House S08EP2 “Transplant”
The conclusion of last week’s episode saw House in solitary confinement, after participating in a prison riot, which unfortunately would leave him with few interesting medical mysteries to solve. Although I might watch a show with a doctor in solitary solving cases by passing notes via cafeteria trays, I suspect that it might have limited appeal with the general television audience. In this week’s episode
a surprising visitor makes House an offer he can’t refuse by giving him the opportunity to help the Princeton Plainsboro team treat a unique patient in order to save the life of an organ recipient being treated by Wilson
Hopefully House will stay out of the Pokey, and back at Princeton Plainsboro! Now back with a recap, and SPOILERS!
Well, I was all ready to bring out the Bogus tag with that episode, as the imagery of the lungs in the box seemed just a little too science-fictiony (or maybe a lot) for me. But I am an open-minded individual, so I did what any curious person would do: I used Google, and found this video clip of the XVIVO perfusion system in action. Doctors at the Toronto General Hospital can keep donated lungs viable for up to 12 hours outside of the body, while hooked up to a ventilator and filter system. It is designed to allow surgeons to repair trauma to damaged donated lungs, increasing the probability of a successful transplant.
With that Suspension of Disbelief issue now out of the way (unfortunately, after the fact for my viewing pleasure,) let’s go back and see where we’ve been. House gets an early release from prison, at the request of the Dean of Medicine of the hospital, who is now Foreman, not Cuddy. He has a patient, and the patient is one who won’t be able to lie or talk back to him, as it is a pair of lungs awaiting transplant in a box. The lungs were all ready to transplant into Vanessa, who is Wilson’s patient, when the surgeons noticed that the donor lungs had “increased airway resistance” and were therefore no longer suitable for donation. They have 24 hours to figure out why, 12 of which have elapsed prior to the House arriving on the scene. House’s old team of Taub, Chase, and Thirteen have moved on with their lives in the intervening 12 plus months, so his new team consists of Dr. Park who is a neurology resident with her own issues.
House goes through a variety of diagnoses and treatments for the lungs, including infection (antibiotic treatment), cancer (biopsy and MRI), lead exposure (chelation therapy), and iron buildup (histological analysis). None of them pan out and Wilson’s recipient steadily gets worse. House’s final epiphany occurs when he sees smoke rising from birthday candles and recalls that the donor had been at an all night poker game the night before he died in a motorcycle accident–second hand smoke in his lungs must have triggered an unfortunate inflammatory reaction, which is constricting the airways now. The treatment is radiation to eliminate the inflammatory cells (eosinophils), allowing the inflammation to go away. Of course this works, and we are treated to the image of the lungs in the box returning to their normal pink color.
So the lungs in the box are apparently medically possible (see the cool Youtube video above for proof,) although the writers did stretch the feasibility just a bit with 1) the time frame in this episode was just a bit too long, and 2) actual lungs in a box would be kept in a sterile environment and not just off a general access hallway, and 3) lungs in a box would likely have far more tubes and monitors hooked up to them. What about the treatment? That actually seems reasonable, and is timely in light of our current classroom discussion on Selective Toxicity.
Recall that most cells in the human body are quiescent, and do not actively divide. This includes the tissues of the lungs, including the supporting bronchii and the alveoli. Lung tissue does not recover well from trauma, and it is difficult to recover lung function with damage. Small amounts of damage (e.g. second-hand smoke) triggers the body’s defenses to remove the particulate matter, and white blood cells migrate into the lung tissue to fix things. The donor’s white blood cells were special and unable to turn off with this stimulus, and therefore those white blood cells must be eliminated to resolve the damage that they are inflicting on the remaining lung tissue. The solution is radiation, which affects actively growing cells (the white blood cells) while leaving the quiescent cells (the remaining lung tissue) alone.