|First Appearance||Sleeping Dogs Lie|
This article is about the patient with insomnia in Sleeping Dogs Lie. For the teenage girl with CIPA in the episode Insensitive, see Hannah Morgenthal. For the woman who was trapped under the debris of the crane crash in the episode Help Me, see Hanna.
Hannah took a whole bottle of sleeping pills to try and help her sleep. Her partner Max found her on the bathroom floor, still conscious and called an ambulance. They were taken to the emergency room of Princeton- Plainsboro.
Dr. Cuddy presented the case to Dr. House while he was sleeping in the clinic. He figured that Hannah was just upset, and was lying about not sleeping for ten days because no one could survive that long without sleep (the neurons degenerate and the brain starts shutting down) and that she swallowed the pills in a suicide attempt and needed a psychiatrist. Dr. Cuddy informed him that Hannah swallowed the bottle of sleeping pills to go to sleep but she still was awake. She also told him that the longest anyone had survived without sleep was eleven days.
Dr. House told his team about the case. Dr. Cameron thought that they should give her more sedatives. Dr. Foreman disagreed with her because sedation is different than sleep. Cameron thought that giving her sedatives would relieve the stress on her brain. Dr. House noted that she had no fever and her white blood cell count was low, ruling out an infection. Dr. Chase suggested schizophrenia, but there were no delusions. Aside from the sleeping pills, her tox screen was clean, particularly for cocaine, methamphetamines and diet pills - the most common causes of insomnia. The steroids and ibuprofen she had been taken wouldn’t cause sleep disturbances. Dr. House thought she had an optic nerve disease which stopped her brain from interpreting the light cues that trigger sleep. Dr. Cameron agreed to test for it.
They injected Hannah with a dye that would allow them to look at her retina and optic nerve. Hannah complained things looked blurry, but Dr. Cameron assured her it was just a side effect of the dye which would last for a few hours. However, Hannah fell asleep during the test and her EEG showed normal stage 1 brain waves. When a few seconds later Hannah woke up, Dr. Cameron told her that she fell asleep, but Hannah didn't think she had. They checked Hannah’s ocular pressure but it was normal. She was negative for optic nerve disease.
Foreman told House about the test results and that the patient was sleeping in periods lasting from about ten seconds to a minute at the very longest. The CT scan showed no tumors, no clots and no seizure disorder. Dr. House realized that Hannah could fall asleep, but couldn’t stay asleep. He thought that whatever she had that was preventing her from sleeping wasn't showing up on the scans because she wasn't sick enough. He wanted them to stress her brain by keeping her awake. His team protested, but Dr. House reminded them that until they saw another symptom, they had no tests to run.
Hannah still didn't remember falling asleep. Dr. Foreman and Dr. Cameron were keeping her awake. Suddenly, Hannah appeared to be suffering from severe rectal bleeding. Dr. House agreed with Dr. Chase’s suggestion to do a colonoscopy to check for a rectal tumor. He also told them that they couldn't sedate her because he still wanted to stress her brain. Cameron reminded him of how much pain she would be in if they kept her awake. He told her that if they found the tumor, they could sedate her, but in any other case he wanted her kept awake.
Hannah was in severe pain during the colonoscopy. Dr. Chase was having trouble because Hannah couldn‘t relax enough. Suddenly, an extremely thin stream of blood came pouring out of her nose and she couldn't breathe.
They packed the nose to prevent the bleed and started transfusing two units of blood. The pathology from the rectal bleed showed traces of nasal epithelium. Dr. Foreman thought it was a massive sinus hemorrhage draining through her throat into the nose. Dr. Cameron thought the cause was more important. Dr. Foreman suggested a combination of a neurotoxin and blood thinner. Dr. Foreman also suggested it could be a coagulopathy. Dr. Cameron thought it was a result of the colonoscopy - the stress raised her blood pressure, which set off the bleeding. However, that wouldn’t explain the insomnia. Dr. House noted that her rash was diagnosed as poison ivy around the same time the insomnia started. The combination of rash, bleeding and insomnia pointed to granulomatosis with polyangiitis (GPA). He told them to give her a triple dose of steroids and to get a C-ANCA and an upper airway biopsy to confirm it.
