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Many of the staff of Princeton-Plainsboro Teaching Hospital were assisting with the collapse of a crane in Trenton, New Jersey when emergency personnel finally got to the injured crane operator Jay. He was conscious and told the emergency responders that he must have fallen asleep for a second and caused the accident. He was shocked and apologetic. He was fitted with a neck brace in the event he had suffered damage to his spine and was strapped to a stretcher board to prevent movement. Several emergency personnel managed to lift him and the stretcher out of the crane cab.
Dr. Foreman was the first physician to examine him and reported to Dr. House that his injuries weren’t so bad considering what had happened. Jay was lucid and responsive, and his only major injury appeared to be a fracture of the right humerus. Dr. Foreman applied a splint. However, he had not yet had the time to examine his lower abdomen. Dr. House told Jay to tell him if the examination was causing any pain, but Jay kept going on about falling asleep and hurting all the people. Dr. House then found caffeine pills in Jay’s pocket. He asked Jay about his caffeine intake, and Jay admitted he took the missing pills (about 4) as well as having 2 cups of coffee. Dr. House asked if he used a lot of caffeine, but Jay said he rarely drank coffee because he doesn’t like it. However, he had been working on little sleep because his daughter had the flu. Dr. House wondered how a person with that much caffeine in their system, who wasn’t used to it, managed to fall asleep. He figured that Jay had passed out from a neurological disorder and not fatigue.
Dr. House asked Dr. Cuddy to take Jay back to the hospital, but she was opposed because his injuries were light. Dr. House ordered Dr. Foreman to find an ambulance and get the diagnostic team together. However, Dr. Cuddy intercepted Dr. House because he was needed at the disaster site until they found 24 persons who had not been accounted for. She told him that Dr. Foreman and the rest of the team could handle Jay’s case.
Jay was still in the emergency room when Dr. House managed to call Dr. Foreman. Dr. Foreman put Dr. House on speaker phone and they started a differential diagnosis for fainting. Dr. Taub objected that Jay was stable and other patient’s weren’t, but Dr. House pointed out that none of the other patients in the ER needed a diagnosis, Jay did. Dr. Chase suggested vasovagal response and Dr. Foreman suggested meningioma and sick sinus syndrome. However, Dr. Taub pointed out they hadn’t ruled out that Jay had merely fallen asleep. Dr. House thought it was a space occupying lesion in his brain and ordered an MRI. However, Dr. Taub pointed out that, given the accident, anything on the MRI might just be head trauma. Dr. House pointed out that finding trauma was a good enough reason for doing the MRI in any case.
Jay complained of claustrophobia during the MRI. They found nothing wrong during the MRI, but when Jay sat up after being removed from the machine, he noticed he had a nosebleed. Dr. Chase put it down to the trauma, but Dr. Taub noticed he was bleeding from his eyes as well, which was unlikely given he had no head trauma. Dr. Foreman called Dr. House with the news. Dr. House felt this was an indication that Jay did have an underlying condition, but Dr. Taub thought it was merely conjunctive coagulopathy from the accident. Dr. Chase suggested a brain infection that went systemic and resulted in DIC. However, Dr. House pointed out Jay didn’t have a fever. He ordered an x-ray veniogram and an examination for venous sinus thrombosis. Dr. Hadley thought they should x-ray Jay’s face first to see if his symptoms were do to trauma, but Dr. House refused the suggestion and ordered them to carry out his diagnostic testing plan.
Dr. House planned to return to the hospital, but one of the patients at the site, Hanna, who was trapped in debris, was suffering from an anxiety attack and Dr. Cuddy ordered Dr. House to stay on site until she calmed down.
Dr. Taub and Dr. Hadley performed the veniogram. However, they found no filling defects. They called Dr. House and also informed him that Jay now had a fever. Dr. Taub suggested a subarachnoid bleed and Dr. Foreman suggested meningitis. Dr. Chase said that Jay hadn’t complained of the sore neck typical of meningitis, but Dr. House pointed out that given the accident, he would be sore everywhere and may not have been able to differentiate. Dr. House ordered a lumbar puncture.
The lumbar puncture was normal, but Jay soon fell into a coma. Dr. Foreman called Dr. House with the news. When Dr. House asked for his vital signs, he was told that a police officer was questioning the patient when he went into the coma. Dr. House asked if anything else was making the patient nervous. Dr. Taub told Dr. House about the claustrophobia. Dr. House asked if Jay’s blood pressure had spiked. Dr. Foreman told Dr. House it had, but that couldn’t have caused his original unconsciousness. Dr. House explained that it did - Jay must have become unconscious because of the caffeine, not in spite of it. The brain symptoms were the result of a clot near his spine. Dr. Chase realized the patient had an arachnoid cyst on his lower spine from sitting all the time at his job. The cyst threw a clot which caused a spike in the pressure of his cerebro-spinal fluid, causing him to black out. Dr. House ordered a CT scan to confirm.