Case History Edit
Matt was admitted after collapsing during the advanced placement calculus exam. He described being nauseous and disoriented. He was suffering from severe bradycardia - his heart rate was 48 and falling fast. The patient did not respond to atropine. Although his tox screen was negative, he was still disoriented, seeming to rule out drugs. His CT scan was clean, there was no sign of infection, and it was not diabetes mellitus. Dr. Foreman brought the case to Dr. House.
Dr. Cameron thought it was shigellosis, but this would not account for the bradycardia. Dr. Chase suggested endocarditis, but this would not explain his disorientation. Dr. Cameron suggested the tox screen was done incorrectly, and Dr. Chase suggested something they don't test for, such as copy machine toner. Dr. House directed Dr. Cameron and Dr. Foreman to do an environmental scan of the patient's home, and directed Dr. Chase to increase the dosage of atropine to 2ml.
Dr. Chase asked the patient if he had taken any drugs, and tested the patient's grip strength. The patient was unresponsive, but his mother denied the patient took drugs. Dr. Chase dismissed the mother's assurances and asked if he had any friends over. She told him that he gave him a home drug test. As Dr. Chase started a medical history, the patient had a seizure.
At the patient's home, they found homemade tomato sauce which showed sign of bacterial contamination. They found an open bottle in the refrigerator and brought it back for testing. However, Dr. House just tasted the tomato sauce because the patient's seizure ruled out food poisoning, and the fact that it happened two hours after admission instead of earlier ruled out drugs. The seizure suggested pesticide poisoning, although there were several classes of pesticides that could cause this group of symptoms. Dr. House ordered the nurses to wash the patient in the event that there was still pesticide on him. His blood tested positive for organophosphate poisoning. He was started on pralidoxeme.
Matt's heart rate fell to 37 and he didn't improve. His heart rate dropped suddenly and Dr. Chase put him on an external pacemaker to get his heart rate up to 56. Dr. Chase thought it might be necessary to put in a pacing wire. Dr. Foreman triple checked the patient's blood tests and confirmed the poison was an organophosphate. Although parlydoxcene is an excellent broad spectrum anti-toxin, given that the patient wasn't improving, Dr. Foreman believed a more targeted approach with a specific hydrolaze was both necessary and possible. However, this would require knowing the exact organophosphate. Dr. Chase confirmed that as the toxin had breached the blood-brain barrier, the patient would die without better treatment. Dr. House directed Dr. Foreman to seek out his old professor about the targeted treatment and directed Dr. Cameron to look for any pesticides the patient may have used in his home garden. Dr. Chase installed a pacing wire and got Matt's heart rate to stabilize at 50.
Dr. Cameron found an empty can of dizlephoton at the patient's house. Dr. Chase prepared to give him the targeted hydrolaze. However, his mother insisted that the can had been filled with orange peel oil as not using artificial pesticides was part of Matt's school project. Dr. Chase believed that the patient had cheated as the symptoms fit. However, the mother wanted the can tested and Dr. Chase confirmed that if they were wrong, the hydrolaze could actually increase the toxicity. The mother refused to consent to the treatment.
Dr. House went to Dr. Cuddy to try to get a court order. However, Dr. Cuddy refused as the mother's concern about the treatment didn't show she was mentally incompetent. She told House to get the mother to sign off that she was refusing treatment.
Dr. House confronted the mother with the waiver and belittled her opinion that the doctors were wrong, then asked her to sign. Instead, she consented to treatment. However, before they could, another patient showed up with exactly the same symptoms. His heart rate was 49 and his blood oxygen level was 84 and falling. Dr. Chase ordered saline, atrophine and diazepam. He also intubated the patient. They managed to stabilize him. Dr. Cameron informed Dr. House the two patients lived 10 miles apart and didn't know each other. As such, the dizlephoton was ruled out.
Dr. House ordered Dr. Chase to increase Matt's oxygen supply from 80% oxygen to 90% despite the risk of damage to the retina because he was not pumping enough blood to the brain. Dr. House also removed Dr. Chase from the case at the mother's request because he had tried to get Matt to admit to taking drugs by admitting he took them himself as a teenager. She also called him a slacker. Dr. Foreman was made Matt's primary physician in intensive care.
Dr. Cameron reported to Dr. Hosue that it didn't appear that the patients had anything in common. However, Dr. House surmised that they both probably took the same bus to school and ordered Dr. Chase and Dr. Cameron to test the bus. They found the bus and convinced the driver to let them test it.
The mother reminded Dr. Foreman that she had been right that the can did not have dizlephoton in it. He told her that most family members are wrong and she called him just as pompous and arrogant as Dr. House.
The bus driver did remember where the two patients were sitting and Dr. Chase entered the bus to do testing. The driver also remembered they drove by a crew that appeared to be spraying pesticides. Dr. Cameron investigated and found out it was ethyl perathyon to kill the mosquitos that carry the West Nile virus. However, the mother refused to allow them to treat the patient until she had heard back from the CDC. As both Dr. Chase and Dr. Foreman were alienated from the mother, Dr. House sent Dr. Cameron to talk to the mother.
The mother wanted to transfer Matt to another hospital and get a second opinion. However, Dr. Cameron informed her he wasn't fit to be removed from the hospital. The mother also dismissed Dr. Cameron, who fired back that if they didn't treat Matt he would die. However, she finally consented to treatment.
Dr. Cameron administered the hydrolase. However, the other patient had an adverse reaction and Dr. Cameron rushed to discontinue Matt's hydrolase. She found Matt having a seizure and started treating him. They managed to stabilize him, but his heart was weak, his lungs were weak, and there were signs of liver toxicity. It was obvious that it couldn't be ethyl parathyon. The hydrolase wasn't binding to the neurotoxins and was, instead, releasing more of them. However, they couldn't find anything else the patients had in common. However, Dr. House concentrated on what they didn't have in common - the time they were admitted. Given that their hearts were failing faster than any other organ, this suggested they absorbed the poison through their skin. Given Matt's time of admission, it was likely he was poisoned before he got on the bus. They started concentrating on what both patients would do first thing in the morning. They thought they might be using a household product in common that was contaminated. He sent Dr. Foreman and Dr. Cameron to search the houses of both patients.
Matt's ALT went up to 800, which meant he might suffer permanent liver failure. Dr. Cameron and Dr. Foreman found out they used the same brand of laundry detergent. The detergent may have contaminated the clothes and been absorbed into his skin. However, the other patient's parents said that their son never used the washing machine and that his clothes were brand new and had never been washed. Dr. House asked about Matt's clothes. Dr. Chase said they were beat-up old jeans, but they went down to check them. Although they looked old, Dr. House noticed that the label was brand new - the jeans had been treated to make them look old. Given that both patient's were wearing new clothes, they tested both of them even though they were different brands.
Dr. Cameron did the test and found phosmet. However, the mother once again refused consent until she got a second opinion from the CDC. Dr. House went to see her anyway, saying he was there to treat Matt if she changed her mind. He told her the CDC would call, but it might not be for a couple of days, and they might not have made a decision. She finally got the call and, as Dr. House predicted, they couldn't make a decision based on faxed records. She finally consented to treatment. Dr. House administered the hydrolase.
Eventually, Matt regained consciousness and his heat rate started to rise. The patient was soon well enough to be released. However, the mother did find out about a deception - it was not the CDC that called, but Dr. Chase that called pretending to be from the CDC. The poison was traced to a day laborer who used the same truck both to sell stolen pants to students and to carry pesticides.