Giles has been diagnosed with Amyotrophic lateral sclerosis and is currently confined to a wheelchair as he is paralyzed below the waist. He has become depressed as he has realized that the disease's progressive effect is slowly paralyzing his diaphragm. Although he has trouble breathing, his condition has left him unable to exercise the type of breath control he requires in order to play the trumpet.
The patient was admitted after he had difficulty breathing after exerting himself during a recording session. He was diagnosed with lumbar pneumonia, but Dr. House learned about the case and was wondering why the patient was paralyzed. However, at the request of the patient's primary care physician, Dr. Marty Hamilton, the case was assigned to the remainder of Dr. House's team by Dr. Cuddy. The patient was on an experimental treatment protocol for the paralysis and Dr. Cuddy believed Dr. Foreman, who had done his residency with Dr. Hamilton, would be more likely to respect the wishes of the primary care physician. Dr. Foreman was assigned as attending.
The patient's O2 count was remaining in the 90% level, and he was not coughing up sputem. He appeared to be in stable condition. Dr. Foreman ordered that his antibiotics be continued. However, he was worried about sepsis and ordered tests of thyroid and adrenal gland function. Dr. House asked what Dr. Foreman was doing about the paralysis, and Dr. Foreman replied he was sticking to the treatment protocol as the patient had already been diagnosed with ALS by Dr. Hamilton. However, Dr. House noted that ALS is a diagnosis of exclusion as there is no test or treatment for it. Dr. Foreman replied that Dr. Hamilton had already ruled out any other possible cause for the paralysis. Nevertheless, Dr. House started a new differential for the paralysis. Dr. Chase suggested Guillaine-Barre syndrome, which is treatable. However, Dr. Foreman pointed out that in Guillaine-Barre, the progression of the paralysis is always symmetrical, and it was not in the patient's case. Dr. Cameron suggested transverse myelitis, but Dr. Hamilton had tested the patient for it and the test was negative. There were also no masses and his AVN was normal. Dr. Chase suggested an autoimmune condition attacking the patient's nerves - small defocal motorneuropathy. Dr. House noted that this fit the patient's symptoms, even though the condition is rare. He asked if Dr. Hamilton had ever put the patient on intravenous immunoglobulin. Dr. Foreman replied that this had not been tried and Dr. House ordered an MRI. However, Dr. Foreman overruled him. Dr. Foreman noted again that ALS fit the symptoms and would also explain the pneumonia. Although Dr. House pointed out that ALS was a terminal diagnosis, Dr. Foreman pointed out that just because it was terminal didn't make it wrong.
Dr. Foreman advised the patient that the pneumonia was likely to get worse. Dr. Foreman asked the patient if he would undergo an MRI. The patient was aware that Dr. House did not agree with the ALS diagnosis, but when Dr. Foreman agreed with the ALS dignosis, the patient did not want to undergo the MRI because he knew it would be pointless. The patient also asked for a do not recussitate order. Dr. Foreman advised Dr. House about the DNR order and that the patient on intravenous steroids and encyntherate. Dr. House advised Dr. Foreman to try the immunoglobulin in any case as the DNR didn't mean "do not treat". Dr. Foreman started the patient on immunoglobulin.
However, the immunoglobulin thickened the patient's blood, slowing blood flow through the patient's lungs. He was soon in respiratory arrest with his blood oxygen level dropping. Dr. Cameron suggested heparin, but Dr. Chase pointed that this would take too long to work and they needed to intubate the patient. However, the patient's DNR order prevented them from doing so. Dr. House came to the room, noticed the O2 level was in the 70% range and started the intubation despite the DNR order. He then demanded a bag to assist the patient's breathing. At that moment, the patient's manager came in. The patient was then put on a ventilator. Dr. House agreed the diagnosis of small defocal motorneuropathy was incorrect. When Dr. Foreman confronted Dr. House about disobeying the DNR order, Dr. House pointed out that the patient only signed the DNR order because he was afraid of dying from ALS, but his condition at the time had nothing to do with the DNS. Dr. Foreman pointed out that Dr. House had screwed up about the immunoglobulin and didn't want to admit it, but Dr. House pointed out that Dr. Foreman was the attending so, technically, it was Dr. Foreman's mistake.
