| abstract | - Bill Koppelman was the patient in the Season 8 episode Nobody's Fault. He was portrayed by actor David Anders. Herein are my factual findings and my decision on whether Dr. Gregory House should have his hospital privileges suspended for his role in the incident. As part of my investigation, I conducted several interviews with:
* Dr. Gregory House, attending physician, Head of Diagnostics at PPTH.
* Dr. Robert Chase, diagnostic fellow.
* Dr. Christopher M. Taub, diagnostic fellow
* Dr. Jessica Adams, diagnostic fellow
* Dr. Chi Park, diagnostic fellow
* Dr. Eric Foreman, Dean of Medicine, PPTH Such interviews are in the process of being transcribed and will be published along with the documentary evidence that was available for my review. It should be noted that Dr. House initially resisted being interviewed and only agreed to be interviewed when he was advised that the documentary evidence in the file was not favorable to his case and supported a conclusion that he should be suspended. He was reminded a suspension would be a violation of his parole. Bill Koppelman is a 32 year old high-school chemistry teacher. He collapsed while jogging and was paralyzed in all four extremities. However, his scans showed no sign of stroke or structural lesions, and there were no broken bones or other sign of trauma. House says it was Tranverse Myelitis. Dr. Foreman says no one has been on the MRI. He then asked Dr. House to take the case. Dr. House took Vicodin during his interview. I asked if he had taken Vicodin during his handling of this case, and he admitted he has been taking Vicodin for most of the last ten years due to ongoing leg pain. Dr. House pointed to his long line of successes and insisted that bad things “just happen” and felt investigations were a way of assigning blame instead of improving processes. He claimed the incident was nobody’s fault. Dr. Adams told me that Dr. House was making jokes as he presented the case, but denied trying to make Dr. House look bad. She too stated she didn’t think the incident was Dr. House’s fault. Dr. Taub said he was the first doctor to have a theory, hepatic encephalopathy, which would explain why he lost consciousness and was paralyzed. However, Dr. Park told me that Dr. House thought Dr. Taub’s idea was “stupid”. She had suggested normal pressure hydrocephalus, but Dr. House denounced that idea as “stupid” as well. I asked Dr. House about how he treated Dr. Park’s theory, but he said that unless I was stupid too, it was obvious from the chart that a lumbar puncture had been done and it showed that cerebro-spinal fluid pressure was low, not normal. I asked him if he had actually made the remark “stop squinting your eyes” to Dr. Park, and he admitted he had. Dr. Chase came up with the theory that he was hypocalemic. Dr. Adams pointed out that the patient’s EKG was normal, but surprisingly Dr. House agreed with Dr. Chase, noting the lab results showed that the patient’s potassium levels were abnormal indicating thyrotoxic paralysis. He ordered PTU, beta blockers and steroids. I asked Dr. House how orange smudges got on the patient’s chart. Dr. House said he was eating cheese snacks. However, the marks obviously weren’t from cheese snacks and I pressed the point. He admitted he had pranked Dr. Chase by dyeing his hair orange. He said he frequently pranked his team. He noted that his team was made up entirely of career minded, driven individuals and he needed to ensure the tension was broken every once in a while. I asked Dr. Adams about the prank and she stated that Dr. House preferred chaos over team cohesion. Dr House believed that the mistrust and disagreement led to better ideas. She had to admit that was usually what happened. After treatment with steroids, Mr. Koppelman regained consciousness and was lucid. He had regained movement in his hands. However, at that moment, Dr. Adams and Dr. Taub learned that the patient had been affected by an explosion, a chemistry demonstration that went poorly. I asked why the explosion hadn’t come up in the patient history, and Dr. Taub noted that the patient had been unconscious until the moment his students came to visit and mentioned the explosion. Dr. Taub also noted he was the one who took the initial medical history from the patient’s wife, who didn’t know about it either. He blamed himself for not doing a more complete job. I asked Dr. Taub if Dr. House thought medical histories were unimportant and that’s why he delegated them to his fellows. Dr. Taub assured me that Dr. House believed that medical histories were a vital part of a diagnosis, but didn’t think meeting the patient is important as it affects his objectivity. He also said that Dr. House was often right about that. I asked Dr. House why he didn’t do more work himself, and he admitted to being lazy. He also said that the worst way of taking a patient history was talking to the patient as everybody lies. However, he assured me that he would never lie to me. I asked him if the case might have ended differently if he had actually met the patient, but he didn’t