Dr. Cate Milton is the research psychiatrist at the South Pole who comes down with a mysterious illness and has to be diagnosed long-distance by House in the episode Frozen. She is portrayed by Academy Award winning actress Mira Sorvino. The character is based on the real case of Dr. Jerri Nielsen (1952-2009) who was diagnosed with cancer while at the South Pole in 1998.
Medical History
Dr. Milton had a full physical work-up prior to being assigned to her posting, which showed no medical problems
Case History
While tending to an injury to the station's mechanic Seth, Dr. Milton was suddenly overcome by terrible abdominal pain and vomited. As she was the only physician at the station, the staff contacted Princeton-Plainsboro Teaching Hospital as Dr. Milton was an adjunct faculty member there. When Dr. Cuddy heard about the case, she referred it to Dr. House. Dr. Milton could not be evacuated for two months due to high winds. The obvious diagnoses were appendicitis, gallstones and kidney stones. However, there was no way they could treat appendicitis - it would rupture leading to inevitable death. If it were one of the other two, they would pass and all she would need was painkillers. However, Dr. Kutner suggested it might be a struvite kidney stone. Dr. Taub agreed - Dr. Milton was on contraceptives and if she had been having sex, she might have developed a urinary tract infection which could cause a struvite stone. If that were the case, the stone would have to be broken up before the infection shut down her kidneys. However, the station had limited medical supplies and nothing that could break up kidney stones. However, Dr. Kutner wondered if they might have sonic rock breaking equipment for taking geological samples - they work on the same principle as the medical devices they use to break up stones.
Dr. Milton set up a test where they put a raw egg in a water filled jar. However, the equipment shattered the jar as well as the egg. She then challenged the diagnosis as she was not having sex - she was there to do psychological profiles of the workers. She also denied having any pain while urinating. Eric Foreman suggested she perform a chem 7 to confirm if her kidneys were working properly. In the meantime, Dr. House suggested intravenous cefuroxime to fight off any infection.
The chem 7 showed declining kidney function, which probably indicated a kidney stone. However, Dr. Milton countered that it could be due to dehydration from vomiting due to a gallstone. Dr. Milton said she was rehydrating and would re-test, and that the pain was about the same. Suddenly, Dr. House realized she was not taking sephuroxine - being right handed, she would insert an IV line into her left arm and that would cause limited mobility in that arm. Instead, she was using that arm to bend her elbow to drink from a water bottle. Dr. Milton argued that antibiotics are a scarce commodity and she couldn't waste them with an unconfirmed diagnosis, particularly when she had a patient with a severed femoral artery who clearly needed them. Dr. House noticed Dr. Milton's respiration rate was rising. She put it down to anger, but he asked her to lift her head so he could see her neck. She complained of chest pain and Dr. Foreman noted her windpipe was deviating to the left. Her right lung was collapsing. Dr. House ordered her to grab a needle and syringe and stab herself between the ribs in order to allow the lung to reinflate. Although she resisted at first, she eventually did so and her breathing improved. However, she noted that this symptom ruled out kidney stones.
The next chem 7 showed further decline in kidney function. She had a PPD before being stationed to rule out tuberculosis. Dr. Foreman thought it might be cancer in her lung or kidney that threw a clot to the other organ. Dr. House broke the news to Dr. Milton, along with the fact she didn't have imaging scanners, a surgeon for a biopsy, proper stains or an oncologist. He told her to x-ray her entire body and she agreed to do so and uploaded them to the hospital.
Dr. Wilson was consulted to review the x-rays and found an enlarged lymph node. However, they would still need a biopsy to confirm. Without a surgical team, the node they were looking at couldn't be biopsied. Dr. House suggested that they look for a node closer to the surface that the patient could biopsy herself. Dr. Wilson saw no other enlarged nodes, but Dr. House thought that an enlarged node could be felt before it would show up on an x-ray. However, they still needed to find an appropriate stain and Dr. House asked Dr. Wilson and Dr. Foreman to test what the research station had on hand for a substitute.