Dr. Chase prepared Hannah for the biopsy by using a topical anesthetic and placing a shield over her tongue. Dr. Chase completed the procedure, and suddenly Hannah started having rapid eye movements; she seemed to have fallen asleep with her eyes open. They reported this to Dr. House, who asked what posture she was in when it happened. When he was told she was sitting up, Dr. House didn't think it was REM - not only had they not started the steroids to treat her, a person in sleep that deep could not remain sitting upright because they couldn‘t keep their muscles tense. This appeared to have ruled out GPA. Dr. Chase thought it was rabies. However, she had no sign of a dog bite. She had a dog for less than a week that she had to give up because of allergies. Dr. House thought that it wasn't allergies and she was planning on leaving Max. She would have been on steroids when she had the dog which would have suppressed any allergic reaction. He figured that Hanna pretended to be allergic to give up the dog because she wasn't planning on being around for much longer. Refusing to believe Dr. House‘s conclusion, Dr. Cameron got permission for an allergy scratch test.
While doing the test, Hannah still felt blood in her mouth, but it was getting better. Max went to get her a soda. While Max was out of the room, Dr. Cameron asked Hannah if Dr. House’s theory about her lying about the allergy was correct. Hannah first denied it, but later admitted to it when she promised not to tell Max. Hannah told her that she had been with Max so long that she got tired of her. She told Cameron that her back hurt, and when Dr. Cameron examined her, she saw signs of massive internal bleeding.
Dr. Chase asked if Hannah had access to aspirin, which acts as a blood thinner. Dr. Cameron said she would have to take a lot to show that much bleeding. Dr. Cameron also admitted to Dr. House that he was right about Hannah wanting to leave Max. Dr. Cameron thought it was drugs or alcohol. Dr. Foreman entered the room and informed Dr. House that Hannah’s liver function tests were through the sky. Her liver was dead. She needed a new liver. Doing tests for cirrhosis would take at least 12 hours and hepatitis would take 8 hours, and Hannah would not last longer than 6 hours. However, without a diagnosis, Hannah would not qualify for a transplant. Dr. Foreman said they should focus on those conditions that could be diagnosed, treated and cured within that time frame. Dr. House noted that Max had donated blood which meant that they were the same blood type. He suggested Max could donate part of her liver. Dr. Cameron considered that unethical because Hannah was about to leave her.
Dr. House informed Hannah and Max about Hannah’s liver failure. They could continue the transfusions and the lactulose, but this would only extend her life a few hours. She was expected to lapse into an irreversible coma within a few hours. Max asked if they could get a donor liver, House told her that all the possible diagnoses would take longer than the time Hanna had left, and even if they arranged a transplant, whatever damaged the first one would do the same to the second. Dr. House agreed that it would give them another day or two to diagnose her, but that no donor agency would risk a liver on a patient without a diagnosis. Max asked if she could be a live donor, and Dr. House agreed it was possible. Max said she didn’t care about the risks.
A liver transplant would give them about 36 hours and he started a new differential diagnosis. Dr. Cameron realized Dr. House hadn’t told Max about Hannah’s plan to leave and said that Max wouldn't go through with it if she knew she was about to get dumped. Dr. House said that the real problem was that Dr. Cameron insisted on getting personally involved with patients - if she hadn’t asked, she would be unaware of the ethical dilemma. Dr. Foreman thought it was hepatitis, but Hannah‘s PCRs were normal. Dr. Cameron insisted they had an ethical problem with the transplant, but Dr. House insisted they didn‘t. Dr. Chase thought it was a cancer like Non-Hodgkin's lymphoma, but it was a poor fit with insomnia. Dr. Cameron was sure it was an ethical problem, but Dr. House pointed out that Hannah‘s plan to leave Max wasn‘t medical information and under AMA guidelines, it wasn‘t relevant. Dr. Foreman thought it was Wilson's disease. However there were no Kaiser-Fleischer rings. Dr. House pointed out they don’t appear in every patient and if there are neurological symptoms, Wilson’s can be confirmed that way. Dr. Cameron kept talking about the ethical problem, but Dr. House reminded her if they told Max and she changed her mind, Hannah would die. Dr. Foreman suggested poison mushrooms could account for her symptoms, but Dr. Chase thought that unlikely given that Hannah was a sports nut. Dr. House told them to run tests while they prepared her for surgery. He instructed his team to use a PET scan to look for cancer, do an endoscopy of her bile duct, scrape her stomach for mushroom spores, do a CT scan of the liver and test for proteins CA-125 and CA-19.5, He also told them that if anyone told Max about Hannah’s plans, they would be fired. Dr. Cameron insisted they had to tell Max, but he reminded her that Max wasn’t her patient. Dr. Cameron pointed out that since she was getting surgery, she had to be someone’s patient.
Dr. House went to Dr. Cuddy to explain that Max needed a representative outside his team because she and Hannah had opposing interests and that put him in a conflict of interest. Dr. Cuddy wondered why House was so concerned about the ethical problem. Dr. House said there was nothing medically relevant, but Dr. Cuddy realized he knew something. Dr. Cuddy tried to find out what it was from the chart, but Dr. House stopped her and told her that if she satisfied her curiosity, Hannah would be dead in three hours.
