Andie had been diagnosed with alveolar rhabdomyosarcoma, a terminal cancer. She had had 5 major surgeries, a bone marrow transplant, fourteen rounds of chemotherapy and blast radiation therapy. As a result of her treatments, she has lost all of her hair. Although her cancer was currently in remission, she was expected to live only another year or so. She was on a very strict and robust pharmaceutical regimen.
Dr. Wilson asked Dr. House to take the case. He told him about the hallucination. House suspected that the cancer had moved to her brain causing the hallucination with a prognosis of no more than seven days. However, her CT scan was clean, and her blood test and protein markers were all negative. That meant the hallucinations were unconnected to her cancer. A successful diagnosis could give her another year. Dr. Foreman thought it was latent neurotoxicity from the chemotherapy but her last round of chemo was two months ago. Dr. Chase thought it might have a genetic component, but neither of her parents showed any genetic conditions. Dr. Chase then suggested graft versus host disease from the bone marrow transplant, but the blood and lumbar puncture were clean. Dr. House thought it might be swelling around the meninges and ordered a tox screen and an MRI.
Dr. Chase prepped Andie for the MRI, she knew what a SAT monitor was. Chase seemed to be impressed, and noticed she had a central line to avoid constant needle sticks to set up intravenous lines. Chase told her that they were looking for an infection. The MRI and tox screen were clean, no infections and no neuro-toxins. Her oxygen saturation was 94%. Dr. House told his team to check her heart. Dr. Foreman thought the oxygen stats were well within range (around 95%), but Dr. House insisted. Dr. Cameron pointed out that low oxygen stats pointed to a lung problem. Dr. Foreman pointed out a lung problem couldn't case hallucinations, but Dr. Chase pointed out it could lead them somewhere that was causing the hallucinations. Dr. Cameron thought it was pulmonary edema or pulmonary fibrosis. Dr. Chase thought it was primary pulmonary hypertension. Foreman thought it was a bizarre case of kyphoscoliosis. Dr. House told them to get arterial blood gases and, once hypoxia was confirmed, to get a plethysmography, chest x-ray, CT Scan and VQ scan. If those tests were negative, they were to insert a catheter into her lungs to look at them directly.
Dr. Chase explained to Andie that the pulmonary angiogram consisted of inserting a tube all the way up the vein by her hip, into the lung. If he found anything there, he could remove it. Andie revealed that she had had this test before. Andie then said that she had never kissed a boy. She asked Chase to kiss her, he said no but after further persuasion, he did.
The pulmonary angiogram of Andie's lungs was clean. Her arterial blood gases and CT scan were also normal. Her heart and lungs were fine. Dr. House still thought the oxygen stats were out of kilter, but Dr. Foreman said he has already told him they were within range. Dr. House continued to be concerned about it. Dr. Foreman thought it might be neurosyphilis. Dr. Chase said that there was no way, he didn't want to admit that he had kissed her. Dr. Foreman thought she had been molested. Dr. House was starting to agree with him, then Dr. Chase told them that she had told him she had never kissed a boy. He also told them that she had asked him to kiss her. Dr. Chase said that it was just one kiss for a dying girl. House told them to see if she had had sex anyway because molestation victims often get manipulative. He then figured out that Dr. Chase had agreed to the kiss.
Dr. Cameron did the examination, but Andie said that no one had ever touched her. The examination confirmed that. Andie's SAT percentage dropped another point, which could suggest a tumor in her lungs but all the tests were clean and a tumor wouldn't explain the hallucination. Dr. House thought that there was a tumor in her heart. However they had an echocardiogram and an MRI that were clean. Dr. House suspected tuberous sclerosis, but Dr. Wilson was incredulous that the same patient would suffer from two different rare diseases. However, Dr. House pointed out that given she had one rare disease for sure, her chances of having a different rare disease was the same as anyone else. Dr. House wanted to do exploratory surgery, but Dr. Wilson objected because in her condition she could die during surgery. Dr. House then played sound recordings of Andie's aortic valve which he downloaded from the audio of the echocardiogram. Next he played her tricuspid valve. Finally he played the recording from her mitral valve. Dr. Cameron noticed an extra flap. Dr. House told the surgeon to search her mitral valve first.