Dr. House remotely examined Dr. Milton while she looked for enlarged lymph nodes. They found a swollen node just above her navel. Under Dr. Wilson's direction, she numbed the area with ice and inserted a biopsy needle into the swollen node. They discovered red wine works as a stain, and so Dr. Milton added it to the lymph tissue and sent an image to Dr. Wilson. He reviewed it and found no cancerous growth, although there was inflammation. Suddenly, Dr. Milton developed pain on her left side, where earlier it had been on the right.
The inflammation and kidney failure pointed to an autoimmune disease, either lupus or vasculitis. He told Dr. Milton to take prednisone as it worked on both. However, she pointed out he had confirmed nothing and she didn't have prednesone to waste as they had a crew member with asthma.
Dr. Foreman suggested letting her go outside - extreme cold would lessen the inflammation and make her feel better if it was an autoimmune disease. However, Dr. House thought it was reckless considering the -70F temperature and double kidney failure. Dr. Foreman pointed out she didn't have equipment to perform an ANA. However, Dr. House asked what they used before ANA was developed. Dr. Foreman reminded him it was C3, but she didn't have equipment for that either. Before that it was LE prep, but she din't have any control port glass beads. However, Dr. Wilson pointed out they didn't need them - all they needed to do was put a paper clip in the test tube with the blood and shake it up to damage some of the cells. They explained to Dr. Milton that if it were an autoimmune disease, her antibodies would devour the dead blood cells and would be visible under the microscope.
The LE prep test was negative, but Dr. House still implored Dr. Milton to try prednesone to see if she improved. Instead, she agreed to Dr. Foreman's plan to go outside for five minutes to see if her kidney pain improved. However, as she was preparing, she collapsed on the floor. Dr. Foreman scrambled to find someone else at the research station and got in touch with Seth. He arrived 20 minutes later, but by that time Dr. Milton was in a coma. They gave her prednesone, but there was no improvement. This seemed to rule out autoimmune. They also couldn't perform another kidney function test because she was the only one who knew the process and it was too complicated to teach to anyone else. However, Dr. House thought of a simpler test.
They asked Seth to taste Dr. Milton's urine. A strong taste meant a kidney problem, a watery taste meant it was a brain problem. Seth agreed to the test and Dr. House realized he cared about her. They instructed him how to use a straight catheter to extract a urine sample. The urine was watery, indicating either increased intracranial pressure or a problem with the hypothalmus. The latter could not be treated. They directed Seth to drill a hole in Dr. Milton's skull. Seth resisted, but Dr. House talked him through it. Seth stabilized her head and sterilized the drill bit. He finally got through and they allowed the fluid to drain. Dr. Milton soon regained consciousness.
It was obvious that increased intracranial pressure caused the coma, and Dr. House approached his team for a new differential. Dr. Taub suggested a tumor throwing off clots, but cancer had already been ruled out. Dr. Hadley noted that bacterial endocarditis also throws off clots, but the patient had no fever. Dr. Taub suggested deep vein thrombosis with a PFO, but the PFO would have been seen at her recent physical. Dr. Kutner suggested it wasn't a clot - perhaps it was plaque from atherosclerosis, but Dr. Milton had no risk factors for the disease. However, Dr. Kutner refused to give up on the idea - he suggested a fat embolism. Dr. House agreed it fit the symptoms, but it was impossible. It required an unrepaired broken bone and Dr. House had seen x-rays or physically examined Dr. Milton's entire body. However, he suddenly realized Dr. Milton wore socks during the physical exam.
He rushed back to the web connection and directed Dr. Milton to remove her socks. They saw her right big toe was broken. Bone marrow leaked into the bloodstream and formed fat embolyisms. She didn't feel the break because her feet were numbed by the cold. They had Seth set the bone. After that, she only needed a splint. She would fully recover.