"He is not sick." "Dr. Riley is throwing up." "He obviously can't lecture." "You witnessed the spew?" "Or you just have his word for it?" "I think I'm coming down with a little bit of the clap." "I may have to go home for a few days." "Dr. Riley doesn't have a history of lying to me." "You said this is the fifth time he's missed a class this year." " Either he's dying or he's lying." " I'll give you two hours off clinic duty." "Fine." "I'll have Cameron do it." "She loves inspiring the inspired." " You'll do it." " Why is it always me?" "Because the world hates you." "Or because it's a class on diagnostics." "Pick whichever reason feeds your narcissism better." "I'm not doing it." "You're supposed to stop me." "Renegotiate." "And you were supposed to keep on walking." "Sorry." "Guess we both screwed up." "Go on." "Do it again." "I'll do the lecture for four hours off clinic." "Two." "I know you'd rather spend a couple of hours... listening to yourself than listening to patients." "Class starts in 20 minutes." " Dr. House, there's a patient." " I'm outta here." "Take it up with Cuddy." "Greg." "Hi, Stacy." "How ya doin'?" "How am I doing?" "The last five years have been like" "You ever see those Girls Gone Wild videos?" "Your life's been like that?" "Or your life's been spent watching them?" "I have missed you." "Is that why you're here?" "I need your help." "Who am I looking at?" "My husband." "Who is suffering abdominal pain and fainting spells." "No sign of tumors, no vasculitis." "Could be indigestion." "Or maybe a kidney stone." "Little one can pack a lot of wallop." "Did you think I wasn't going to get married?" "Not to someone so poorly endowed." "This guy's pancreas is pathetic." "There is no kidney stone, no indigestion." "Three hospitals, five doctors-- Not one of them found anything." "Maybe there's nothing to be found." "Right." "You suddenly trust doctors, love puppies and long walks in the rain." "Walks are out." "I was around you long enough to know when something's not right." "Mark's had personality changes." "He's acting strange, disconnected." "Interesting." "Means there's either a neurological component, or he's having an affair." "No affair." "No nothing." "He's sick." "I know you're not too busy." "You avoid work like the plague." "Unless it actually is the plague." "I'm asking you a favor." "I'm not too busy." "But I'm not sure I want him to live." "It's good seeing you again." "Three guys walk into a clinic." "Their legs hurt." "What's wrong with them?" "I'm not gonna like you, am I?" "The most likely cause of leg pain is muscle strain." "Apply heat and rest affected areas." "Statistically, you're right." "Very good." "My experience, over half of leg pain is musculoskeletal, generally from excessive exercise," "Twelve percent is varicose veins brought on by pregnancy, and most of the rest is the result of vehicular accidents." "I said three people." "That's six legs." "So you've got three hurt jogging, two in collisions, and one of the legs is pregnant." "What were they doing when pain presented?" " I have no idea." " You didn't ask?" "You didn't take a history?" "Ofcourse." "But all that told us is what they said happened." "Person "A", farmer, says he was fixing a fence." "Tightness in the ankle, loss of muscle control." "Person "B", volleyball practice." "Coach figured it was a pulled muscle." "And "C", we've got Carmen Electra golfing." " Yes!" " Whoa." "You treated the Baywatch chick?" "The Baywatch thespian." "And no." "I gotta disguise the identity of each of the patients, and I got tired of using the middle-aged man." "Carmen seemed like a pleasant alternative." "Also, she's apparently quite the golfer." "In less than two hours, one of these three... will be tossed out of the hospital because they were faking it to score narcotics, and one will be very close to death." "Any guesses on which is which?" "Okay, I say we start with the farmer." "Did you hike to the fence, and how far?" "Yes." "It's about a half a mile from my farmhouse." "Where is the pain localized?" "It started just above my ankle, and it's radiating up." "So, what should we do first?" "Family history?" "Indicative of leg pain?" "That's a very short list." "Any history of bone cancer, osteogenesis imperfecta or multiple myeloma?" "Could be a blood issue." "We should run a C.B.C. and a D-Dimer." "And get an M.R.I." "M.R.I. or a PET scan?" "If the problem's vascular, he's better off" "Sorry." "Thanks for playin'." "Patient's dead." "You killed him." "We had no time to run any tests." "There was nothing we could do." "You had time to look at the leg." "I thought we were starting with the