- 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." (upbeat music) (static bristles) (upbeat music) (static bristles) - [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) (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. (upbeat music)
You also have to take what Dr. Mike says with a grain of salt. He is a physician, but he’s trained in family medicine, not any of the narrow specialties required by House’s patients: infectious disease, nephrology, neurology, cardiology, critical care, etc.
Repost?
What I'm posting about is I'm hearing the phrase "Oh, fuck!" at the time that I've linked. I've listened to just that word, loudly, and it just sounds more clearly like "fuck". Is it unclear enough that no one else hears it, or is surprised? What do other people hear?