Alfredo was fixing Cuddy's roof when he fell off. He had earlier complained that his asthma had been acting up, but Dr. Cuddy had asked that he complete the work on her roof. In the ambulance, Dr. Cuddy examined Alfredo after he had been immobilized and determined that his spinal cord had not been damaged. She also ruled out a pneumothorax. However, when she was examining his ribs she noted that two of the fingers on his right hand were darker than the other two. Alfredo told her that they felt like pins and needles and that he hadn't noticed them being like that before that day
Dr. Cuddy gave the case to Dr. House, advising him that given the state of Alfredo's hand, he was likely to lose it. Dr. House thought that a vertebrae might have impinged on the ulnar nerve cutting blood flow to the hand, or it could be DIC, which is often caused by trauma. Dr. House told his team about Alfredo and ordered them to do a cervical MRI and a blood work-up for DIC. Dr. Cuddy offered to help, but Dr. House reminded her that she hadn't seriously practiced medicine in 10 years.
General counsel Stacy Warner advised Cuddy not to talk to Alfredo so that they could avoid losing a lawsuit if she accidentally admitted fault or offered compensation. Dr. Chase drew the blood for the blood test and administered blood thinners. Alfredo was worried about how long he would have to be in the hospital because he was a janitor at a fast food restaurant and he thought that he would be fired. His little brother Manny offered to work for him but Alfredo didn't want him to because he was too young and he wanted Manny to get a good education instead of having to work to support he family like Alfredo had to. Dr. Chase told him they had to find out what was wrong with him, but they would release him as soon as possible. Dr. Chase noted that Alfredo's fingers had become much blacker and the darkness had spread to another finger.
The PPT was prolonged and the fibrin split products were not within normal range. Dr. Cameron thought it was a mild case of DIC, but Dr. House noted that this "mild" case was destroying Alfredo's hand and was likely to spread further unless they could stop it. Dr. Cameron wanted to start Alfredo on heparin. However, Dr. Cuddy didn't think heparin was strong enough and wanted to use Human Activated Protein C. Dr. House argued that that drug was only for severe sepsis, Cuddy considered it severe because his limbs were at stake. Dr. House reminded her how dangerous the treatment was. Dr. Cuddy ordered the team to administer it.
Dr. House told Dr. Wilson that Dr. Cuddy's decision was almost irresponsible, but he admitted heparain wasn't working. Dr. Wilson reminded him that this is the sort of risk he takes all the time. Dr. House admitted to him that he was joking when he tried to stop Cuddy, but she took him seriously.
Dr. Cuddy talked to Stacy Warner about her decision. Stacy expressed surprise that Dr. House had tried to protect Dr. Cuddy. Dr. Cuddy was worried that she had overruled the best diagnostician in the hospital. However, Stacy thought that Dr. Cuddy's judgment should be worth more than Dr. House's because she cared about Alfredo.
Next, Alfredo became unable to move his right arm. Dr. Chase determined he had a bleed in his brain due to the human activated protein C. Dr. Chase stopped the treatment and he called a neurosurgeon to relieve the pressure from the bleeding. The neurosurgeon drilled into Alfredo's skull while Cuddy watched over his surgery. She felt guilty about giving him dangerous treatment.
The surgery was successful. Afterwards, Alfredo regained control over his arm. However, he started having trouble breathing and he was coughing, his fingers were even darker, his temperature was 102 F and spiking and the x-ray showed lung infiltrates. Dr. Cuddy thought it was acute respiratory distress from the fall. Dr. House thought that Alfredo might have had an underlying condition before he fell off Cuddy's roof, but merely hadn't noticed any symptoms. Dr. Foreman thought that it was pneumonia - it can cause DIC as well. However, Dr. Chase noted pneumonia has a slower progression. Dr. House agreed because Alfredo hadn't complained of breathing problems before the fall, but Dr. Cuddy told them all that before he fell off the roof he wanted to go home because he was having trouble breathing, she dismissed it as asthma and sent him back up on the roof. Dr. House admonished her for not mentioning it earlier - they could have started blood cultures. Dr. Cameron assured Dr. Cuddy that if Alfredo only had bacterial pneumonia, he would be fine. Dr. House ordered levoquin and an echocardiogram. He also ordered an environmental scan of Alfredo's house. Dr. Cuddy thought that the bloodwork would be sufficient, but Dr. House reminded her that if it was caused by a toxin, an environmental scan would be faster. He sent Dr. Cuddy and Dr. Cameron to do the scan.
However, Dr. House had other plans - he, Dr. Chase and Dr. Foreman went to Dr. Cuddy's house to do an environmental scan as Alfredo had been there almost every day for three weeks. Dr. House found fungus under her bathroom sink. Dr. Cameron and Dr. Cuddy found a dead rat in a trap.