farmer's case first." "We are." "But if we're gonna look at a leg" "I need you to take off your pants." "Puncture." "Snakebite." "That would be my guess." "Farmer didn't know he'd been bitten by a snake?" "That's what he said." "Sudden shooting pain, tall grass." "Never saw a thing." " What kind of snake?" " You want me to tell you what kind of snake it was from the shape of the hole in the leg?" "How are we to know what kind of antivenom to use if we don't know what kind of snake it is?" "Oh, there are people to find those things out." "Shouldn't we wait for the Humane Society or something?" "Guy might only have a couple of hours." "And while we wait for the Humane Society to show up, what say we check in on the volleyball player." "You have tendinitis." "How old is this person?" "I mean, it's not really a 40-year-old man on a girls' volleyball team, right?" "It's a leg." "A leg is a leg is a leg." " Well, I was just worried that" " Would you worry about her more if she was younger?" "Obviously, we should care about all our patients, no matter what age" "Yeah, right." "I saw the way you were looking at Carmen." "She's mine." "Stay away." " Would you operate on your mother?" " Ofcourse not." "I'd be too nervous." "Couldn't be objective." "Then why are you so anxious to treat every patient like they're family?" "The actual patient is 16." "Here's what happens when doctors care too much." "I need to know everything about you." "I went back three generations." "No history of cancer, Parkinson's or any other degenerative condition." "But there's this boy at school, and he's on the boys' volleyball team." "They made out at a party, and now he won't call her back." "And this friend of hers at school said this boy didn't like her and never did." "You got all this from an examination of the knee?" "I think she's depressed." "She doesn't have tendinitis?" "She has tendinitis." "She's depressed about having tendinitis?" "She's depressed for the same reason that she has tendinitis." "Not the boy?" "No, the boy's a jerk." "She knows that, and yet she's depressed." "I found a nodule." "Ahh." "Problems with the thyroid gland-- causes depressed mental state... can cause inflammation of the tendons." "I'll run the tests." "So because she took such an extreme interest, she found out that the person had a thyroid condition." "No." "Because she took such an interest, she discovered a tiny nodule... which in reality signified nothing but gave us no choice... but to put a person with tendinitis through an expensive and painful test." "Here's how a well-adjusted doctor handles a case." "Can I put my pants back on now?" "I'd rather you didn't." "Which Carmen Electra is this?" "The first one." "The golfer." "Then why isn't she wearing pants?" "You have decreased reflexes in your patellar tendon." " Anyone?" " Slipped disc." "Could be." "How bad does it hurt?" " It hurts really, really bad." " Yeah?" "It doesn't seem real." "Is she the one faking?" "Oh, for God's sake." "She's here to play into my fantasy, not 'cause she's Meryl Streep." "Fine." "What the hell is wrong with me!" "Do something!" "Too much pain to be a slipped disc." "Could be herniated and impinging the nerve root." "Or it could be referred pain from his groin." "Sir, are you getting pain anywhere else?" " He's curling." "It's not the back." " Sir, where are you getting pain?" " Help me!" " He's not gonna tell us anything if we don't get him out of pain." " Give him 50 milligrams of Demerol." " We have no history." "He could be allergic." " What do I do?" " We can't diagnose him while he screams." "Better than killing him with painkillers." "That" "Apparently he's not allergic." "Thank you." "I feel a lot better now." "We screwed up." "No." "You did exactly what his attending did." "And that was the proper way to handle the case?" "Yeah." "The guy used him as a dealer." "You're gonna see a lot of drug-seeking behavior in your practice." "There's a reason" " It works." "Meanwhile, back on the farm" "Yeah." "Timber rattlesnake." "Four vials of the CroFab antivenom." " Hey, how ya doin'?" " All right." "Thank you." "This will start making you feel better really fast." "He's having an allergic reaction." "Bag." "Paddles and epi." "His heart's fine." "It's not gonna stay that way." "Paddles!" "What say we take five, get some coffee, go pee." "You didn't think she was gonna get married?" "She asked me the same question." "And... what?" "You're not gonna treat him?" "There's probably nothing wrong with him." "Oh, sure, that makes sense." "She's just using the old sick husband routine... as an excuse to get back in touch with you." "You think this is