The Beautiful House

I’ve made no real secret of my long-time fascination with medical shows and their distortions of reality, and how I think that distortion creates an “ER-effect” just as much as we have the “CSI-effect” or “Law & Order-effect”. In fact, if I get off my rear and out of the house enough in the next couple of days, I’ll be tossing off at least one, if not two, abstracts proposing book chapters for just this sort of thing. (Well, one on this sort of thing in a broad sense. I might also submit one that’s more focused on the problems of representations of chronic pain, and the difference between addiction and dependency – but much of my critique of that still stems from the fact that their inaccurate representations have an effect on real people.)

Apparently I’m just always on the cutting edge of trendy. In the last couple of weeks, the number of stories and books I’ve seen around House have truly shot up in number, and most of them are cranky. Which is fair – I have rarely seen so cranky a show that deserves its cranky critics, more than House. But I do wish, if people wanted to be cranky about the show, they would do so in a more novel way. Yes, the hospital is bright and pretty and new. Yes, there are only four major characters, two supporting, and a host of rotating background characters. Yes, they do everything – a fact the cottages have even started commenting on.

But these are the complaints inherent with any television show. The medium itself demands these constrictions. You’re not going to find a falling down hospital from the 1970s if that’s not a central character in the story (and yes, the setting is as much a character as someone portrayed by an actor – just look at the fabulous use of scene-as-character courtesy of Joss Whedon’s Firefly). You’re not going to find as many people in a television show that are actually needed to run a hospital, because of salary and budget issues, and the fact that ensemble shows can only be so big before they fall apart. (ER suffered from this problem – in fact, most ensemble shows do.)

So you make sacrifices. You make the teaching hospital shiny and new, so that it drops more to the background – a well-lit place with little character. (In fact, there are only two settings within the show that I would argue actually have character – the MRI/CT room, which I’m convinced is the same set, and House’s office.) They drop back the number of supporting staff cast members in order to keep the focus on the main characters. People become more technically brilliant than they would be in the “real” world – all to move the story along. But these are accepted shortcuts to take in television. Show me a show based on a real life occupation that doesn’t make similar sacrifices.

The Salon article touches a sad note when the nurse writing it talks about how the stories she lives on a daily basis are not so engaging to make it to television, because she’s comparing her cases against the fictional ones of House. Of course fictionalized shows bring a more dramatic story to air than might be lived out – but that doesn’t mean the lived out story can’t be translated from a lived narrative medium to one of television. That doesn’t mean it doesn’t belong in a book, short story, column for Health Affairs “Narrative Matters” column. It’s another facet, I suppose, of the medical show effect. People become disillusioned with the life they live, because it’s not the life they see.

During my time at the University of Washington, I spent many hours roaming the halls of our medical center – for personal, academic, and professional reasons. I joked, many times, that I needed breadcrumbs and string to find my way through the dark corridors populated with half floors hidden in the middle of the building, stariways to no-where, and a jumbled architecture that only comes from piecemeal building. The brand new Foege building was lovely, as I was leaving, an attached jewel on a fading cardboard crown of a hospital – most of us lived and worked in tunnels that more closely resembled submarine quarters than the floor to ceiling windows that grace Princeton Plainsboro Teaching Hospital (or for that matter, Seattle Grace Hospital). Many of us watched the medical dramas (and comedies) that were on TV, and we had special affection for Grey’s Anatomy – being located just across Lake Union from us in the fictional world.

But few of us wandered around complaining about the lack of placed realities on these shows. Some of us banded together and blogged about the fictional Seattle and its geography. Some of us started to critique the medicine on the shows, much like Penn’s bioethics center did, and some of us even said “well, hell, I can write that!” and took to prepping and sending out our own scripts (and several even got picked up).

As much as there is to complain about these shows – and really, there is oh so much – they also open the door for dialogue, discussion, education, and so much more. As much as they define, often broadly and badly, they create a place for a public discourse to happen. We, those of us in the medical field (and its fringes) have a choice: we can rail against what’s there, or we can collect ourselves, join the fray, and insist on being heard.

to intubate or not to intubate, that is the big ethical question

We’re in the middle of an impressive snowfall, so I’ve decided to curl up on my couch and watch TV. Currently, an older episode of House is playing, and as you well know, I love the ethical spin the show brings. To catch you up on what’s happening, House doesn’t believe a patient has ALS. Patient thinks he has ALS and has signed a DNR while he can’t. House’s team decided to try a medication on top of what the patient was already receiving, to rule out another possibility for paralysis. The patient reacted badly to the medication, and went into respiratory distress. House’s team refused to intubate, citing the DNR, so House intubated and bagged the patient, then placed him on a vent.

House: Everyone knows what’s wrong with me. What’s wrong with him is much more interesting.
Foreman: You tubed him and he didn’t want to be tubed! He has the legal papers saying just that!
House: To intubate or not to intubate, that is the big ethical question. Actually, I was hoping we could avoid it and maybe just practice some medicine.
Foreman: There’s no question. It’s the patient’s decision!
House: If the patient is competent to make it. If his thyroid numbers aren’t making him sad.
Foreman: Oh my god, you don’t believe that.
Cameron: His thyroid levels were a little-
Foreman: It’s nothing. Do NOT defend him.
House: Why do you think he signed that DNR?
Foreman: Wha – I didn’t talk him into it!
House: No, he signed a DNR because he didn’t want a slow, painful death from the ALS. What was happening to him had nothing to do with the ALS.
Foreman: Right! Exactly! It is the IViG! You screwed up! You’re not going to let him die because you screwed up!
House: Technically, your case. You screwed up. Is that what this is about? Looking bad in front of your old boss.
Foreman: You assaulted that man.
House: Fine. I’ll never do it again.
Foreman: Yes you will.
House: All the more reason this debate is pointless.

So, who’s right here? Is House right – do you intubate because the patient was not dying because of the ALS? Or is Foreman right, and House assaulted the patient?

Now, in many treatment facilities, this entire scenario is moot because the DNR (which, as House notes earlier in the episode, stands for do no resuscitate, not do not treat) is specific enough that you can actually decide things like whether or not you want treatment for medical issues not related to your primary diagnosis. You can specify out how far you want treatment, at what point it should stop, even if you want only comfort care. Of course, the key here is “many” – I’ve seen DNR forms that simply specify no treatment and that the patient should be allowed to die from whatever disease or illness they have; this is when the scenario that played out in the episode of House comes in to play. At what point is it assault, when is it treatment, when is it counteracting side effects of treatment, and when do you just stop?

So I’m curious – given the scenario outlined above, where a patient has a non-descript DNR and a side effect from a treatment not treating the primary condition, what do you do?

House (M.D.) Trivia

Occasionally it’s fun read the IMDB trivia page for TV shows. For example, while I’ve long dismissed the criticism that there’s no such thing as a diagnostician team/division of diagnostic medicine in hospitals (while I am willing to accept I sometimes have a creative mind, I’m not yet willing to believe I’ve completely made up people I know, working in hospitals, who are working in that field), I’ve been puzzled by Chase’s title, intensivist. According to IMDB, an intensivist is doctor who specializes in intensive care. This specialty is new and uncommon in the United States, but well-established in Australia, where the character is from. Neat, eh? A good attention to detail, which is something I can appreciate.

(For those who might have missed out, I’m actually working on a project about television, media, medicine and responsibility. And by working on, I mean doing a lot of reading, and debating justifying the purchase of the first two seasons of House, MD…as research, of course.)