Sarah was brought to the Princeton-Plainsboro Teaching Hospital emergency room after coughing up blood and collapsing while teaching a class. Dr. Cameron, who was recently appointed deputy administrator, brought the case to Dr. House. Dr. House brought the case to his team, and noted that Sarah had no dysnea or weight loss. Dr. Taub thought it was a bleeding gastric ulcer, but a scope of the stomach and lungs were clean. Dr. Foreman thought the blood was to blame - probably leukemia or Von Wildebrant's disease. However, Dr. Hadley thought a tumor in the thorax was a better fit. Dr. House ordered a bleeding time test.
Dr. Kutner made the incision for the test and congratulated the patient for barely flinching. She said whenever she's upset, she imagines she's in her class. She talked about how fulfilling it is to help her students with basic tasks. Sarah's blood didn't clot and Dr. Kutner planned to run blood tests to find out which clotting factor was not working.
The tests showed her clotting factors were normal, but her platelets were damaged. Dr. Taub thought it was lymphoma, but Sarah's LDH was normal. Dr. Kutner thought it was ITP and suggested methyltrexate. Dr. House agreed and also suggested radiation therapy. However, the team thought it was reckless, premature and potentially lethal. Dr. House went to see Dr. Cameron to get permission. Dr. Cameron suggested methyltrexate as well, but Dr. House reminded her that the patient may start bleeding into her brain. Dr. Cameron agreed to the radiation therapy.
Dr. Hadley reported that the patient wasn't responding to methyltrexate and her bleeding time hadn't improved. Dr. House admitted to his team that the only reason he suggested radiation was to see how far he could push Dr. Cameron. He agreed that it was premature and now he needed a reason to back off. Dr. Hadley suggested they just pretend to irradiate her - take the patient to the lab and fill out the paperwork, but don't turn on the radiation. Dr. House agreed, and ordered the dose of methyltrexate doubled and to add prednisone.
During the "procedure", Sarah complained that she had to urinate. Dr. Taub and Dr. Hadley agreed that they could let her go, but when she got up off the table, she collapsed on the floor. Dr. Taub couldn't find a pulse and directed Dr. Hadley to get the defibrillator. They managed to restore her heartbeat, but it was clear that she didn't have ITP.
They could not find any structural defect in Sarah's heart. Dr. Hadley thought it might be a calcified valve or PFO, but they had already performed an echocardiogram and bubble study and found no problems. Dr. Hadley suggested the patient might have started urinating when she got up, interrupting her vagal tone which caused an arhythmia. Dr. House wondered why the patient had such an urgent need to urinate. Dr. Kutner suggested heavy metal poisoning and Dr. Taub suggested drugs or alcohol. Dr. Hadley suggested cold aglutanins. Dr. House proposed that they give Sarah an ice bath to try to set off another heart attack. He went to Dr. Cameron to get approval and found Dr. Cuddy with her. Dr. House waited for Dr. Cuddy to leave. Dr. Cameron approved the procedure, but only after Dr. House confirmed that her blood would congeal when it was cold. Dr. House ordered his team to draw the blood.
Dr. Kutner went to draw the blood and found Sarah with one of her autistic students. Dr. Foreman and Dr. Hadley chilled the blood and noted it had clumped, confirming that they should proceed with the ice bath. Dr. House went to supervise the procedure and found Sarah talking about her autistic student and career. However, although she stayed in for three minutes, her heart rate remained normal. However, from observing the patient, Dr. House believed she had brain damage because she mentioned mixing up a room number.
Dr. House though the confusion about numbers indicated a lesion in her left perihippocampal region. However, Dr. Kutner noted that people transpose numbers all the time. Dr. House countered that her failure to urinate before the fake procedure indicated an inability to predict the future. Dr. Hadley had to agree - that function is controlled by the same region of the brain. However, Dr. Kutner wanted to ignore the "brain problems" and concentrate on the other symptoms which could be caused by a tumor on the pancreas. Dr. House also suggested multiple sclerosis. He wanted to do a brain biopsy to look for the characteristic plaque. He thought it would spread to her lungs next. Dr. Kutner wanted to do an ERCP, which was much safer. Dr. House and Dr. Kutner went to Dr. Cameron to argue the matter. Dr. Cameron agreed with Dr. House that they had to rule out any brain problem and ordered an MRI with T2. If the MRI confirmed plaques, he could do the biopsy. Dr. House refused, but Dr. Cameron insisted.
