Title: Damned If You Do
Original airdate12/14/2004
Episode: 105
Synopsis: A nun comes to the clinic with a rash, and House's treatment sends her into cardiac arrest. The doctors have to figure out if she has a real medical condition, or if House made a mistake.
Patient: Sister Augustine
Initial symptoms: rash, joint pain

*****Spoilers below*****

Differential diagnosis:


Sister Augustine comes to the clinic for a nasty rash on her hands, which resembles stigmata. House brushes away the religious implications of the wounds, and asks of she has been washing any dishes. Her companions, Sister Pius and Sister Eucharist tell House of a large donation of pots and pans, which Augustine washed. He diagnoses contact dermatitis from an allergy to dish soap. House gives Augustine diphenhydramine, an antihistamine, and tells her to get some over-the-counter cortisone cream. He offers water, but Augustine washes the pill down with tea.

Shortly after, Augustine has an asthma attack. House grabs a syringe from a drawer and injects Augustine with epinephrine, which soon stops Augustine's wheezing. House thinks the ashtma attack was allergic reaction to the antihistamine, and suggests steroids. Augustine tells House her heart feels "funny." He takes her pulse and finds her heart rate is alarmingly fast. He calls a code and tells a nurse to charge the defibrillator. He loses her pulse and begins CPR.


House has made no notations in Augustine's chart, which makes Cuddy believe that House gave Augustine 1 cc of epinephrine to cause the cardiac arrest. House insists he gave her .1 cc, and she must have a heart condition. Cuddy gives him 24 hours to discover the cause of the cardiac arrest, or she will have to notify the hospital attorneys of the error.

Cameron suggests a skin infection such as cellulitis, which could present with tachycardia. Foreman points out that Augustine does not have a fever, and the CBC showed no signs of infection. Cameron says the eosinophils are slightly elevated, as is the sed rate, so a systemic allergic response is possible, though House says that would not account for the cardiac arrest. House suggests Churg-Strauss vasculitis, which would account for all the symptoms if the blood vessels in her hands, lungs, and heart are inflamed.

Foreman thinks the most likely explanation is that House made a mistake. House again insists he did not, and orders a chest CT and prednisone for Sister Augustine. The CT shows no vascular pathology, leaving Foreman even more convinced that House made an error in the clinic. Cameron disagrees, and suggests thyrotoxicosis or carcinoid.

While in the scanner, Sister Augustine complains of a strong odor, which the tech ascribes to a previous patient's vomit. When the smell begins to overwhelm Augustine, the Cameron pulls her out of the machine, but cannot smell anything unusual herself. Augustine suddenly exclaims that she can see Jesus, and that he is burning her with his touch. Foreman realizes that smells and religious visions are symptoms of temporal lobe swelling, and orders Ativan. Sister Augustine begins to seize, and Foreman discovers a rash of blisters on her leg.

Tests show Augustine has herpetic encephalitis, which means her immune system is compromised. Cuddy believes the prednisone is responsible, but Cameron thinks Augustine has not been given enough to affect her immune system to that degree. Chase suggests mixed connective tissue disease. Foreman disagrees, because Augustine's ANA was normal, and they cannot use the ususal treatment, corticosteroids, because of the encephalitis. House orders hyperbaric oxygen treatments for Augustine, dismissing Foreman's concerns about oxygen toxicity. House and Foreman butt heads over the treatment, so Foreman takes his objections to Cuddy.

Chase explains to Augustine that the pressure chamber will saturate her blood with oxygen, increase her white cell activity, and help with the inflammation. Augustine emerges from the chamber weak and thirsty, so Chase brings her her tea.

Sister Eucharist finds House watching his soap opera on a miniature TV in the chapel. She tells House she believes Sister Augustine is a hypochondriac, constantly complaining of sore throats, joint pain, or some other ailment, to get out of work duties.

Cuddy agrees with Foreman, and boots House off the case. Cuddy rounds up the Doclings and has them report on her status. She believes Sister Augustine has no underlying condition, and wants to treat the symptoms only. Chase says Augustine's breathing is labored, which Cuddy diagnoses as pneumonitis from the hyperbaria. She orders 40% oxygen to increase her O2 sats. Sister Augustine's BUN and creatinine are rising, and her ALT and AST are twice the normal range. Cuddy thinks this could be from the hypotensive episode, and orders monitoring with labs. She also orders a non-steroidal anti-inflammatory for the rash and joint pain. When Chase checks on Augustine, her pulse is 104.

House visits the monastery to speak with the Mother Superior about Augustine's past. He noticed a tattoo on Augustine's shoulder, from which he deduced she has not spent her entire life with the church. The Mother Superior tells House that Augustine ran away from foster care and spent several years on the streets, used drugs, and became pregnant at age 15. Augustine tried to abort the pregnancy herself. She lost the child, became ill, and returned to the church.