answer. However, the answers of Dr. Adams and Dr. Taub did tend to support Dr. House’s statement. The patient denied there had been an “explosion”, but his students insisted there had been one. There was even a video of it on the internet. However, the patient then started coughing up blood. Dr. House described this as when the case got “interesting”. I told Dr. House I thought his reaction to the patient’s symptoms was interesting. The patient recovered and reviewed the video with the doctors. He admitted a student helped set it up and probably added extra hydrofluoric acid. As a result, the large glass beaker exploded when the flame was applied. They surmised that the patient had inhaled some of the excess hydrofluoric acid, burning his lungs. The video also showed the patient had struck his head against the wall backing away from the explosion. A concussion affecting the brainstem explained the loss of consciousness and paralysis. Dr. Park noted that they finally decided to treat the patient with aerosolized heparin. However, I noted she skipped over the details of the differential diagnosis and was avoiding eye contact. She admitted that during the differential, Dr. House entered the conference room carrying a sulfur dioxide canister and wearing a gas mask to pressure the team into coming up with ideas. She also admitted that Dr. Chase had placed the canister in Dr. House’s office to get revenge for the earlier prank, but Dr. House found it. Before coming up with heparin, he rejected a brochoalveolar lavage and silver sulfadiazine as they would most likely result in drowning. Dr. Park did advise me that she objected to aerosolized heparin because the treatment was experimental. I asked Dr. House about it, but he insisted it has been used successfully on sheep and that given the patient’s rapidly deteriorating condition, they needed to do something drastic. I accused Dr. House of pressuring his team to come up with unsafe medical ideas just to avoid being choked by sulphur dioxide. He called it inspiration and noted that the safer available treatments would have been pointless in the circumstances. I asked Dr. Park about Dr. House’s idea and she said she had objected to it in the strongest possible terms because it was likely the heparin would increase the amount of bleeding into his lungs. I asked her why she didn’t press the matter and she insisted after Dr. House rejected her concerns, she went to Dr. Foreman. I asked Dr. Foreman about it, and he admitted he told Dr. Park that if Dr. House was trying something risky, he knew it was only because he thought it was the only way to help the patient. He also noted that Dr. House’s decision to use heparin had no effect on the outcome of the case. I noted that if he always supported Dr. House’s decisions, it would affect how Dr. House’s team reacted to his behavior. Dr. Foreman noted he had worked for Dr. House for seven years and generally gave him the benefit of the doubt because Dr. House was brilliant and got excellent results. I asked Dr. Adams why there was a discharge order for Mr. Koppelman in the chart after he was treated with heparin if he was never actually discharged. She noted that before they released him, they wanted to give him a bath to ensure that none of the chemicals from the explosion were left on his skin. However, during the bath, they found a rash and when they went to examine it, the patient became extremely anxious and attempted to climb out of the bath. He had to be restrained. Dr. Adams felt the rash was a new symptom indicating invasive streptococcus, but Dr. Park was more concerned about the patient’s behavior, which she attributed to psychosis caused by the treatment with steroids. Dr. Taub had a third theory to tie these two new symptoms together with the lung problems - Wegener’s disease. Dr. House decided to run a diagnostic trial by giving the patient high doses of steroids. If it were Wegener’s, the patient would quickly improve. If it were streptococcus, the patient would quickly start running a fever combined with low blood pressure and they could treat with antibiotics. If it were steroid induced psychosis, the patient would become more psychotic, eliminating that as a symptom of the underlying illness. I noted that two of the options would make the patient worse. However, Dr. House countered that the real problem was the lack of a diagnosis and that this was the fastest path to getting one. I asked him whether, in hindsight, he thought it had still been a good idea. He thought and said it still was. He argued he had properly accounted for all the possible medical outcomes, just not the behavior of his own team members. I asked Dr. House if Dr. Adams or Dr. Chase was to blame for their disobedience, but he refused to blame either one. I asked him who was to blame, but he didn’t answer. Dr. Chase believed Dr. Adams was right about the streptococcus and decided to do a skin biopsy. However, as they entered the room and Dr. Adams prepared the lidocaine, the patient suffered a psychotic break and attacked Dr. Adams. Dr. Chase