easy for her?" "The only reason she'd be anywhere near you is if she was desperate." "So I should help her because she hates me?" "She doesn't hate you." "She loves you." "She just... can't stand to be around you." "Uh, Dr. House?" "It's been almost six minutes." "Found him." "The volleyball player... was responding to the anti-inflammatories as you'd expect in a case of tendinitis." "Whoa, whoa, whoa, whoa, whoa." "What about the snakebite guy?" "I don't really care about the volleyball player." "What if I told you the volleyball player had a sudden massive stroke?" " Really?" " No." "But that would make you interested, right?" "What if her T-4 came back low?" "It's not quite as interesting, but it has the benefit of being true." "You said the thyroid biopsy was a wasted test." "No, I didn't." "I said she put a person with tendinitis through an expensive and painful test." "Apparently, the patient had tendinitis and a thyroid condition." "We're gonna start you on thyroxine." "It'll make you feel better and level your moods." "Thank you." " So that's it?" " You were right the first time." "Snakebite guy's way more interesting." "Gross, actually." "The patient responded to epinephrine, and the allergic reaction was arrested." "Unfortunately, the patient continues to deteriorate." "Maybe the snake wrangler was wrong about the type we caught." "He faxed us the venom test." "Confirmed." "It's a timber rattlesnake." "No, it's not." "Notice the volume?" "I skimmed over that and the gender and the coloring." "Jumped right to the name of the snake." "Two hundred milligrams." "Our guy got bit less than four hours ago." "There's no way a snake regenerates that much venom that quickly." " We're supposed to know how fast snakes make their venom?" " No." "Unless you've got a patient bit by one." "Then it might be helpful." "So what do we do now?" "He must have been bitten by a different snake." "We go back and find it." "Or you go online, and you find there's only three poisonous snakes common in New Jersey:" "the copperhead, timber rattler and the coral." "Copperhead and timber rattler both respond to the antivenoms we gave the guy." " So we give him the antivenom for the other one?" " Is that a question?" "We can't just blindly give him another antivenom, especially after the first one almost killed him." "You said only three types of poisonous snakes commonly found in New Jersey." " Well, what if this is an uncommon one?" " Very good." " We gotta find the right snake." " No need." "Odds are by the time you get back, the autopsy results will tell you what kind of snake it was." " But you said" " So we do give him the antivenom for the other one?" "Again, was that a question?" "I asked what you would do." "It seems unfair for you to ask me what you would do." "Who gives the guy the other antivenom?" "And who goes looking for the snake?" "I assume that one choice kills him, the other one saves him." "That's usually the way it works at the leg-turning-black stage." "So half of us killed him, and half of us saved his life." " Yeah." " We can't be blamed for" "I'm sure this goes against everything you've been taught, but right and wrong do exist." "Just because you don't know what the right answer is-- maybe there's even no way you could know what the right answer is-- doesn't make your answer right or even okay." "It's much simpler than that." "It's just plain wrong." "We gave the guy the antivenom." "What if I'm allergic again?" "That's why these people are here." "If you have a reaction, we're ready to do whatever's necessary... to ensure your airways stay open and your heart keeps beating." "My wife's on her way in." "Can't this wait?" "I'm sorry." "It can't." "It hurts again." "He came back?" "On average, drug addicts are stupid." " I'd call the cops." " Good for you." "A lot of doctors wouldn't risk their careers on a hunch." "It's not a hunch." "I mean, I know he wants drugs." "Well, even drug addicts get sick." "Actually, for some reason, they tend to get sick more often than non-drug addicts." "Luckily, you don't have to play your hunch." "There's a faster way." "Actually, there are several." "My preference is urine testing." " But you already know he has drugs in his system." " That's not what I'm testing for." "We're gonna put this hard rubber tube up your urethra and into your bladder." " It may be a little uncomfortable." " Shouldn't I be getting some sort of anesthetic?" "We're concerned about allergic reactions today." "If the guy can handle a rod in his penis for half an hour, he's really sick." "Or he's really jonesing." "There's easier ways to get ahold of drugs." "Other hospitals, for