The human heart is a giant muscle
squeezing or contracting over 60 times each minute.
That's 3,600...
At this point, your blood is a deep purple
because it's just finished dropping off oxygen
for all the parts of your body.
Come on, follow me.
Come on.
Ian.
I have a question and I need to go to the bathroom.
Which would you like to do first?
The question.
- Okay. - Where's the bathroom?
Who knows where the bathroom is?
I do.
Go with Ian to the bathroom.
I don't have to go.
We're not at school, nobody goes anywhere by themselves.
- Why? - In case you get lost.
Or in case somebody kidnaps us.
If somebody kidnaps Ian, they'll kidnap me, too.
I want to stay with the class.
Michael, go with Ian...
Do you need help?
I need you to find a grown-up.
Is the baby coming?
- Who should I take with me? - You're fine.
Go to the front desk or find a security guard.
I really have to pee.
Oh, God.
Is the baby coming? I don't know how to do this.
Are you okay, Ian?
Yeah. Sure.
I don't think you are.
You're bleeding.
Help!
- $20. - Call.
You'll call anything.
My stack is bigger than your stack.
You in or out?
You know that relative to their size,
gorillas have smaller testicles than humans.
Well, then you'd probably have an edge over a gorilla, but not over me.
Reason is, primate testes' size
inversely corresponds to the fidelity of our females.
You think there might be a better time to annoy me about my wife?
- I'm talking about poker. - Right.
Women are evil, you're right to drive them away.
Call, fold or raise. Story time can wait.
We're smaller and better than chimps,
bigger and worse than gorillas.
For all our rationality,
our supposed trust and fealty to a higher power,
our ability to create a system of rules and laws,
our baser drives are more powerful than any of that.
We want to control our emotions, but we can't.
If we're happy, things don't annoy us.
If, on the other hand, we're sitting on crappy hole cards,
little tiny things annoy us a whole lot more.
I raise.
So, are you gonna tell me an annoying story every time I raise?
God, that would be annoying.
I call.
Dr. Cuddy, I got one of your patients in the ER.
Ian Alston, six-years-old.
Oh, I know him. What's the problem? I'm all in.
Bloody diarrhea. Hemodynamically stable,
but he's been developing some coordination problems.
It sounds like gastroenteritis and dehydration.
Order fluids and I'll take it on my service.
Bet's to you, House.
- They scan his head? - No, why would they scan...
Don't play games. You gonna call?
- How's the heart rate? - Stable.
I'm sorry. House, it's gastroenteritis. I'm not going anywhere.
Put the order in,
and have someone tell Alan and Sarah that I'll be up when I'm done.
You in or out?
I'm out.
Stone cold bluff.
You might want to spend a little more time paying attention to your cards
and a little less time staring at my breasts.
They don't match either.
I'm gonna take some air.
Follow my finger with your eyes.
How much longer will Dr. Cuddy be?
Well, given the number of Mojitos she's knocking back at the party,
I'd say it's gonna be at least three hours before she's even conscious.
Weren't you at the same party?
I don't drink.
I want you to reach out and grab my cane.
What's wrong?
Your son's brain is losing control of his muscles.
Dr. Cuddy's message said it was just dehydration from diarrhea.
She's wrong.
Is he gonna be all right?
I don't know.
So, were you in one of those cages?
No. No, no, no, no. No, those are for tourists.
You were in the water with the great white?
Sure, it's no big deal. You just have to keep an eye on them.
If they get too close, punch them in the nose.
Send them on their way.
I had you going.
You are mean.
Hey. How's that anal fissure?
Did it heal yet? Or is it still draining?
Oh, I'm sorry.
I didn't realize you'd come back for seconds.
I figured that after that girl in the stairwell you'd be done for the night.
He's joking.
No Adam's apple, small hands.
It's no surprises this time.
I'll see you later.
Got a case.
Well, you could've just said that.
You didn't have to screw with me.
If I didn't screw with you,
you'd spent the whole night thinking you might get laid,
which means you'd be useless. Better to extinguish all hope.
Get Foreman and Cameron and meet me upstairs. Stat.
What's so urgent?
Two cases, same symptoms.
What do six-year-olds and 70-year-olds have in common?
Their immune systems don't work as well.
- Could be listeria. - I already checked for that.
Leukemia has a higher prevalence in both young and old.
- So does asthma. - No, no, no.
They can both get diabetes.
No!
The nearly dead and the newly bred
have more in common with each other than with people in the middle.
It's weird. It's kind of a circle of life thing.
- This kid doesn't have kidney failure. - He will.
Based on this file, the kid just ate some bad food.
Was the old man...
They were nowhere near each other in any of the four dimensions.
- This case is 12 years old. - Yep.
And this case is Cuddy's.
She assigned it to me.
She agrees with you that this is something more than gastroenteritis?
She wouldn't have assigned it to me if she didn't, would she?
What were we talking about?
Two patients with two symptoms in common.
And five symptoms not in common.
While you were all wearing your "Frankie Says Relax" t-shirts,
I was treating a 73-year-old woman
who went through this progression of symptoms.
The last of which was...
And in case any of you missed that class in med school,
that one's untreatable.
Kid's got the first two.
It took Ester an hour and 20 minutes to go from two to three.
And less than a day to make it all the way to the rear exit.
This is all because a child has some blood in his diarrhea?
He's got a tummy ache.
If there was any reason to think it was anything worse,
Cuddy would be all over it.
Great. Do a colonoscopy.
On a six-year-old kid who probably has nothing worse than some food poisoning?
And if you happen to find any purple papules,
do me a favor and grab a slice.
I wanna check for Erdheim-Chester.
A disease that there have been, what, maybe 200 reported cases of ever?
