Original airdate: 2/1/05
brilliant trumpeter confined to a wheelchair develops pneumonia and
signs a DNR to prevent a slow death from his ALS. House doubts the ALS
Patient: John Henry Giles
Initial symptoms: difficulty breathing
group of young musicians wait in a recording studio for John Henry
Giles, a legendary jazz musician. He arrives very late, in a wheelchair
pushed by his companion. He begins to play his trumpet, but experiences
extreme difficulty breathing. His trumpet falls to the floor as his
companion rushes to his aid, and one of the musicians calls an
House barges into Cuddy's office demanding John
Henry's case. House is intrigued by John Henry's paralysis, though
Cuddy tells him the only aspect of the case important to the hospital
is simple (and boring) lobar pneumonia. Cuddy informs him that John
Henry's inability to walk is already being treated by Dr. Marty
Hamilton of California, with whom Foreman did his residency, and has
asked Foreman to treat John Henry's pneumonia.
Chase about John Henry's O2 sats, which are in the 90s on a nasal
cannula, and John Henry is not coughing up much sputum. Foreman
decides to keep John Henry on broad-spectrum antibiotics, and since he
shows septic physiology, he orders tests to measure his adrenal and
House blocks the team's path as they try to
leave, asking what Foreman is going to do about John Henry's paralysis.
Foreman informs him that the paralysis has already been diagnosed by
Dr. Hamilton as ALS, or Lou Gehrig's disease. House commandeers
the white board, and asks the team for alternatives. Chase suggests
Guillain-Barré, which Foreman shoots down because the progression of
the paralysis was not symmetrical. Cameron suggests transverse
myelitis, for which Foreman says John Henry tested negative for, along
with masses and AVMs. Chase them suggests multifocal motor neuropathy.
House likes this idea, and asks if Dr. Hamilton ever tried IVIG to
treat John Henry. Foreman says he did not, due to John Henry's negative
MRI. House ask for a new MRI. Chase and Cameron begin to move, but
Foreman reminds them that it's his case, not House's. Foreman insists
ALS is the best diagnosis due to the progressive paralysis and the
pneumonia would be expected, as well.
While Foreman is drawing
blood, John Henry asks Foreman if his breathing problems are due to the
ALS. Foreman says they are. John Henry tells Foreman that he likes Dr.
Hamilton, but it's become clear that his experimental treatment is not
working. Foreman suggests an MRI, but John Henry is dubious of an
MRI for pneumonia. Foreman tells him that House thinks they should test
for other things. John Henry is familar with House's reputaion for
John Henry asks Foreman who he believes his
right, and Foreman tells him that ALS fits all his symptoms. John Henry
decides against the MRI, and asks to sign a DNR before he becomes
Foreman finds House lying on the floor of his
office listening to John Henry's albums. Foreman tells House of the
DNR, which House doesn't find surprising since Foreman did not tell
John Henry he might not have ALS. Foreman says he started John Henry on
IV steroids and Synthroid. House says if the case was his, he'd add
IVIG. Foreman reminds him that John Henry doesn't want anything done,
to which House replies that the DNR prevents resuscitation, not
Foreman orders John Henry's steroid dosage
increased and also orders IVIG. While House is seeing a clinic patient,
he receives a page for a Code Blue for John Henry, who is now gasping
for air. Chase notes that John Henry's O2 sats are dropping and
his breath sounds are "junky." Cameron asks if it is a mucus plug, but
Foreman says it is sludging from the IVIG preventing blood from
getting to his lungs. Cameron orders heparin by IV push, though
Chase thinks John Henry will die before it has a chance to work, and
needs to be intubated immediately. Foreman points out that they can't,
due to the DNR. He
arrives in John Henry's room to find that John Henry's O2 sats are in
the 70s, and John Henry has been struggling to breathe for ten minutes
due to the IVIG.
House orders Chase to intubate John
Henry. Chase can not, so House does it himself and calls for a bag,
despite Foreman's vehement protests. John Henry's companion enters the
room, and asked what House has done, to which Cameron replies he saved
John Henry's life.
John Henry is now stable on the ventilator.
House notes that the IVIG made him worse which means multifocal motor
neuropathy was the wrong diagnosis, and seeks new ideas. Foreman is
outraged at House's violation of John Henry's DNR. House tries to
suggest that John Henry was not competent to sign the DNR due to
depression caused by his low thyroid levels. Foreman brushes the
suggestion aside, know that even House didn't believe it.
reasons that John Henry signed the DNR to avoid a slow, torturous death
from ALS, but the breathing problem had nothing to do with the ALS.
Foreman counters that House didn't want John Henry to die only because
it would have been his own mistake that killed him, though House notes
that the error was actually Foreman's responsibility, since Foreman is in charge of
After Foreman storms angrily from the room, House
ask why John Henry's lungs would have gotten worse. Chase suggests
vasculitis, though it is unlikely to occur in both lungs. Cameron
suggests Wegener's granulomatosis. Just then, House is served with a
restraining order preventing him from going within 50 feet of John
Henry, and is also informed that he is to be charged with battery.
asks Cameron to test John Henry's blood for C-ANCA. House asks Chase if
he is still doing bronchoscopic suctioning for John Henry's pneumonia,
which he is, every four hours. House tells him to get a biopsy to
confirm Wegener's next time he does this. He also tell him to move John Henry
to the second floor ICU, which is directly above the clinic, so he can
avoid clinic duty.
Cuddy asks House if he needs a lawyer, and
informs him that Dr. Hamilton is flying in from California to "pull the
plug" on John Henry, at John Henry's request. House says he does need a
In the courtroom, House's lawyer argues that John Henry
must stay on life support against his will because his death would
violate House's Sixth Amendment right to face his accuser. He also
argues the DNR might not be valid, depite being witnessed by Foreman.