example." "The volleyball player is not responding to treatment." "At least we think it's not working... on account of the fact that she's getting worse." " Can you still hear me?" " No." "A little!" "Not really!" "Well, if you can't hear me, how do you know what I asked?" " Ow!" " I'm sorry." "What did I do?" "I don't know." "It really hurts." "I promise to be very careful." " Susan" " Not her real name." "Susan, I barely touched you." "It hurts so much!" "I'm sorry." "I have to get this blood." "Just hold on." "Hypersensitivity to touch." " Her calcium up?" " Lab over 16." " Question is why." "Likely suspects." " Parathyroid adenoma." " Kidney problems." " Vit "D" intoxication." " Hyperthyroid." " Caused by our treatment?" " Whoa, whoa." "Can you please slow down?" "The adenoma is most likely." "Check her P.T.H., phosphorus... and ionized calcium." "And do a technetium sestamibi." "Okay, that's enough about the volleyball player." " What's up with the farmer?" " What farmer?" "Snakebite guy." "Oh, right." "You guys don't know about him." "He doesn't get bitten until three months after we treat the volleyball player." "Luckily, it's been well established that time is not a fixed construct." "His condition is not improving." "Double the dosage." " Already did." " There's another antivenom." " It's not as effective, but" " Already tried it." " The first stuff, the stuff he was allergic to." " Gave it to him with high-dose steroids." " Nothing's working." " What does it all mean?" " Wrong snake?" " We tried every other antivenom we had." " We're too late?" " Yep." "He's dying." "His wife's here." "Finally found a babysitter." "Who wants to let 'em know?" " Actually, I'm kidding." " He's not dying?" "Oh, yeah, he's dying." "But there's no wife and kid." "Which is great." "Makes the breaking-the-news thing way easier." "Oh, yeah." "One more piece of news." "The drug addict is peeing blood." "How do they teach you how to tell someone that they're dying?" "It's kind of like teaching architects how to explain why their building fell down." "Do you role-play and stuff?" "Yeah." "One of us gives the bad news, and one of us gets the bad news." "What do you have to do to get an "A" in You're Dying 101?" "They grade you on gentleness and supportiveness?" "Is there a scale for measuring compassion?" "This buddy of mine" "I gotta give him 10 bucks every time someone says thank you." "Imagine that." "This guy's so good, people thank him for telling 'em that they're dying." "Needs brown." "I don't get thanked that often." "You're dying." "In a few hours." "There's nothing we can do except deal with the pain." "Well, I need to go home." "You're not going home." "But my dog." "What will happen to my dog?" "Her neck looks clean." "No adenoma." "Wait, wait, wait." "The guy's dying, and all he cares about is his dog?" "Any of you guys go the dog route in your improv sessions?" "It's a basic truth of the human condition that everybody lies." "The only variable is about what." "The great thing about telling someone they're dying... is that it tends to focus their priorities." "You find out what matters to them." "What they're willing to die for." "What they're willing to lie for." "You must have a neighbor who-- Neighbors don't like him." "So the Humane Society will take him in and find him a home." "No, they won't." "Yeah, but maybe my aunt" "It wasn't a snakebite, was it?" "I said I don't remember bein' bit." "Sure you do." "Just not by a snake." "I assume that Cujo bit one of your neighbors a while back." "You tell me that he bit you, and I gotta report it." "Cujo's got a record." "He gets the chair." "The good news is you might just live." "The bad news is your dog's gonna die." "Guy risked his life to save this thing?" "I'll hold him." "You swab the mouth." "I think I've got a better grip here." "You go for the mouth." "All right." "I'm odds." "You serious?" "One, two, three!" "Damn." "I don't care if he's scratching your nads off, you don't let go." "Just do it!" "I say we let the guy die." " I got his head." "Just do it." " Got it." "What would you call that?" "It's tea-colored, right?" "The guy we thought was just after the drugs" "What's the differential diagnosis for urine that's tea-colored?" "Kidney stone." "Kidney stones would cause what?" " Blood in urine." " What color is your pee?" " Yellow." " What color is your blood?" " Red." " What colors did I use?" "Red, yellow and brown." " And brown." "What causes brown?" " Waste." " Which means the kidneys are shutting down." "Why?" " Trauma." " None that his history would indicate." " Could be damage done by the self-injection of the