| abstract | - The patient was severely injured in a bus crash and was admitted as a Jane Doe into Princeton General Hospital. Surgery to repair her damaged kidneys and other injuries was successful and the patient was put on dialysis. However, post-op, she failed to regain consciousness and developed persistent tachycardia well after surgery. She was given potassium, adenosine and verapamil with no effect. She was scheduled for a coronary angiography, but there were more severely injured patients ahead of her. She was eventually identified when her boyfriend and Dr. House arrived at the hospital looking for her. Her boyfriend posed as her husband and gave consent to transfer her to Princeton-Plainsboro Teaching Hospital because she was hemodynamically stable. However, on the ambulance trip, the patient had a cardiac arrest. However, instead of defibrillating the patient, she was put into protective hypothermia as keeping her heart beating would result in the release of free radicals into the bloodstream. Dr. House ordered cold saline solution to lower her body temperature. At Princeton-Plainsboro, the patient was put on heart-lung bypass and her body temperature was lowered to 90 degrees F. She was stabilized. Dr. House surmised the trauma set off a pre-existing heart condition. Dr. Taub suggested it might be an autoimmune disorder or lead poisoning. Dr. Kutner suggested looking for arterial blockages. However, Dr. Foreman pointed out that most of the tests they run required the patient to have a functioning heart and normal body temperature. Dr. Kutner suggested that Dr. House take physostigmine in order to attempt to recall the symptom that Dr. House believed he saw in Amber before the crash. Dr. House ordered an angiogram as it would work even in the patient's present condition. He also ordered tests for any toxin, drug or heavy metal that would make her heart race. Dr. Taub asked Dr. House if he had a sexual relationship with the patient, but he denied it. Dr. Taub suggested that in addition to alcohol at the bar they were at, they may have done drugs together. He went to do a tox screen. Dr. Hadley and Dr. Kutner went to do an environmental scan of the patient's home. They found diet pills. Dr. Hadley expressed reservations about treating a patient they knew. Dr. House suggested to Dr. Cuddy that he undergo deep brain electrical stimulation to try to revive his memories. However, Dr. Cuddy and Dr. Wilson agreed it was too dangerous. The patient's brain activity spiked, but Dr. House put it down to a random event. The coronary angiogram was normal and the tox screen showed no drugs. Dr. Wilson denied that the patient took drugs. However, he was told that the patient hid her diet pills in a vitamin bottle. Too many diet pills might have damaged her mitral valve. Dr. Foreman suggested returning her body temperature to normal and doing a CT Scan to confirm the diagnosis. However, Dr. Wilson objected. Dr. House instead instructed the team to do exploratory surgery and inspect the valve manually. Dr. Foreman objected, but Dr. House insisted. Dr. House also admonished Dr. Hadley for her lack of objectivity on the case. However, as they took the patient to surgery and prepared to inspect her mitral valve, they noticed the patient was jaundiced. Diet pills would not have damaged her liver, so they returned the patient to intensive care. It was clear that whatever the patient had it was spreading despite the hypothermia. Dr. Hadley suggested anti-trypsine deficiency. Dr. Foreman suggested a liver biopsy, but Dr. Taub noted that her heart symptoms also fit, buf if it were an infection, it would be necessary to bring her body temperature back to normal. Dr. House agreed with Dr. Wilson that the patient had to be made colder and ordered the team to fill the patient's lungs with crushed ice. Dr. House went to the bar where he and Amber had been, but the bartender only noticed that Amber had been sneezing and had a runny nose. Dr. House believed this meant that Amber probably had an infection. Dr. Kutner and Dr. Hadley filled the patient's lungs with ice. The patient's body temperature was lowered to 70 degrees F. Dr. House confirmed that the liver biopsy showed infiltrates and minor inflammation. The most likely diagnosis was hepatitis B. Dr. House ordered interferon. However, he later realized he saw a rash on the patient's back earlier. He confirmed the existence of the rash, which pointed to influenza. However, this would not explain the failure of her organs. Dr. Kutner suggested dermatomyositis, but this would not have caused tachycardia. Dr. Hadley suggested an allergic reaction to interferon, but Dr. House was convinced he saw the rash prior to the treatment. Dr. House decided to check for abcesses and instructed Dr. Taub to insert a needle into the rash to attempt to detect pus. The fluid was clear. Dr. Foreman suggested rocky mountain spotted fever and Dr. Wilson realized that Amber may have been exposed to ticks on a dog. Dr. House ordered doxycycline followed by returning her temperature to normal and schocking her heart to get it beating again. However, Dr. Wilson wanted to run blood cultures. Dr. Foreman noted this would be too slow. Dr. House agreed to run the blood cultures. Dr. Foreman objected to this course of action, but Dr. House insisted. Dr. Foreman approached Dr. Cuddy about Dr. House's actions and Dr. Cuddy ordered Amber's body temperature raised so they could shock her heart back to sinus rhythm. Dr. Wilson arrived when it had reached 80 degrees F and noticed that her EEG activity was lower. He realized the disorder had spread to her brain. The spread of the disorder to her brain suggested an autoimmune disease. Dr. House ordered a course of prednisone followed by returning her body temperature to normal. Dr. Wilson objected because steroids would make her immunosuppressed allowing any infection to spread. However, Dr. Cuddy reminded Dr. Wilson that Dr. House was the attending physician. Dr. Wilson asked Dr. House to undergo deep brain stimulation to attempt to recall another symptom. Dr. House agreed to the procedure despite the risk to his own life. Dr. House recalled the events of the previous evening - he had called Dr. Wilson to pick him up at the bar, but Amber arrived instead. House left and got on the bus, but Amber followed him with his cane. She was suffering from the flu and took amantadine just before the crash. After the crash, he gave her first aid for shock and noticed the damage to her kidneys. It was realized that the amantadine, which is usually filtered by the kidneys, stayed circulating in her bloodstream. This caused an overdose. However, the drug would have bound to her proteins, so dialysis would not clear it from her system. Her case was terminal and there was nothing that could have been done from the moment she suffered the cardiac arrest. A heart transplant was out of the question because too many of her organ systems were damaged irreparably. At Dr. Cuddy's urging, Dr. Wilson agreed to return her body temperature to normal and wean her off anesthetic. Amber regained consciousness and realized her situation once she was told about the tachycardia, cardiac arrest and liver failure. The patient later became extremely fatigued and asked to be taken off bypass. Dr. Wilson discontinued life support.
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