Dr. House started a new differential with Dr. Chase and Dr. Cameron about the patient's lungs getting worse. Dr. Chase thought it might be vasculitis, but this would not affect both lungs. Dr. Cameron thought it might be Wegener's disease, and this would explain the pneumonia and may explain the paralysis as it can affect the spine. However, Dr. House was served with an order to stay away from the patient and he was charged with battery. Nevertheless, Dr. House ordered a test for C-anka from the remaining blood in the lab and ordered Dr. Chase to get a biopsy the next time he did bronchial suction.
Dr. Cuddy informed Dr. House that Dr. Hamilton was coming to Princeton-Plainsboro to put an end to the patient's life. However, she agreed to pay for Dr. House's lawyer to fight the restraining order. Dr. House obtained an order to keep the patient on life support until the criminal charges could be dealt with.
The biopsy only showed inflammation. Dr. House ordered cytoxan. However, Drs. Cameron and Chase noted they had no authority to treat the patient without Dr. Foreman's permission. Dr. House administered the cytoxan himself. However, he ran into Dr. Hamilton and told him about the cytoxan. Dr. Hamilton realized that Dr. House thought the patient had Wegener's. Dr. Hamilton had already tested for it, but the biopsy and blood tests were negative, just like Dr. House's tests were negative. Dr. Hamilton planned on taking the patient off the ventilator, but Dr. House noted the order was in place preventing that. However, Dr. Hamilton had anticipated that and all the criminal charges against Dr. House had been dropped.
The ventilator was discontinued, but the patient was able to breathe on his own. His 02 stats remained stable. This definitively ruled out Wegener's. However, the paralysis had spread to one of his arms. Drs. Cameron and Chase believed that this was a progression of the paralysis typlical of ALS, but Dr. House thought that the arm and leg paralysis may be unconnected. Dr. Cameron suggested that the patient may have had a stroke when he was intubated. Dr. House wanted to perform an angiogram and went to see the patient when Dr. Hamilton wasn't there. He asked for a chance to diagnose the patient. However, the patient explained he wanted the DNR order because he couldn't play the trumpet any more. He had made that his life the way Dr. House had made medicine his life. However, Dr. House performed an MRI angiogram anyway.
The MRA showed that the patient had suffered a stroke caused by a clot in his brain and that they could still break up the clot with TPA. They asked for permission to treat the patient with heparin, but the patient refused because of the risk of damage to the lungs. However, Dr. Foreman suggested surgery to remove the clot, which would either restore the use of the arm or kill him. The patient agreed to the procedure.
The patient was prepped for surgery and Dr. Chase inserted the tube into the patient's carotid artery until it reached the brain. The clot was removed and the patient was doing well. The patient's arm function returned. However, the patient also found he had feeling in his left leg all the way up to the calf.
Dr. House started a new differential. Dr. Hamilton thought it was his experimental protocol. Dr. House thought it was one of the medications they were giving him, so he proposed withdrawing them all and then starting them again one at a time. Dr. House dismissed the experimental protocol as the cause as if it had worked, the patient would have improved before he got to the hospital. However, the patient's condition got worse. Even Dr. Hamilton realized it was one of the medications the patient was on at Princeton-Plainsboro. Dr. House wanted to start the patient on steroids for 24 hours, but Dr. Cameron pointed out that steroids could lead to respiratory collapse in the patient's current condition. Dr. House ordered them anyway. He also ordered another MRI and MRA despite the fact they had performed those procedures. Incredibly, the new MRI showed an arterial-venous malformation compressing the patient's spine. This would explain the paralysis. They and Dr. Hamilton had missed it, as had the previous scans at Princeton-Plainsboro, because the malformation was hiding behind its own swelling. The steroids reduced the swelling and revealed the malformation. The patient only needed surgery to remove the malformation.
The patient underwent surgery and soon recovered feeling in his legs. Within a few weeks he was receiving physiotherapy and he was soon able to walk on his own and was discharged.