Alfredo's lung function continued to get worse, ruling out bacterial pneumonia. Dr. Cuddy and Dr. Cameron thought Alfredo's scars were from rat bites and he had streptobacillus. However, Dr. House told Dr. Cuddy he had been to her house and found aspergillis under her sink. She was angry, but when she was Alfredo's latest lung x-tray, she realized that Dr. House was right - the focal consolidation made fungal pneumonia more likely. Dr. House ordered amphotericin B despite the danger.
Alfredo developed another symptom - he hadn't urinated in almost a day. Dr. Cameron discontinued the amphoterracin and reported to Dr. House that it has probably damaged his kidneys and that he was dying. However, Alfredo's mother overheard her and became very upset.
The toxicity to the proximal tubular epithelium conformed that the amphoterracin had shut down his kidneys. Moreover, the test of the fungus from Dr. Cuddy's house showed it wasn't aspergillis, and the blood tests had ruled out streptobacillus. He had also tested negative for moraxella, malacaria and cryptococcus. He did test positive for chlamydia, but the x-rays ruled it out as a cause for the pneumonia. Dr. Cameron thought his low sodium levels showed Legionellosis, but he had tested negative for it. Dr. Cuddy went back to the fall and DIC, but DIC would not account for the high fever. Dr. House asked what his temperature was, and Dr. Chase reported it had been 103F an hour ago. Dr. House admonished for not knowing what his current temperature was.
Dr. House went to see Alfredo to take his temperature. Dr. House asked him if he was using his left hand because his right one hurt. Alfredo denied it, but Dr. House though there was the smell of putrefaction and put pressure on his hand. Alfredo cried out in pain.
Dr. House suggested amputation to buy them more time to find a diagnosis, but Dr. Cuddy was opposed because it would destroy Alfreo's livelihood. They went to Stacy Warner who advised them to work it out between themselves because if they disagreed, a lost lawsuit was likely. Dr. Cuddy argued that the worse symptoms were probably the result of the treatment, but Dr. Hosue insisted the necrosis was the result of an underlying illness. She argued that he still had a pulse in his wrist, but Dr. House countered that the hand was quickly turning into a home for harmful bacteria. When Dr. Cuddy argued about his lost livelihood, Dr. House told her she wasn't being objective. They finally agreed that amputation was the best course. They went back to Stacy who was afraid Dr. House was being too aggressive, but he insisted on the surgery. Dr. Cuddy agreed to break the news to Alfredo. She told him that the bacteria in his dying hand would spread to the rest of his body soon. The amputation wouln't cure him, but he wouldn't die of gangrene. When Dr. Cuddy told him she was sure, he consented to the amputation.
Alfredo was prepared for surgery. It went well, but during the operation, Dr. Chase noted that the little finger on his left hand was now getting darker. In the recovery room, his fourth finger got darker too. His blood oxygen stats fell to 88% indicating imminent lung failure. He was put on a ventilator. Dr. House wondered why the necrosis had spread to his left hand. He thought the tests confirming mild DIC may be unimportant, taking them away from the real problem. He thought it might be endocarditis. The bacteria that generally stayed on the heart valves occasionally broke off and colonized other parts of the body - first the right hand, then the kidneys, then the left hand. It would also explain the fever. However, Dr. Cuddy noted that his cultures had tested negative for endocarditis. However, Dr. House noted that there was one infection that caused both pneumonia and culture-negative endocarditis - Psittacosis. Dr. House had earlier thought Alfredo might have a pet bird, one of the reasons he ordered an environmental scan. Dr. House wanted to give him doxycycline, but Dr. Cuddy objected - it would make the clotting worse. Dr. Cameron pointed out if they were wrong, he might be lucky to just lose both hands and both feet. He was more likely to die. Dr. House reviewed Alfredo's other jobs - janitor at a fast food restaurant. However, Dr. House (who is fluent in Spanish) had overheard Manny planning to fill in for Alfredo and no restaurant would allow a 12 year old to do that. He went to Alfredo to demand to know what work he did. However, Alfredo was unconscious. He asked the mother instead, who was astounded to learn he spoke Spanish. The mother didn't know where he worked, but Dr. House had a suspicion - he told Dr. Cuddy to take the team and look in warehouses and other large buildings near their home for someone who looked "like crap" and tell them they wanted to place a bet. Dr. Cuddy and Dr. Foreman found a cock fighting ring where Manny was working, explaining Alfredo's exposure.
Dr. Cuddy called Dr. House, but he had already started Alfredo on doxycycline. He started to improve rapidly. Afterwards, he insisted that he followed good hygiene procedures, but Dr. Cuddy told him that Psittacosis can be transmitted in the air through dust. Alfredo wondered why no-one else got sick, and Dr. Cuddy explained his asthma made him more succeptible. Although he had lost his right hand, he was expected to make a full recovery.
Later, Alfredo brought a lawsuit against the hospital. Dr. Cuddy and Stacy settled the suit.
Dr. House reminded Dr. Cuddy that her guilt affected her work as a doctor, but made her a good administrator.