Fletcher Stone was the journalist with aphasia who was the patient in Failure to Communicate.
Medical History[]
Fletcher was diagnosed as being bipolar but he hadn't told anyone. His bipolar disorder made him seek excitement. He took topamax to try and control it, but to try to completely stop it he got a bilateral cingulotomy. He also had a history of taking sleeping pills and amphetamines.
Case History[]
Fletcher Stone was at his boss Greta's retirement party. He told the story of the first story that he ever wrote - he was accompanying a man named "Barrelhead" who was transporting guns to NYC. Afterwards the DA wanted to know Barrelhead's real name. He tells them how afterwards Greta and him went to a bar, where she told him that the magazine was behind him. He asked if she could get the DA off his back. She told him no but when he gets out of jail he'll still have a job. He told them that he gave up drinking and he gave up drugs. But Greta taught him that there are two things that you never give up: one's rock and roll, the other's a source. He made a toast to Greta. He was in the middle of telling her that he hopes she can adjust to the lack of stress in her life when he collapsed and banged his head. He was briefly unconscious. He got up though, and his wife asked if he was okay. He said, "I flung the investment." His wife laughed and asked what he said. He said, "I flung the investment," again and then said, "Why consign?" Everyone stared at him. He said it again. Greta went to call 9-1-1. Fletcher said, "It's proficient," and then "Why disqualify the rush? I'm tabled." He said "I'm tabled," again. He seemed unaware that what he was saying didn't make any sense.
Dr. House was in Baltimore with Stacy Warner to discuss his Medicaid billings. Dr. Cuddy comes to Dr. Foreman for a recommendation for a diagnostic department referral. Dr. Foreman assures Dr. Cuddy that he and the rest of the team can handle the patient without Dr. House, but Dr. Cuddy insists on getting a referral. Dr. Foreman asks what the symptoms are so that he can know which hospital to recommend. Dr. Cuddy tells him that the EMT's report is that he struck his head and is suffering from aphasia. Dr. Foreman asks for the case because he is a neurologist. He suggests Dr. Taylor, who Dr. House almost hired instead of Dr. Foreman. Dr. Cuddy tells him that the patient is Fletcher stone a man who has written twelve books and exposed scandals in three administrations. Dr. Foreman realizes that the famous patient needs a famous doctor. He goes to call Dr. Taylor, but stops and asks Dr. Cuddy to do it because he might do something stupid. Dr. Cuddy agrees to give him the case.
Dr. Chase goes to see Fletcher, he asks if he is taking any drugs, but Fletcher still isn't making any sense. His wife says that he used to drink regularly, but he's been clean and sober for nearly a year. Dr. Foreman tells him that he thinks he's speaking normally, but really his speech is impaired. He tells the wife that he knows what he wants to say but when he reaches for a word, he finds something else. In addition, all the words he's saying seem to make sense to him. He tells Fletcher to write his name and draw a face. He can't do that either, he has agraphia loss of ability to write, but most often it's temporary. Dr. Foreman asks how hard he hit his head. His wife Elizabeth says that it was a pretty hard crack and it made a really ugly noise. Dr. Foreman asks if Fletcher can understand what he is saying. Fletcher says "Of golf." (perhaps meaning Golf Course-Of golf=Of course). Dr. Foreman tells him to give them simple yes or no answers. Fletcher manages to say "yes". Greta comes in and asks if he is okay, Elizabeth says that they don't know and introduces Dr. Chase and Dr. Foreman to Greta. Greta says that she wanted to make sure that the EMTs told them the right story, Dr. Chase asks how many stories there are. Greta tells them that he didn't trip, he just fell out of the blue. His foot jerked a little bit first and that's what made it look like a trip.
Dr. Foreman thinks that it may have been a stroke or a seizure. Dr. Chase says that they shouldn't believe Greta because everyone else in the room saw him trip. Cameron adds that his symptoms can all be explained by the head trauma. It causes a contusion or a seizure and that causes the aphasia. They should get an EEG. If it was a stroke it could be a clotting issue. Dr. Chase says that even if he fell drug use is far more likely. He is going to order a tox screen. Dr. Foreman stops him and says that they aren't done with the differential. Dr. Chase tells him that he isn't his boss. Dr. Foreman tells him that he is Dr. House's boss and House is his boss so that makes him Dr. Chase's boss. The team fights over authority and Dr. Cameron suggests they work towards a consensus about what do to.
They do an EEG and an ultrasound of his carotid artery. Dr. Foreman tells Fletcher that it will show them if there's a problem that might cause a blood clot. If it went to his brain it would cause the aphasia and the falling down. Dr. Cameron tells Elizabeth that the EEG is in case there was increased swelling, in which case they need to keep him stable until the body can repair the damage. Greta asks if Dr. Chase thinks that they're both wrong, but Dr. Foreman tells her that they're just covering all the bases, they're being safe. Suddenly Fletcher starts coughing, and his O2 stats start dropping. They realize there is fluid in his lungs. They push 40 IV lasix. They need to intubate as he's losing his respiratory drive.