The MRI showed no plaques or abnormalities in the hippocampus. Dr. House allowed Dr. Kutner to proceed with the ERCP. However, that procedure showed nothing wrong, but during it Sarah's oxygen level dropped to 89%. This showed a lung problem just as Dr. House predicted. Dr. Kutner stopped the procedure.
Sara had surgery to drain pleural effusions, but remained weak. Dr. House thought a virus may have caused demylination. He suggested cutting into her skull to do a nerve conduction study on the surface of the brain. Dr. Kutner still thought it could be a pancreatic tumor, but Dr. Hadley agreed the ERCP was negative. Dr. Kutner wanted to perform an endoscopic ultrasound. He went off to perform it while Dr. House went to see Dr. Cameron to get permission to cut the patient's skull off.
Dr. Cameron was aware of Dr. House's plans. He said he was searching for equine encephalitis that set off the multiple sclerosis. Dr. Cameron was skeptical - equine encephalitis is very rare in humans, particularly during cold months as it is transmitted by mosquitos as a vector. Dr. House argued she may have been infected months ago, or that it might be another infection. However, it was clear that the left side of her brain was in distress. Dr. Cameron insisted she needed confirmation.
Dr. Foreman and Dr. Hadley did an environmental scan of Sarah's classroom to look for sources of infection. Dr. House came back to Dr. Cameron with evidence that one of Sarah's students had a raging viral infection and he found three dead mosquitos. However, Dr. Cameron noted the "mosquitos" were merely fruit flies and the student had a simple common cold. Dr. House countered that the endoscopic ultrasound was negative and the only way to find out what was wrong with Sarh's brain was to look inside. In addition, if she didn't let him do it, he had no other course of action and the patient would die. Dr. Cameron relented, but insisted on assisting with the procedure.
Dr. Kutner argued with Dr. House that he was being premature and was still trying to test Dr. Cameron. He thought that they should just remove the patient's spleen as splenic lymphoma could explain all the symptoms. Dr. House said he could try that after the procedure.
Dr. House and Dr. Cameron started the procedure by testing Sarah's perceptions and found them normal. He then asked questions designed to stimulate the logical and rational part of the left brain. However, Dr. Kutner reported it to Dr. Cuddy and she called and tried to stop the procedure. During the commotion, Sarah's blood pressure started to drop. Dr. Cameron administered dopamine. Sarah started to complain about Rachel Cuddy's crying over the phone line and Dr. Cameron noted her nerve conduction rate was actually speeding up even though her blood pressure continued to drop, putting Sarah at risk of stroke. Dr. Cameron administered another 10cc of dopamine and put an end to the procedure. Sarah complained about the baby crying again, and Dr. House became intrigued - nothing else that happened to her at the hospital had annoyed her or made her upset. He asked why the baby crying did. However, once the baby stopped crying, Sarah stabilized.
Dr. Kutner still wanted to proceed with the spleenectomy, but she could not be put under anesthetic until the dopamine cleared her system. Dr. House was still wondering why Sarah found the baby so annoying when she regularly deals with special education children in a loving and supportive manner. He also noted that although low blood pressure causes chest pain and lightheadedness, it doesn't lead to annoyance.
Dr. House went back to his office. Dr. Cuddy came by for a visit with Rachel, who promptly spit up on Dr. House. When Dr. Cuddy laughed it off, Dr. House started talking about why babies throw up so much - its because their digestive tract isn't as mature as it is in other mammals due to the limitation of human hip size. However, he suddenly realized babies have other differences from most adults.
Dr. House came to see Sarah while Dr. Kutner prepared her for the spleenectomy. Dr. House told Sarah her spleen was fine and grabbed the ultrasound probe from Dr. Kutner. He told Sarah that in the womb, blood bypasses the lungs because they don't work yet. The blood passes between the pulmonary artery and pulmonary vein through a hole - the ductus arteriosus. After the lungs expand, the hold usually closes. However the ultrasound indicated a patent ductus arteriosus - the hole never closed. When her blood pressure went up, blood leaked through the hole into the rest of the body, causing the bleeding they saw. It also starved the left half of the brain for blood. As such, when she was under stress, it actually reduced her stress level. They could do surgery, but it might change her personality as a result.
Dr. Cameron submitted her resignation as deputy administrator. Dr. Cuddy told her she made the right decision to allow the procedure, but Dr. Cameron said she could not say no to Dr. House and that any other doctor she hired would consistently say no to Dr. House.
The surgery went well, but Sarah's tolerance of her student's mistakes continued unchanged after the procedure.