Dr. Cuddy agreed to speak to Max about the surgery. Max was impatient and wanted to proceed. Dr. Cuddy told her there was a chance she could die on the table. Max said she just wanted Hannah to live. Dr. Cuddy started to prepare her for surgery.
Dr. Cameron checked Hannah for vascular abnormalities and at the same time checked her for mushroom spores. Hannah denied using mushrooms, but Dr. Cameron told her she couldn’t be trusted. Dr. Cameron also confronted her about what Max was going through and the risk she was taking. She told Hannah that if she cared at all about Max, she would tell her. Hannah asked Cameron if she would really tell her lover if she were in the same position. When Cameron said she would, Hannah reminded her she would die. Dr. Cameron didn’t respond.
Dr. Foreman informed Dr. House that Max had agreed to the transplant. He also said Hannah looked negative for Wilson's and Dr. Chase confirmed blood proteins were normal. Dr. House realized that both Max and Hannah were about to be put in the same room, both would be conscious, and both would be with Dr. Cameron. Max asked Hannah if she was ready for surgery, and Hannah was about to tell Max when Dr. House came along, sedated Hannah on the pretext that she needed sleep and sent her in for surgery. Dr. House then admonished Dr. Cameron for trying to get Hannah to admit her deception.
Hannah’s surgery went well. However, Max went into cardiac arrest, although they managed to restore her pulse. Dr. House came by and told Dr. Cameron to return to his office so they could start a new differential.
Max's cardiac arrest was caused by hypoxia from hypoventilation. They restarted her heart, and the right lobe of her liver was successfully transplanted into Hannah. Dr. Foreman reviewed Hannah‘s test results - Wilson‘s disease was definitely ruled out because her DOPA decarboxylase was being processed normally and her ceruloplasmin and copper levels were normal. The spore test for mushroom toxicity was also negative. The cancer tests were negative, but Dr. Wilson informed them because she had taken immunosuppressants before the tests, the readings were unreliable. Dr. House decided to stop the immunosuppressants, even though they were protecting her new liver. She realized she would die if they were stopped, but Dr. Foreman told her she would die anyway if they could not diagnose her. Dr. Foreman told her it would be painful, but they could sedate her. She rejected sedation so she could talk to Max once she regained consciousness.
Hannah developed a fever of 106F, showing she was rejecting her liver, but her white count remained normal. Dr. House realized that given what Hannah had been through, her white count should be very low, not normal. Dr. Foreman thought it was an infection and Dr. Chase wanted to start broad-spectrum antibiotics. However, Dr. House realized that broad-spectrum would be useless - they needed something more targeted, which meant they needed the exact infection. Dr. Chase suggested tularemia, but Hannah‘s chest wasn‘t congested and it wouldn‘t cause movement disorders. Dr. Foreman said it might have proceeded to meningitis, but there were no ulcerations on the skin. Dr. Cameron thought it was leptospirosis., but the patient didn’t have conjunctivitis and her creatinine levels were normal. Dr. Foreman suggested typhoid or another type of relapsing fever, but those are unknown in the United States and Hannah hadn't been out of the country. Dr. Foreman thought they should talk to friends and neighbors to be sure. Dr. House, however, started thinking about the dog they had. It dog came from a breeder at a place called Blue Barrell Kennels. Dr. House recognized the blue barrel as a type of cactus which meant that the dog came from outside New Jersey, most likely from the southwest. He went to examine the patient and found a large group of pustules on her right armpit. Dr. Cameron noted that it hadn’t been there in the morning. Dr. House took a sample of the swelling and told Dr. Chase to give it to the lab and call the CDC to tell them that they have a patient with the plague. She most likely got it from the fleas on the dog. Sleep disturbances are rare with the plague, but they do happen. The symptoms were suppressed by the steroids and immunosuppressants, which kept the bacteria contained. Once they stopped them, the disease spread and caused the characteristic buboes. Dr. Foreman went to find out what happened to the dog. Dr. House told Hannah that it was treatable and started her back on the immunosuppressants as well as streptomycin sulfate, gentamicin and tetracycline. He also ordered his team to get preventative treatment.
Dr. Cameron went to see Max. She revealed to Dr. Cameron that she knew Hannah was planning on leaving her and she donated her liver so that Hannah would stay with her out of guilt. Dr. Cameron warned her that guilt wouldn't make them happy, but Max said she just wanted to stay with Hannah.