rushed to her aid, but had difficulty subduing the patient. Dr. Adams called a code grey. Two orderlies and Dr. Taub rushed to help and Dr. Taub managed to sedate the patient. However, the patient had injured Dr. Chase with the biopsy scalpel he had planned to use, piercing an artery near the heart and lacerating the heart itself. Dr. Taub called for them to get an operating room ready while Dr. Adams plugged the hole in Dr. Chase’s chest to prevent him from bleeding out. She blamed herself for the incident. Dr. House noted the diagnostic trial had worked, showing that the patient had steroid induced psychosis which was not the symptom of an underlying disease. I asked Dr. House why he didn’t care more about Dr. Chase’s injury. Luckily, they put Dr. Chase on bypass and sutured the wound. The witnesses agreed that Dr. House came into the operating room to try to continue the differential. Dr. Park asked why Dr. House hadn’t listened to her, and he countered that he had and that he admitted she was right. He noted that Dr. Chase hadn’t listed to either one of them. He left when the fellows refused to help him with the diagnosis. I asked Dr. Taub if that didn’t seem callous, but he noted there was nothing Dr. House could have done for Dr. Chase and he didn’t think it was right to punish Dr. House for callousness. He also noted that he himself would not have entered the room given the possibility of psychosis. I asked Dr. Taub if he wasn’t implicitly blaming Dr. Chase. Dr. Taub admitted that given the possibility of psychosis, Dr. Chase had endangered himself, Dr. Adams and Mr. Koppelman. Meanwhile, Dr. House went to retrieve the patient’s EKG record. He went to the recovery room to ask his team what would cause excessive R-R variability. However, once again his fellows were more interested in Dr. Chase than Mr. Koppelman. When Dr. House suggested autonomic dysregulation, Dr. Adams shouted at him to shut up. At that point, Dr. Chase regained consciousness and complained that he couldn’t feel his legs. Dr. Chase admitted he was angry with Dr. House about the prank. However, he insisted he wasn’t distracted, and he too didn’t think the incident was anyone’s fault. He also noted that it was Dr. House who came up with the idea that he was suffering from a clot to the arteries of his spinal column. Dr. Taub performed a successful embolectomy and removed the clot. However, the team agreed that again Dr. House interrupted the embolectomy to ask why Mr. Koppelman’s kidneys were now failing and insisted they work on the problem because the patient was being transferred to Princeton General. He blamed the transfer on their lack of objectivity about the patient. However, when asked about it, Dr. Chase said that Dr. House already knew that his team had refused to do any further work on the case and it was merely Dr. House’s way of checking up on how he was doing without letting his team know how much he cared. I expressed disbelief that Dr. House’s complete lack of concern was evidence of his deep concern for Dr. Chase’s well being. I asked why he brought a scalpel into the room when he knew about the risk of a psychotic break. Dr. Chase said he thought he was right about the rash and he would do the same thing again. Luckily, Dr. Chase started to regain the feeling in his legs. Given Dr. Chase’s attitude however, I could only come up with one of three conclusions:
* That Dr. House’s methods encourage his team to defy his orders;
* That Dr. Chase was distracted by trying to get revenge for the prank; or
* That Dr. House treats diagnosis like a game that Dr. Chase was trying to win. In any of these cases, it is clear Dr. House creates an atmosphere that promotes recklessness. During his final interview, Dr. House left before I could complete my questioning. Mr. Koppelman’s transfer to Princeton General was completed. However, just as I was about to give my decision, Mr. Koppelman asked to speak to me. Just as she was about to leave the hospital, Dr. House came to her to tell her that her husband had a lymph node tumor. Due to the trauma from the explosion, one of the tumors burst open causing tumor lysis syndrome, flooding the patient’s body with phosphates and potassium acids. The psychotic break was solely from the use of the steroids and as Dr. House believed, wasn‘t due to the underlying condition. She told the doctors at Princeton General who found the tumor, removed it and started radiation therapy and plasmapheresis. He was expected to make a full recovery. Dr. House is obviously brilliant, but Dr. House is also a fiasco. If I were to exonerate him, condone his completely reckless, immature, almost misanthropic behavior, I would essentially be sending a message to all the other doctors in this hospital that it’s okay to act that way. Dr. House’s process is dangerous, inappropriate - but he is effective. I’ve decided that I would be doing this hospital a disservice if I did anything to change that process. This unfortunate stabbing incident is officially nobody’s fault.
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