabbed the syringe from the physician and injected himself in the leg. His "symptoms" disappeared, he immediately became calmer and was discharged within a few minutes. The attending clearly saw it as drug seeking behavior and marked the patient's chart accordingly.
You're going to see a lot of drug seeking behavior in your practice. There's a reason. It works.
Case History Edit
A few days later, the patient returned, again complaining of pain in his right thigh.
Well, even drug addicts get sick. Actually, for some reason, they tend to get sick more often than non-drug addicts.
In order to determine whether the patient was faking, the attending ordered he be catheterized without the benefit of an anesthetic on the pretext that they were worried about an allergic reaction. The patient agreed to this rather painful procedure for 30 minutes, seeming to indicate his pain was real. His urine was also tinged with blood and was tea-colored.
Tinged urine can indicate several conditions, such as a kidney stone. However, the blood will only turn the urine orange - a combination of the two colors. Brown material in the urine can only be the result of waste, and that can only be caused by kidney failure.
Dr. House asked the students what could cause the kidney failure. One student suggested trauma, but there was no history to support that diagnosis. She also surmised that it might be damage from drug injection, which would mean applying heat to the muscle and resting it. Dr. House pressed for more causes. She thought it might be an infection, which would mean administering antibiotics. Dr. House kept pressing for more causes, but the student had exhausted her possibilities.
You're useless. But at least you know it.
Dr. House also noted the patient tested for elevated creatine kinase and asked what that indicated. Another student said this indicated that trauma was the cause of the pain and with rest it should resolve itself in a few days. The elevated CK levels ruled out infection.
You know what's worse than useless? Useless and oblivious.
Dr. House asked what everyone was missing. When a student complained that they were being berated, Dr. House asked if he thought it would be easier with a real patient who was dying. Suddenly, Dr. Cameron appeared and suggested muscle death. The first student realized that the dying muscle would release myoglobin, which would poison the kidneys.
In the case, none of the doctors recognized the possibility of muscle death and they gave the patient antibiotics and bed rest. He continued to get worse for three days.
It is in the nature of medicine that you are going to screw up. You are going to kill someone. If you can't handle that reality - pick another profession, or finish medical school and teach.
After three days, the patient himself suggested it might be muscle death. The patient was finally given an MRI, which showed an aneurysm which had clotted, leading to an infarction and muscle death. The damage was so bad that surgery was necessary to remove the necrotic tissue and it appeared that they may have to amputate the leg. However, the patient would not consent to amputation.
Dr. House said that surgeons prefer to amputate because it is a much simpler procedure which requires much less precision on the part of the surgeon. Trying to save tissue can lead to other complications which can result in the death of the patient if anything goes wrong. The hospital administrator tried to talk the patient into accepting a prosthetic leg, but the patient wanted the surgeon to bypass the damage and restore circulation to the leg. The hospital administrator reminded him that amputation was safer. The dead muscle would still release cytokines that would poison his organs and potassium that could cause cardiac arrest as he healed. However, if the bypass were successful, he would regain full use of his leg. The hospital administrator tried to remind him how bad the post-operative pain would be, but the patient insisted on the bypass.
The patient's girlfriend objected to this course of action, believing he was risking his life on the off chance he would get his leg back.
The patient was prepared for surgery. The surgical team carefully broke up the clot and routed blood around the dead tissue. However, the dying tissue was released into the patient's bloodstream, causing him intense pain after the anesthetic wore off. They gave the patient morphine, but it was not enough to reduce his pain. He asked for more, but the doctors were afraid his system could not handle it in his weakened condition.
The hospital administrator explained that the amount of pain was related to how much dead muscle there was, and there was no way to tell for sure how long it would last. The patient could get full use of his leg, or he could be in pain for the rest of his life even if he did survive. She suggested more surgery to remove the dead tissue.
The patient realized from looking at his own EKG that he was about to go into cardiac arrest from an excess of potassium and called to the nurse for calcium glucinate to treat it. She refused, but the patient immediately went into cardiac arrest from wide-complex tachycardia. When the doctor arrived the nurse communicated the diagnosis and the patient's heart was restarted. However, he was clinically dead for over a minute. Dr. House believed the visions the patient saw were merely a result of chemical reactions from the brain shutting down.
I find it more comforting to believe that this - isn't simply a test.
The pain didn't improve, but the patient still refused amputation despite his girlfriend's entreaty that his life wasn't worth the risk. She felt the pain alone could be fatal. The patient chose to be put into an induced coma to sleep through the pain. The hospital administrator agreed, but the girlfriend wondered if, as the patient's medical proxy, she could make decisions for him while he was unconscious. The administrator agreed that she could.
They put the patient into a chemically induced coma. However, when he was unconscious, his girlfriend gave consent to surgery to remove the dead muscle from the leg. The administrator assured her she was saving the patient's life, but she didn't feel the patient would see it that way.
Because of the amount of muscle removed, the utility of the patient's right leg was severely compromised. Because of the delay in the diagnosis, the patient has chronic pain. The students argued about the ethics of the decision of the medical proxy, and whether her wishes would overrule those of the patient.