A seizure can't cause both aphasia and fluid in his lungs, and neither can a stroke unless he had an abnormal heart rhythm. His urine test was positive for amphetamine, but amphetamines don't cause pulmonary edema unless you smoke them. Dr. Foreman had read one of Fletcher's books where he talked about giving up drugs and alcohol and how it changed his life. Chase says everybody lies and tosses the B.O.U.O. around.
Dr. House calls Dr. Wilson and asks how his team is. He asks whats new with "Mr. Aphasia". Dr. Wilson asks if Cuddy told him about Fletcher and his aphasia, and Dr. House tells him that everybody covers their ass. Dr. Wilson tells him how Dr. Chase did the tox screen and it came back positive for amphetamines. Dr. House tells Wilson that he thinks that there is more to it. Dr. Wilson wonders how Dr. House knew Dr. Chase was wrong about it being just the drugs and tells Dr. House that Dr. Foreman asked Fletcher about his drug test and found him running a fever. That can't be the result of the amphetamines.
Dr. Foreman thinks that encephalitis and meningitis are the obvious suspects. He tells them to start him on antibiotics. Dr. Cameron thinks that it could be an autoimmune disease such as lupus or Behcet's disease. She thinks that they should start him on a high dose of steroids. However, if he does have encephalitis, steroids could weaken his immune system. Dr. House calls and asks how high a fever he has and asks why they haven't called him. Dr. Foreman tells him that it is 101°F. House tells them to start with broad-spectrum antibiotics for the possible bacterial meningitis, and an antiviral in case it's herpes encephalitis. Dr. Cameron asks what if it's autoimmune. Dr. House admits if that is the case, there is nothing they can do. Dr. House tells them that they need more information, like a family history to rule out genetic conditions. Dr. Foreman reminds him that he can't talk so his medical records are a little sketchy and his wife's only known him a couple of years. Dr. House asks if the MRI showed anything, and Dr. Foreman says that the CT scan was negative. Dr. House asks about the MRI again and Dr. Chase tells him that they have one schedules in twenty minutes - the earliest appointment that Foreman could get. Dr. House admonishes them for not cutting into the MRI queue earlier, then tells them to get an MRI and a better medical history.
Dr. Chase asks him a series of questions. They find out that he stopped traveling for work two years ago. His last vacation was six months ago at golf resort at Key Biscayne. Greta says that there was no way that it was a golf resort. She says that knowing Fletch, she assumed he was working his way through every bar in the Florida Keys as a last hurrah before settling down. Dr. Chase asks Fletcher about alcohol and amphetamines he says no. Dr. Chase tells him that he tested positive. Elizabeth says that there is no way that it is drugs he wouldn't do that. Greta tells Dr. Foreman that before he met Elizabeth he used to use drugs recreationally. Greta tells him that now he only takes medicinal drugs because he was having trouble sleeping. She says that when the sleeping pills knocked him out, he needed something to perk him back up during the day. Fletcher tries to tell Dr. Chase something, but he figures he's worried about Dr. Chase telling his wife about the amphetamines. Dr. Chase does the MRI and tells him that he won't tell the wife about the drugs.
The MRI shows a little edema which is brain swelling and an area of scarring. Elizabeth asks if that is what was causing the aphasia. But Foreman tells her that the scarring is in the part of the brain that is not normally associated with aphasia. It's also old - it happened before he hit his head, he might of had a small stroke or some other underlying condition or it might be something completely different. Foreman asks if he has had head trauma before. But he hasn't.
Dr. Cameron says that the scarring on the MRI could be anything from multiple sclerosis to toxins to a demyelinating disease. If it's meningitis, they need to identify the bug fast. Dr. Chase thinks that they need to do a lumbar puncture, but Dr. Foreman says that they can't with edema because it will most likely paralyse him. Dr. Cameron asks what Dr. House says but Foreman tells her that he turned off his phone. Dr. Foreman says he needs more information and tells the rest of the team to break into Fletcher's house. Dr. Cuddy comes by for an update, but Dr. Foreman and Dr. Chase leave quickly, saying they have dinner reservations for two.
Dr. Foreman and Dr. Chase break into Fletchers office. Dr. Foreman finds the caffeine pills and amphetamines. Dr. Chase finds topamax, which is an anticonvulsant. However, Fletcher had said that he had no history of prior seizure. However, it's not even prescribed to him and it wouldn't cause a fever so they figured he's probably just using it for weight loss - another lie. Dr. Chase thinks that the wife may be hiding something. The next stop is the patient's house, but there's nothing but aspirin and flu meds in the bathroom. Dr. Foreman finds some abandoned woodworking projects.
Fletcher is complaining about something. He tries to tell them by licking a fork. Dr. Cameron tries to guess what he means. Dr. Cameron asks if he means taste, Fletcher says yes. She asks if it's a metallic taste, he says yes.