Demerol." " Treatment?" " Heat and rest" " Other possible causes?" " Infection." "Start him on antibiotics." "What else?" "Come on!" "Come on!" "I-I don't know." "You're useless." "But at least you know it." "Blood tests show elevated creatine kinase." " What does that tell you?" " The trauma diagnosis was right." " He takes it easy for a few days, he'll be fine." " You sure?" " The elevated C.K. rules out infection" " You know what's worse than useless?" "Useless and oblivious." "What are they missing?" "It's kind of hard to think when you're in our face like" "Yeah?" "You think it's gonna be easier when you got a real patient really dying?" "What are you missing?" "Muscle death." " Not your case." " Nothing wrong with a consult." "Dying muscle leaks myoglobin." "It's toxic to the kidneys." "Brilliant." "M.R.I. his leg." "See what's killing it." " Why is the girl getting the M.R.I.?" " Because the neck scan revealed nothing, and her doctor's way more obsessive than she thinks she is." " But you said the guy needed the M.R.I." " Because Dr. Cameron back there said muscle death." "Not one of you said it." "Not one of this guy's doctors said it." "They gave him bed rest and antibiotics, just like you guys would have." " Did he get better?" " No." " How long" " Three days." "It is in the nature of medicine that you are gonna screw up." "You are gonna kill someone." "If you can't handle that reality, pick another profession." "Or finish medical school and teach." "Three days before they thought it might have been muscle death?" "No, three days before the patient suggested it might have been muscle death." "The M.R.I. revealed an osteosarcoma." "A cancerous tumor on your femur." "It needs to be removed surgically." "With chemo, she has an excellent chance of survival." "But I have to warn you-- depending on how large the tumor is and how ingrained it is, the surgeon may need to amputate your leg." "I'm sorry." "It's okay." "Dogs' mouths are pretty filthy, but they have natural antibodies to fight off most of the stuff." "We don't." "That's why dog bites can be so nasty." "Lab tests of your dog's saliva revealed a type of strep bacteria." "It's commonly known as the flesh-eating disease." "We need to operate immediately to remove the damaged tissue." "We may need to remove the leg." "The M.R.I. revealed a problem." "No kidding." "I'm sorry none of your doctors found it earlier." "I am personally gonna oversee your treatment from now on." "You're gonna cut me open, aren't you?" "We may need to remove the leg." "His M.R.I. showed that the leg pain wasn't caused by the self-injection." "It wasn't caused by an infection." "It was an aneurysm that clotted... leading to an infarction." "My God, you were right." "It's House." "We have to do the surgery." "The necrotic tissue has to be removed." "If there's too much" "I don't care what you find." "It may become necessary in order to save your life." "I like my leg." "I've had it for as long as I can remember." "Greg, I love your leg as much as you do." "They're not cutting it off." "The patient made the right choice." "Tell a surgeon that it's okay to cut a leg off, and he's gonna spend the night polishing his good hacksaw." "Right." "Surgeons could care less about saving limbs." "Ofcourse they care about their patients." "They just care about themselves more, which is not an unreasonable position." "Trying to maximize the tissue you save... also maximizes the chances of something going wrong, which means you've gotta be extra careful, which is such a pain in the ass." "Amazing advances have been made." "Kids with prosthetic legs... are running the hundred-meter dash in 12 seconds." "Yeah, they're just not as pretty." "Do a bypass." "Restore the circulation." " Amputation is safer." " For you or me?" " The blockage of blood flow" " Four-day blockage." "Yes." "It caused muscle cell death." "When those cells die, they release cytokines and potassium." "And if you restore the blood flow instead of just lopping it all off, then all that crap gets washed back into my system." "The cytokines could cause organ failure." "The potassium could cause cardiac arrest." "On the other hand, I may just get the use of my leg back." "The postoperative pain alone will-- I'll get through it." "I understand the risks." "You're in the clear." "Go schedule an O.R." " God, you're an idiot." " I think I'm more of a jerk." "I'm not being glib, and I'm not being cute." "I don't want you to kill yourself." "I'm not gonna die." "Oh, I feel completely reassured." "More suction." "Inserting now." "They gotta up the morphine." " Doctors say they can't." " Doctors recommended bed rest and