Case History Edit
Peng was a passenger on a non-stop 18 hour trans-Polar flight from Singapore to New York. After drinking heavily, he started to feel nauseous and vomit. Dr. House put the symptoms down to drunkenness. However, the flight attendant was worried. She asked if anyone spoke Korean as Peng spoke nothing else and when no-one did, she asked if there was a doctor on board. Dr. House went to get Dr. Cuddy.
Dr. Cuddy reported back to Dr. House that Peng had a fever, severe abdominal pain, a headache and a rash. She was afraid it might be contagious, and might even be meningococcus, which could kill half the passengers before they reached New York. Dr. House downplayed Dr. Cuddy's concerns - they had been at a conference on pandemics and Peng had been drinking heavily and probably had a hangover. Dr. Cuddy pointed out that alcohol wouldn't account for the rash, but meningococcus would. Dr. House pointed out the rash could just be an allergic reaction. The flight attendant came to report that Peng was throwing up again, and Dr. Cuddy wanted to turn the plane around and land at the nearest airport. However, Dr. House downplayed her concerns. Dr. Cuddy pointed out they would soon pass the point of no return on the flight, meaning the next emergency room could not be reached for another 15 hours. The flight attendant pointed out Dr. House hadn't examined him, but he knew his height (about 5'9") approximate age, approximate weight (160 lb.), with a scar on the right side of his jaw and a Medic Alert bracelet showing he's allergic to penicillin. Dr. Cuddy pointed out they were in no position to do a lumbar puncture and as such could not be sure it wasn't meningococcus. Dr. House agreed but told the flight attendant that he was a board certified infectious disease specialist. The flight attendant agreed that the best course of action was to monitor Peng's condition.
Peng kept vomiting, and another passenger started vomiting as well. Dr. House was about to attribute the nausea to a sympathetic reaction to Peng, but then noticed a rash on her lower back. Dr. House enlisted a 12-Year-Old Boy, a Sour Faced Woman and a non-English speaking passenger to help him. He listed the symptoms on the plane's movie screen and suggested organophosphate poisoning. Dr. Cuddy informed him that they had passed the point of no return and had to continue to Canada before they could land. When he suggested organophosphates to the flight attendant, she told him the flights were not sprayed with pesticides. He suggested an overdose of dramamine, but Dr. Cuddy pointed out it wouldn't explain the fever. He suggested jet lag, but it wouldn't explain the abdominal pain. He suggested deep-vein thrombosis, but it wouldn't explain the nausea. He finally suggested food poisoning. The flight attendant told him that first class got steak and sea bass, while coach got fettucine and sea food kebabs. All the sick passengers ate fish and Dr. House suggested ciguatera poisoning - it would explain all the symptoms. Dr. House announced over the P.A. system that they should proceed to the rest room to vomit if they ate fish for dinner. Dr. Cuddy pointed out meningococcus explained all the symptoms too, and Dr. House agreed.
Peng continued to get worse, and the other passenger was afraid she was going to die. Dr. House felt confident that he was right - Peng ate before the other passenger. However, Dr. Cuddy pointed out if he were wrong, they would see neurological symptoms next, such as paralysis and ataxia. However, Dr. House pointed out they would not see ataxia in a patient who was lying down. He motioned to Peng to stand on his feet, but Peng's knees started to buckle and he immediately collapsed.
Dr. House examined Peng more closely. He definitely had ataxia and a rash. One of his legs was thinner, indicating he had been in a cast. He thought it might be radiation poisoning from faulty x-ray equipment, such as is found in parts of North Korea. It would also explain why he had no hair. However, the other passenger pointed out she didn't show baldness as a symptom. Dr. House thought she was just pregnant - it would explain her symptoms, including why she appeared to be wearing a bra too small for her breasts. Dr. Cuddy pointed out that it was unlikely two sick passengers on the same plane would have two different illnesses when they had the same symptoms. Dr. House went to get some iodized salt to protect Peng's thyroid gland, but then Dr. Cuddy started vomiting as well. She also showed a rash on her lower back.