Dr. Wilson calls Dr. House and tells him that Fletcher is tasting metal. Dr. House asks where Fletcher's creatinine is. Dr. Wilson tells him that it's 6.8 and he's got kidney failure. Dr. Cameron has him on dialysis and he's stable for the moment.
Dr. Cuddy looks for an update and Dr. Foreman tells her its got to be meningitis, encephalitis or autoimmune. Dr. Cuddy is unimpressed and tells the team to call Dr. House. Dr. Chase tells her that he's not answering his phone. Dr. Foreman thinks that they need to a lumbar puncture despite the risk of paralysis. However, Dr. House finally calls back. He tells Dr. Foreman to do the lumbar puncture just right. Dr. Cuddy is angry with Dr. House for being out of contact, but he tells her the patient is too ill to be taken to another hospital and to leave his team alone so they can work. Dr. House tells Dr. Foreman that the patient could know something that they don't. Dr. House asks if he has tried to tell them something important, but he hasn't. Dr. House tells them that he isn't scared enough. He tells them to tell Fletcher that he is going to die. He tells them not to let Dr. Cameron do it.
Dr. Foreman and Dr. Chase break the news that they will do the lumbar puncture, but it may not give them the answers and if they can't find out what is wrong with him, he will die. Dr. Chase asks if there is anything he hasn't told them, but Fletcher denies it. However, as Dr. Cameron is about to do the LP and starts to tell him that what he heard about dying may have scared him, Fletcher tells her pointedly that "He couldn't tackle the bear," and "They took my stain."
Dr. Foreman calls Dr. House, who asks how the LP went. Dr. Chase tells him that it points to some kind of infection. Dr. Chase adds that at the way his organs are deteriorating, he's got maybe a day or two. Dr. Cameron tells Dr. House that he was trying to tell them something and tells House what he said. Dr. House explains that an aphasic retrieves words that are stored somewhere close to the one he that wants. It can be based on sound or meaning. e.g. if he wanted to say table he could say label or chair. Dr. House tells them to keep him talking and write down everything he says.
Dr. Cameron asks Fletcher what he meant by stain: if he meant dirty or soiled. He didn't. Dr. Foreman asks Fletcher about pain or brain. They continue to ask questions and Dr. Cameron once again asks if there is something he hasn't told him.
Dr. House is trying to find out what Fletcher meant. He writes down words on a wall with Stacy's makeup. Dr. Foreman and the team have been taking to Fletcher for hours. Dr. Cameron tells House that he mentioned stain once before when Dr. Chase was giving him his MRI, before they scared him. He only mentioned "stain" when his wife is out of the room.
They wake Dr. Cuddy up to get Elizabeth out of the room. Dr. Foreman tells her to tells Elizabeth that there has been a miscommunication over their insurance coverage. He gives her coffee.
Meanwhile in Baltimore, House is still trying to figure out what he meant. In New Jersey they put House on speakerphone to talk to Fletcher. He tells Fletcher to start talking. He repeats the couldn't tackle the bear and took my stain sentences. Fletcher says yes to brain, but Dr. Foreman says that doesn't get them anywhere - they have been looking at the patient's brain since he was admitted. Dr. Chase suggests drugs again, and Dr. House implies Fletcher is an addict. Fletcher protests the remark, but Dr. House points out his sleeping pills and amphetamines are just to artificially calm him down and pep him up. However, when he thinks about that pattern, Dr. House thinks of something else. Dr. House starts talking about a polar bear, and Fletcher grabs Dr. Cameron's hand and nods. Dr. House asks Fletcher if he is bipolar and he says yes. Dr. House tells them that Topamax isn't just off-label for weight loss, it's off-label for mood disorders. Many people with bipolar disorder have their manic phase during the day and their depressive episodes at night. Dr. House tells them that he's been self-medicating for years with alcohol and sleeping through the bad hours. Bipolar disorder explains the danger journalism. House tells them that being bipolar makes you take risks: you seek excitement and have a tendency to make up stories. Fletcher couldn't tell anyone because people might think that he made up his stories. This situation was fine until he fell in love with Elizabeth and felt he had to change. Dr. House tells them that he got a bilateral cingulotomy, an experimental surgery that some people claim can help mood disorders. If the surgeon had used a gamma knife, there would be no trace of an incision. Dr. Cameron says the surgery is irrelevant because the scars are in the wrong place. Dr. House agrees and reminds them that Fletcher also has recurring fever and asks them what causes it. Elizabeth walks in while House is taking about Fletcher's drug use and continuing bipolar problems - he probably still has it.. Elizabeth gets mad at him because "some guy on speakerphone" knows him better that her and she feels he doesn't trust her. Dr. House tells them to look at Fletcher's blood instead of just putting it in a machine for the tests. Dr. Foreman runs the test and easily sees cerebral malaria. They get him started on intravenous quinidine. Dr. Foreman noted ironically that if anyone had looked at his blood, like they used to when they did blood tests, the parasites would have been obvious.
Fletcher was last seen talking to Greta who tells him that Elizabeth will be back.