Adam suffered severe burns over 40% of his body in an ATV accident. He was rushed by helicopter ambulance to Princeton-Plainsboro Teaching Hospital. He was immediately put on lactate ringers. He was put under anesthesia to deal with the pain from the burns during the recovery process and was placed in a clean room to prevent infection.
The matter was referred to Dr. House when he exhibited tachycardia. Dr. Foreman noted that the burns themselves could cause that, but Dr. House realized it must be more than that because the burn unit would have realized that already. He went to see the patient. On the way, Dr. House noted that Adam’s potassium level was also low, although that could be explained by the burns as well. However, he also noted that the burn unit would have given him fluids, which meant that even if the potassium started low, it should be rising, not falling. Dr. Foreman suggested amphetamines, but Dr. House suspected that a bacteria could be destroying heart tissue, or that he might just have a cardiomyopathy or other heart issue. He realized the patient needed an EKG, but when he looked at the patient he realized that there wasn’t enough skin to attach the leads. Dr. Chase wondered if he would even survive the burns, but Dr. House noted that if they could prevent infection, probably about 10% of his skin would continuously regenerate. The rest would require about 20 skin grafts and, although there would be scarring and pain, he would probably live unless his heart shut down. Dr. House ordered his team to find a galvanometer.
Dr. Chase and Dr. Foreman hooked up the galvanometer while Dr. Cameron explained to the parents that it picks up the pulse in the wrist and ankles, charting the result on graph paper. Dr. Cameron took a medical history, but Adam had no history of recent illness or behavioural problems. She asked about amphetamines and cocaine, but his parents denied he had ever used anything other than marijuana. The galvanometer worked, showing prominent U-waves and an inverted T-wave. The Q-wave was normal, but suddenly the graph showed what appeared to be an arrythmia, but suddenly, it was obvious Adam was having a seizure.
The team started a new differential. Dr. Chase thought it might be epilepsy or another seizure disorder, but it wouldn’t explain the tachycardia. Dr. Cameron thought it might be some sort of neurological disorder. Dr. Chase suggested adrenoleukodystrophy . Dr. Foreman thought it might be multiple sclerosis, with the seizures being caused by plaques and lesions on the brain. Dr. House wanted to do an MRI, but Dr. Foreman reminded him that all nuclear imaging was out because the patient would not survive a move to radiology. That eliminated a CT scan as well. Dr. House wanted to do a lumbar puncture to see if his proteins were elevated, but Dr. Chase ruled that out as the burns on his back would merely mean that if he didn’t have a brain infection, he would get one from the needle. Dr. House finally realized they could use Transcranial Doppler stenography. This would show if he had more active neurons in his occipital cortex, which would make MS more likely. Dr. Foreman and Dr. Chase prepared the patient for the procedure by propping open his eyes. They put images in front of his eyes. Dr. Cameron explained to the patients that MS would increase blood flow, while an infection would decrease it due to swelling around the arteries. Dr. Foreman found a bleed in the sub-arachnoid space.
Dr. Foreman went to tell Dr. House about the bleed. However, he realized that couldn’t cause the seizures. Dr. Wilson overheard and reminded him that in about 10% of cases, the cerebral cortex would be damaged as well. Dr. Foreman suggested bacterial meningitis and Dr. Wilson suggested viral encephalitis. He ordered Dr. Foreman to have the bleeding repaired.
To repair the bleed, Dr. Chase had to insert a wire into Adam’s vein and work it up to the sub-arachnoid space. He had to admonish Dr. Foreman for moving the ultrasound probe towards the bleed and away from the wire he was using. He reminded him that the procedure was usually done with a contrast CT scan – without it he didn’t know where the end of the wire was. He eventually reached it and repaired the bleed.
Adam was placed in a hyperbaric chamber for burn treatment while Dr. Foreman and Dr. Chase discussed whether MS was still a possibility. Dr. Foreman thought that plaques would explain the interruption in nerve function. When Dr. Cameron arrived, she noticed that Adam appeared to be waking up. Dr. Foreman called for the anesthesiologist, but Adam soon returned to unconsciousness. Dr. Cameron thought he might be in pain, but Dr. Foreman took a closer look and realized that Adam had an orgasm and had ejaculated.
Dr. Cameron reported this to Dr. House. He started a new differential. Dr. Cameron thought it might be due to the pain medication. Dr. Chase suggested it was a rebound effect – the pain released endorphins. Dr. House realized that if sensory information was mixed up in the medial forebrain bundle, pain could be perceived as pleasure. This could be caused by an infectious neuropathy or a vasculitic neuropathy. Dr. Cameron suggested Krabbe disease and metachromatic leukodystrophy. They realized that given Adam's condition, there was no way to confirm either one. However, Dr. Cameron said it could still be an infection, but not a brain infection. She suggested that given the patient is on so many medications, an infection in his skin could have overloaded the brain. However, the only way to confirm this was to allow the burns to heal. Dr. Foreman noted if she was wrong, the patient didn’t have that kind of time. However, Dr. House realized there was a faster way to deal with skin infection – cover the patient with maggots, which would eat the dead and diseased skin and kill any bacteria as a side benefit. They put the maggots on the burns.