Dr. House did an examination of Dr. Cuddy. Her heart rate was normal. Dr. House admitted to the flight attendant that there was a chance it was spreading, but told her to tell the passengers otherwise and to give him a flashlight. Dr. Cuddy exhibited photophobia, a symptom of meningitis and noted they needed antibiotics. In the absence of lab tests, Dr. House used his nose to see if he could identify any particular infections. The flight attendant reported three more passengers were sick.
Dr. House went around with the 12-Year-Old Boy to the passengers collecting pharmaceuticals. He found several bottles, but only found three capsules of augmentin to treat six patients. Dr. Cuddy suggested giving a dose to Peng. Although he was allergic to penicillin, the emergency kit on the plane had two Epipens. Dr. House pointed out if it wasn't meningitis, they would be risking his life and wasting medication. Dr. Cuddy told him to do a lumbar puncture - if it was cloudy, they would have to give him the medication and risk the anaphylactic shock. Dr. Hosue pointed out they didn't have an LP needle and the shaking of the plane would make it more likely that he would damage the spinal cord during the procedure. However, Dr. Cuddy called his bluff by telling him to let Peng die and to give her the medication.
Dr. House found a syringe in the first aid kit and found his guidemarks for inserting the needle through Peng's spine. He managed to insert the needle and collect the cerebro-spinal fluid in a small clear cup. The fluid was clear. However, Dr. House went to the P.A. system and announced they had a confirmed case of bacterial meningitis on board and that if anyone exhibited left hand shaking they should be isolated in the first-class cabin. However, when several patients complained of having a shaking left hand, Dr. House made another announcement - they were suffering from conversion disorder due to the stress of the situation. When Dr. Cuddy told him he was wrong and the blonde passenger showed him her shaking hand, he pointed out that left hand shaking is not a symptom of meningitis or anything else. The "sick" passengers were responding to suggestion and to Peng's symptoms. Even the nausea, rash and Dr. Cuddy's anger with Dr. House could be explained that way. He suggested that everyone calm down and have some alcohol. Dr. Cuddy soon felt better. She asked Dr. House how he knew and he said the lumbar puncture was negative so he had to come up with an alternative theory and test it. Now the only mystery was what made Peng sick and Dr. House had no idea what it was.
Dr. House added extensor posturing to the symptoms. That could indicate head trauma, cerebral infarction or intracranial hemmhorage. Peng was so ill that he probably could not wait for the plane to land to get to a hospital. Peng's baldness made it clear he had no bumps on his head, so head trauma could be ruled out. Dr. Cuddy suggested syphillis, but Dr. House thought it was unlikely. Dr. Cuddy pointed out that he could have been with a prostitute in Singapore, but when she mentioned condoms, Dr. House realized he might be a drug mule and if a condom containing cocaine had burst in his digestive tract, he would exhibit the exact symptoms they were seeing - focal limb paralysis. He realized they would have to operate on him.
Dr. House got his helpers together. He attached a razor blade to a handle with tape and gave Peng alcohol to deaden the pain. He instructed his helpers to hold him down as the faster they could do the surgery, the less likely it was Peng would die of shock. However, the 12-Year-Old Boy lost his grip. He soon reapplied pressure to Peng's right shoulder, but when he did, Peng seemed to be less agitated. Dr. House told him to do it again, and when he released pressure, Peng was in more severe pain, which again seemed to lessen when he reapplied pressure. Dr. House applied pressure to Peng's right knee and released it, and it had the same effect. Pressure on his joints relieved his pain. Dr. House asked to see his wallet. He found a scuba cerfification card and a receipt from a scuba rental facility in Singapore dated the day before. Dr. Cuddy told the flight attendant to tell the captain to drop to 5,000 feet from their 38,000 foot cruising altitude. Peng had decompression sickness, probably from surfacing too fast and then getting on a plane pressurized to 8,000 feet above sea level. Dr. House also ordered oxygen to flush the nitrogen from his system.
Peng started to improve and was out of pain, but weak, when they arrived in New York. He was rushed to hospital for further treatment, but was expected to fully recover.