antibiotics." " They screwed up." "It doesn't mean they're wrong this time." " Sure doesn't mean they're right." " Morphine will kill you." " I can handle it." " You're in pain." "You're not thinking right." " That's why I need the damn morphine!" "I'll talk to them." "Oh, my God." "How much longer is the pain gonna last?" "It depends on how much muscle cell death there was." "He could be right." "He could come out of this with almost full use of his leg." "Or?" "He could be in pain for the rest of his life." "There's a third option..." "surgically." "A middle ground between what we did and amputation." "He's not big on middle ground." "Yeah." "Nurse?" "Nurse!" " I need more calcium gluconate." " You just had five m.l.'s." "The Q.R.S. is getting wider." "My potassium is rising." " I'll talk to your doctor." " Well, you better make it fast, 'cause I'm about to go into cardiac arrest." "You give me the dose, or I go into wide complex tachycardia." " I could get in trouble" " Listen, it's not a narcotic!" "I'm not looking for a buzz." "You got about 20 seconds." "I was wrong." "What do you got?" "Wide complex tachycardia." "You diagnosed-- He did." "Defibrillator." "Paddles." "Charge." "Clear." "The patient was technically dead for over a minute." "He's back." "Do you think he was dead?" "Do you think those experiences were real?" "Define "real"." "They were real experiences." "What they meant" "Personally, I choose to believe that the white light people sometimes see, the visions this patient saw, they're all just chemical reactions that take place while the brain shuts down." " You choose to believe that?" " There's no conclusive science." "My choice has no practical relevance to my life." "I choose the outcome I find more comforting." "You find it more comforting to believe that this is it?" "I find it more comforting to believe that this... isn't simply a test." "How bad is the pain right now?" "It's bad." "It's not getting any better." "If you were right, the pain would be subsiding." "You'd be getting better." "It's just taking longer." "No, it's not." "We've gotta let 'em cut the leg off." "It's my leg." "It's my life." "Would you give up your leg to save my life?" "Ofcourse I would." "Why do you think your life is worth less than mine?" "If this were any other patient, what would you tell them to do?" "I would say it's their choice." "Not a chance." "You'd browbeat them until they made the choice you knew was right." "You'd shove it in their face that it's just a damn leg." "You don't think you deserve to live?" "You don't think you deserve to be happy?" "Now let them cut off your leg." "I can't." "I can't." "I'm sorry." "The pain alone is gonna kill you." "I know." "I know." "I need you to talk to the doctor." "He change his mind?" "No." "He's asked to be put in a chemically induced coma... so that he can sleep through the worst part of the pain." "We can do that." "What happens after he's in the coma?" "We'll obviously monitor his condition closely, and if he can get through the next 48 hours without another cardiac incident" "I meant, I'm his health care proxy." "I get to make medical decisions for him if he's not able to." "You should talk to him about what he wants to do." "I know what he wants." "But if he's out, it's my call, right?" "You'll be out in less than a minute." "Thank you." " Hey." " Hey." "I'll see you when I wake up." "We'll go golfing." "I love you." "I love you too." "I'm sorry." "You've got nothing to be sorry about." "The middle ground you were talking about" "We go in, take out the dead muscle." "There's still some risk of reperfusion injury, but" "Give me the forms you need signed." "You're saving his life." "He won't see it that way." "Because of the extent of the muscle removed, the utility of the patient's leg was severely compromised." "Because of the time delay in making the diagnosis, the patient continues to experience chronic pain." "She had no right to do that." " She had the proxy." " She knew he didn't want the surgery." " She saved his life." " We don't know that." "Maybe he would've been fine." " It doesn't matter." "It's the patient's call." " The patient's an idiot." "They usually are." "Do you have a buzzer or something?" "What time does this class end?" "Twenty minutes ago." "I'm not doing this again." "And this guy is not the world's greatest dad." "Not even ranked." "Who the hell lets their kids play with lead-based paint?" "That's why he's always sick." "Find him some plastic cups, and the class is all his again." "Stacy, it's Greg." "I've got an opening in my calendar for 10:00 tomorrow morning." "Make sure your husband isn't late."