Andie went in for surgery, and Wilson noticed how brave she was. Dr. Murphy performed the surgery with Dr. Chase and Dr. Wilson observing. They found a tumor in her lung extending to her heart. It wasn't visible on the MRI because it was growing along the heart wall. Because of the placement, the surgeon would have to temporarily remove Andie's heart. They cut out the tumor and replaced the missing heart muscle with bovine patches. The problem was, there might not be enough heart left once they removed all of the tumor. In addition, if the tumor had metastasized, there was nothing they could do. During the surgery, Dr. Chase also noticed bleeding in her eye.
The surgery was successful however the bleed in her eye could not have been caused by a heart tumor. In addition, the cardiac tumor was benign. That meant it didn't cause her hallucinations and was just a coincidence. Dr. Chase thought it was a clot creating pressure on her brain behind the eye which caused the bleeding, but wouldn't cause hallucinations. Dr. Foreman thought the hallucination was caused by post-seizure psychosis, but this wouldn't explain the tumor. Dr. House finally realized that the tumor may have thrown out a clot before they removed it. He ordered an angiogram of her brain.
Dr. Cameron performed the angiogram but it was clean. There was a clot but they couldn't find it. Dr. Wilson realized was going to die from the clot. Andie didn't take the news badly, she comforted her mother. Dr. House thought that Andie's bravery might be a symptom of where the clot was. The clot was causing hallucinations and messing with her emotions. The fear center of the brain is the amygdala, near the hippocampus. Trying to find it with exploratory surgery would likely kill her. The only way to see the clot was at theautopsy. Suddenly, Dr. House realized they could do an autopsy procedure on a living patient, it was just dangerous. He asked Dr. Cuddy if it was still illegal to perform an autopsy on a living person. Dr. House wanted to induce hypothermic cardiac arrest. Once Andie was on heart-lung bypass, they would siphon off two liters of blood, and perfuse the brain while she was in an MRI. If they did nothing, she would not last more than two days. Dr. Cuddy thought they would need FDA approval for any surgical technique used for diagnostic purposes, but Dr. House reminded her that only applied to invasive techniques - this was non-invasive even if it did kill her. Dr. Cuddy agreed to allow it if the mother was informed that it was a million-to-one shot.
Dr. Wilson informed the mother about the procedure. She consented to it. However, he didn't tell Andie the specifics. Dr. House thought Andie deserved to know what was going on and he went to talk to Andie. He told her that given her present condition, she might not make it through and even if she did, she would only have a year. He offered her a chance to end it all by not performing the procedure. However, Andie felt her mother needed her and wanted to go through with the procedure.
They did a practice procedure with the cadaver of a man named Morty Randolph. Dr. House explained that once the body was cooled and put on bypass, they had 60 seconds to get two liters of blood out of the body and back into the body for the MRI to find the clot in her head In addition, her head had to be absolutely still during the MRI or the test results would be useless. They would have neurosurgeons viewing the monitors and cardiac surgeons in case they had to open her up as well as two anesthesiologists. The first several attempts were a fail as they kept moving the body slightly. However, Dr. Foreman suggested they bolt everything to the table to keep it steady. This worked and the test was a success.
They were ready to perform the procedure on Andie. There were a lot of doctors in the operating room. They anesthetized her and lowered her core body temperature. When she stared shivering, Dr. House ordered vecuronium to keep her still. Her body temperature was lowered to 21 degrees Celsius and Andie went into defibrilation. They removed two liters of blood, put it back in. The scan didn't seem to show a clot. They started to over the time limit and had to start rewarming her. However, Dr. Foreman thought he saw the clot, four millimeters lateral to the hippocampus. They rewarmed her and ere able to restart her heart, and was doing as well as could be hoped. Dr. Murphy operated to find the clot. At first, he didn't see anything where Dr. Foreman had seen the clot, but he finally saw it and successfully removed it. Andie soon regained consciousness. However, the clot was no where near the amygdala, meaning the bravery wasn't a symptom. On her way out, all of her doctors applauded her. Dr. Chase gave her two tickets to a museum. She even said goodbye to Dr. House by giving him a hug. She left with her mom.