The epiphany:
House decides that Augustine's unfortunate past is not relevant to her current illness. The Mother Superior serves him tea, which he notices is homemade.

Sister Augustine continues to deteriorate under Cuddy's care. All her symptoms have worsened, and she has developed a fever. Cameron suggests she may have a genetic or metabolic disorder, but Cuddy refuses to listen unless Cameron has something specific to offer.

House returns to the hospital with a bag of tea from the monastery, and tosses it at Cuddy, explaining that the tea contains figwort which causes cardiac arrest when mixed with even a small dose of epinephrine. Without the cardiac arrest, all of Augustine's symptoms are due to explained by a severe, long-term allergic reaction.

Since her symptoms persisted, and House doubts they can all be acribes to the tea, Augustine must be allergic to something in the hospital. They move her into a clean room to avoid environmental contaminants, but Augustine goes into anaphylactic shock and needs to be intubated.

Wilson suggests mast cell leukemia, but House says her blood tests rule it out, along with eosinophilia and idiopathic anaphylaxis.

Another epiphany:
Sister Augustine wants to go back to the monastery to die, and won't be dissuaded. House disgustedly tells Wilson that Augustine has "God inside her." When Wilson replies, "Maybe she's allergic to God," House realizes they haven't looked inside Augustine. He orders a full body scan, during which they find a copper cross, an IUD that Augustine had forgotten she had. Her exposure to the copper cookware, and the food cooked in it, triggered her severe reaction. The IUD was surgically removed, and Augustine began to improve.

Diagnosis: Copper allergy

Incidental terms:
TID
jaw block
infirmarian
stethoscope
ambu bag
lung cancer
colorectal cancer
prostate cancer
endometrial tissue

Soap Opera:

Conflicts abound.
Foreman is convinced House made a mistake, as is Cuddy. Cameron firmly believes he did not. Chase is more pragmatic, and cares only about House's mood. Foreman believes that Sister Augustine's cardiac arrest was caused by the epinephrine, so the hyperbaric treatments will do more harm than good. He reminds House of the Hippocratic Oath, and House points out that the oath mentions a number of principles which are not relevant to modern medicine. Foreman also objects to House's disdain for medical protocols, and believes House should show some humility.

House challenges Foreman to do something about it if he is not convinced of the diagnosis and treatment, which he does by reporting House's actions to Cuddy, thereby getting him removed from the case. When House discovers that the cause of Augustine's cardiac arrest was the tea, he chastises Cameron for not sticking by her original diagnosis, and praises Foreman for sticking to his guns, even though he was proved wrong.

Chase's conflicts are internal. Chase reveals that he was in the seminary before going to medical school. He tells Sister Augutine that he failed his test of faith. House surmises that Chase went to medical school only to please his father, but Chases doesn't reply. When Augustine asks Chase of he always wanted to be a doctor, he replies, "Always," but his response lacks conviction.

Cameron gives House a Christmas present, causing him a moment of extreme social awkwardness.

At Christmas, Cuddy is tending patients. Foreman is dressed as Santa, handing out presents to sick children, and Cameron is still in the office, opening a gift from an unknown sender.  Sisters Augustine, Eucharist, and Pius attend mass in the chapel. Chase stands in the doorway for a moment,  then leaves, looking unhappy.

Wilson invites House to Christmas dinner. After reminding Wilson that he is Jewish, Wilson switches to Hannukah dinner, the point being to enjoy food and the company of people. House declines, and Wilson decides to go to House's place. Wilson's decision to leave his wife alone at Christmas makes House raise his eyebrows, but Wilson doesn't want to talk about it. House doesn't either, and they retire to House's apartment for an amiable evening with Chinese food. Despite House's disdain for religion, he likes Christmas carols, and plays "Silent Night" sweetly on his piano.



Comments:

The sign outside the chapel carries the symbols of five major religions: Star of David (Judaism), the Star and Crescent (Islam), the Latin Cross (Christianity), Wheel of Dharma (Buddhism), and the Aum (Hinduism). Nine symbols hang behind the altar.

Nuns living in a "monastery" is not a mistake. Not all nuns live in convents or cloisters.

House's piano was made by Sohmer & Co.

TV clip

Oops: Foreman says "eo-siph-a-nil instead of "eo-sin-a-phil" and no one makes fun of him for it.

Clinic Patients:

Santa Claus - department store Santa with inflammatory bowel, for whom House prescribed cigarettes.



Everybody Lies:
Sister Augustine, and the other nuns, omitted the more sordid details of Augustine's past.
Wilson has apparent difficulties in his marriage, but declined to speak on it.
Chase (unconvincingly) says he always wanted to be a doctor, but House thinks otherwise.


People: 

Sister Eucharist
Sister Pius
Arsenio
Nurse
Tech
Dr. Shopius
Mother Superior

Priest

Nurse Arnold - soap character
Dr. Riles - soap character

Dr. Jorkins - soap character
Nurse Crandall - soap character
Dr. Brown - soap character



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