The maggots worked to clean the burns, but the patient’s EEG didn’t improve. This ruled out infection as a cause of his illness. Dr. House wanted to do a lumbar puncture, and when Dr. Chase objected again, he told him to do it in the space between the C2 and C3 vertebrae – higher than normal. Dr. Foreman noted that this would increase the chance of paralysis, but without the test, Adam would most likely die. Dr. Foreman went to the parents for consent and told them that despite the risk of paralysis, they had to do it. The mother was angry, but they eventually agreed.
Dr. Foreman started the procedure and inserted the needle in Adam’s neck. The needle wouldn’t go in, so Dr. Foreman decided to go in one vertebrae higher. Dr. Chase told him that would most likely cause the brain to herniated, but Dr. Foreman went ahead. The patient’s blood pressure spiked to 180/120, and Dr. Chase was afraid he would have a stroke. However, Dr. Foreman found the space between the vertebrae and managed to take a sample of cerebro-spinal fluid. However, the test results showed no trace of MS or infection. His IGM was elevated, but his IGG was normal. The elevated IGM was probably because of the previous bleed. Dr. House wondered if the patient had peripheral neuropathy before the ATV crash. Dr. Foreman realized Dr. House still thought it was MS despite the negative test. Dr. House figured there must be lesions blocking Adam’s nerve conduction. However, they couldn’t scan for them. Dr. House figured the only course of action was to ask Adam how he felt before the crash.
Dr. House called the anesthesiologist and went to see Adam. The anesthesiologist said Adam was fine, but Dr. House instructed him to bring Adam around. The anesthesiologist protested because Adam would be in too much pain, but Dr. House reminded him that he was the attending and ordered that Adam be woken up. The anesthesiologist relented. When Adam awoke, Dr. House asked him if he had any numbness or tingling in his fingers before the accident. He said the only thing he remembered before the accident was that he urinated in his pants. Adam was put under again.
Dr. House got his team together again and said he thought Adam had clinical depression. Urinating in his pants and blacking out showed it was likely he was having a seizure at the time of the accident. Dr. Foreman argued that depression doesn’t cause seizures, but Dr. House pointed out anti-depressants sometimes do. Dr. Chase pointed out that Adam’s tox screen was clean, but Dr. House pointed out that those tests were given after he was put on several different medications for his burns which could have masked the results. Dr. Foreman pointed out the anti-depressants wouldn’t explain the orgasm, but brain trouble would. Dr. House argued that in rare cases, the effect of anti-depressants tricking the brain into thinking they have more serotonin than there actually is sets off a chain reaction where the brain overproduces serotonin. Serotonin storm could kill him, but it was treatable with cyproheptadine. However, Dr. Cameron pointed out that if it was his dopamine level that was too high, the treatment would kill him. Dr. House wanted to speak to Adam again, but the anesthesiologist had spoken to the parents and the parents wouldn’t let Dr. House near their son again.
Dr. House went to speak to the parents to ask them if Adam was depressed. He told them that Adam had a seizure and that caused the accident. He needed to wake Adam up to see if he was taking anti-depressants. The parents insisted he was not. Dr. House insisted there were things that Adam wasn’t telling them. They insisted that their son told them everything and that they were sure he wasn’t depressed.
Dr. House returned to his team, telling them the patient seemed to be happy. Dr. Cameron returned to seizure disorders, but Dr. House realized they couldn’t cause the orgasms. Dr. Chase suggested vascular malformations, but they would have seen those on the sonogram. Dr. Foreman suggested hepatic encephalopathy, but the liver enzyme test was normal.
Instead, Dr. House went to wake up Adam again. He scrubbed and when the parents tried to object, he told them that if they came after him, their son would develop sepsis. However, Dr. Foreman scrubbed up quickly and tried to stop Dr. House. Dr. House told him he wasn’t sterile, but Dr. Foreman grabbed Dr. House’s arm anyway. However, Dr. House noticed a small perfectly circular burn on the patient’s wrist. He pointed this out to Dr. Foreman who didn’t see the significance. Dr. House pointed out that there were no burns on either forearm except in this one spot. Dr. Foreman put it down to a drop of gasoline or a hot screw, but Dr. House examined the hand further and found yellow stains typical of nicotine. The circular burn was from a cigarette.
Dr. House asked the parents if the son smoked, but his father said they would kill him if he did. Dr. House realized that the one thing that Adam would lie about was smoking because of his parent’s objections. Dr. House assured them he was trying to quit and that anti-depressants are often used for that purpose. However, anti-depressants from internet pharmacies are often the cheapest available and are more likely to cause side effects. Dr. House ordered treatment for serotonin storm.
Adam’s heart rate soon improved on treatment. He was soon taken off of anesthetic. Although he still needed months of treatment for the burns, he was likely to make a full recovery.