House interrupts the legal proceedings to ask the judge if he has any
history of heart disease in his family, as he noticed clubbing of the
judge's fingers. He advises him to see his doctor, lest he keel over
like Bart Giamatti. The judge is now paying more attention to his
fingers than John Henry's lawyer, and wins the round.
returns to the hospital, and Chase tells him the biopsy shows only
inflammation. House orders Cytoxan.
Cameron and Chase are reluctant to
violate John Henry's wishes, and risk their medical licenses, so House
starts the medication himself. As he leaves John Henry's room,
House runs into
Marty Hamilton. He has a brief conversation with House, pointing out
that he tested for, and ruled out Wegener's.
Foreman arrives and
shares a friendly greeting with Dr. Hamilton. House reminds Dr.
Hamilton that he has a court order keeping John Henry alive. Dr.
Hamilton tells House that the charges have been dropped, so he no
longer has an accuser to face, and that John Henry's decision is to be taken off the ventilator.
Henry's companion kisses him goodbye, and Dr. Hamilton removes the
ventilatior while House and Wilson watch from the hall. Everyone waits,
but John Henry continues to breathe on his own. House now knows he was
wrong about Wegener's.
John Henry continiues breathing on his
own, but now he can't move one of his arms. Cameron believes the
progression of the paralysis confirms the diagnosis of ALS, but House
thinks the paralysis of the arm and legs are not related. Cameron then
suggests a stroke since blood clots are common in paralyzed patients.
House orders an MR angiogram to look for an embolic stroke, but Foreman
notes that John Henry is not House's patient, and John Henry wants
nothing to do with him.
House goes to John Henry's room to try
and talk him into treatment. House speculates as to why John Henry
signed the DNR, though he acknowledges that John Henry's life "sucks
more than most." He tries to strike a bargain. If John Henry will allow
House to find out what's wrong with him, House will assist him in dying
if he still wishes it. John Henry declines telling House that his life
is no longer worth living if he cannot play music. Music is his "one
thing," as medicine is for House. The cost of such a gift is everything
else that other people have, leaving nothing when the gift is gone.
digests this for a moment, and begins to wheel John Henry's bed from
the room, his reasoning being that if John Henry wants to die, he can
do it anywhere, including an MRI machine.
Chase and Cameron review the MRA and find a clot in John Henry's brain.
Chase thinks it might not be too late to break the clot with tPA.
Foreman tells John Henry that they want to start him on heparin.
John Henry asks about the side effects of the treatment. Foreman tells
him that because of the pneumonia, there a chance of an effusion, or
bleeding into his lungs. John Henry is unwilling to risk further damage
to his lungs. Foreman then suggests an embolectomy to remove the clot
without risk to the lungs, but may kill him. John Henry agrees.
the procedure, Dr. Hamilton pages House to John Henry's room to
tell him John Henry can now move his arm. House is irritated that Dr.
Hamilton didn't just use the phone, but says he's glad the procedure
worked, and pats John Henry on the leg. To everyone's surprise, John
Henry felt the touch. John Henry now has feeling in his leg up to his
Dr. Hamilton thinks his experimental enzyme replacement
protocol is reversing the ALS, and House is convinced it's one of the
drugs his own team has given John Henry. To figure out which one is
helping, House stops all of them. Cameron objects, but House points out
that John Henry is on antibiotics, anti-inflammatories, and steroids,
and cannot stay on all of them indefinitely, since they will eventualy do more harm than good. His idea is to stop the
drugs, and restart them again one by one. Foreman thinks House wants
him to ask Dr. Hamilton to stop his drug therapy as well, but House
thinks the other drugs are irrelevant.
Dr. Hamilton comes to
House to ask which medications he's stopped giving John Henry, but
House refuses to tell him. He is suspicious as to why Dr. Hamilton is
asking, and goes to John Henry's room to find he has lost the feeling
in his legs again. House orders John Henry put back on the steroids,
which was the first drug he was given, and another MRI from the T-9 to
the cauda equina. Cameron is startled by something on the MRI.
and Cameron run back to House's office to show him they've discovered
the cause of John Henry's paralysis, an intradural arteriovenous
malformation which has been pressing on John Henry's spine. Foreman
wonders how Dr. Hamilton could have missed it on the MRI, and House
points out that it was not visible on the previous MRI due to the
swelling it caused. John Henry was given steriods, which reduced the
swelling, allowing the AVM to be detected. Once it is removed, John
Henry will be able to walk.
his surgery, and an unknown
period of physical therapy, John Henry is able to leave the hospital,
walking with a cane. He meets House in the lobby as he departs. He
thanks House for his determination, and gives House his trumpet.
Diagnosis: arteriovenous malformation
seriously violates medical ethics by intubatung John Henry, thus
violating the DNR. Foreman is outraged at House's behavior, and
believes House should be more like Dr. Hamilton, who is not abusive and
forgives mistakes. House tells Foreman that what he perceives as
"abuse" is actually accountability, which will make him a better doctor.
man - comes to the clinic asking for the "blue pills." House tells him
he doesn't need the blue pills, however, he needs to better manage the
diabetes he failed to mention. House noticed the man's hands had no
hair, indicating nerve damage. He also noticed his shoes were too
small, denoting a lack of sensation in his feet, and powdered sugar on
his pants indicating an unwise affinity for donuts. House writes him
the prescription anyway, with the caveat that if he has heart disease
from the diabetes, the pills will kill him. Other than that, he should
go enjoy himself.
House made a half-hearted attempt at attributing John Henry's mental status to low thyroid numbers.
John Henry Giles
Dr. Marty Hamilton
What a Wonderful World - Louis Armstrong