If Ester's family had let me do an autopsy, there'd be 201.
See anything?
No, and I don't expect to.
House usually avoids cases.
If he's actually stealing a case from Cuddy, there's gotta be a reason.
It's not the first time I've seen this file.
About a month before Cameron was hired,
some trucker came in here with these symptoms.
House decided he was dying.
Two days and a spinal tap,
bone marrow extraction, and three colonoscopies later,
we send the guy home with a bunch of painkillers
and a diagnosis of a bad cheese sandwich.
One of the guys who worked here before me
said House tried to cure Ester at least three other times.
You know how people see the Virgin Mary in danishes and stuff?
Someone died 12 years ago and House doesn't know why.
House sees that case now in paint peeling,
in clouds, and now in this poor kid.
Erdheim-Chester is an abnormal growth of some of the cells that fight infection.
Is that cancer? Cos he seems okay now.
The other doctor kind of scared us about that.
He shouldn't have. We're just testing. It'll probably be negative.
I don't understand.
You don't think that's what it is but you want to do this thing to him anyway?
- We need to be sure. - Isn't there any other way?
It shouldn't take long.
All right.
Those ridges look a lot like purple papules.
They're not purple. They're red. Probably just blood blisters.
Give me the biopsy needle.
- How long is this gonna take? - Forget it, Chase.
Your punching out the shark story's good, but she's not waiting for you.
So?
We couldn't confirm the source of the bleeding,
but we did biopsy some...
- Blood blisters. - You mean papules.
Come on, Cameron. Who's right?
Chase is. Negative for Erdheim-Chester.
Let me see.
If it's not Erdheim-Chester...
It's exactly what we said before, a garden-variety viral gastroenteritis.
Can we go back to the party?
Do a kidney biopsy.
Ester's shut down in exactly...
This kid is not Ester.
You screwed up. She died. I'm sorry.
But that does not mean this kid is dying as well.
Jeez, you're testy when you don't get any fuzz. Come on.
What'd the test say?
Colonoscopy was clean.
And the biopsy was negative for Erdheim-Chester.
So Ian's going to be all right? It was just some sort of virus.
What's that?
Urine.
Yeah, but it's brown.
Ian's kidneys are shutting down.
Still think it's not the same case?
So, what can cause bloody diarrhea,
ataxia and kidney failure?
- I'll go do a biopsy. - Forget it!
That battle's over.
His rising creatinine is his kidneys' way of saying,
"Go on without me."
What explains everything?
E. coli HO-157 causes bloody diarrhea
and leads to Hemolytic-uremic Syndrome.
Toxins from the bacteria cause his kidneys to shut down.
We should start him on plasmapheresis.
Clear, concise and completely plausible.
And exactly what I did last time. Didn't work.
- What else? - Goodpasture's Syndrome.
Circulating antibodies cause kidney failure and bleeding.
But not the purple papules.
If you throw in Ester's next symptom,
brain, makes me think heavy metal toxicity.
His hematocrit would have to be low. It's at 44,
and Ester's never dropped below...
- 42. - You have the file memorized?
It's my lucky number.
What about lymphoma?
Causes kidney failure, GI bleed, and can infiltrate the base of the brain.
You check Ester for that?
She never showed any signs of...
If he has lymphoma this far advanced,
we should be able to see it in his blood and brain.
Chase, run a blood smear and immunochemistries.
Foreman, get an MRI.
- I'll page Cuddy. - No, you won't.
She thinks the kid has a stomachache.
Then she'll come right up here and do one of two things.
If she agrees with me, I don't need her. If she disagrees, I don't want her.
Can't handle people disagreeing with you?
She might have a different take on this.
Subordinates can disagree with me all they want. It's healthy.
People who can shut me down on the other hand...
Forget Cuddy. I'll have Wilson keep her busy.
Keep your answers short and discreet. Is Cuddy still playing?
The chicken is still in Piccadilly Square.
Brilliant. She'll never suspect that Normandy is our target.
Is that House?
Tell him that the blinds just went to 20-40 and he's running out of chips.
- How's she doing? - What's going on?
The way you took off, something's obviously...
Love to chat but got a game to play. How's she doing?
The patient is on life support. We're about to pull the plug.
Are you talking about me?
What've you got?
Those sounds like high-dose cardio meds.
Two hearts.
You got the flush?
Still waiting on the final labs.
Is she drinking her seltzer?
No, hydration is not a problem.
She's bluffing. Push her all in.
Call.
Two pair. Show me your hearts.
Seven of clubs.
Oh, dear. Sounds like I messed up.
You're gonna be stuck with her for a while.
Talk to you soon.
Oh, yes!
Why are you taking a picture of his head?
We're looking for lymphoma, but...
So, it's not Erdheim-something and it's not his kidneys,
but his kidneys are failing.
Where's Dr. Cuddy?
Dr. House mentioned another case.
Is there another patient with the same thing that Ian has?
- Not exactly. - What does that mean?
Dr. House had a patient a while back
who exhibited the same symptoms as your son.
- Then you know what's wrong? - No.
So what do you know?
We know the likely course the disease will take.
Which is?
She had multiple system failures affecting...
What happened to her?
She died 24 hours after her admission.
Mr. or Mrs. Alston, would you mind giving me a hand?
He's having trouble sitting still.
It's impossible to get the detail we need.
So I figured he might feel more comfortable hearing your voices.
Ian, honey.
Just sit still. They'll be done in a moment. We're here with you.
I'm scared.
It's okay, honey. It's...
It's only a big camera. It's gonna take a picture of your head.
You love it when I take your picture at home, don't you?
Yeah.
And you have to hold still for that, too, right?
But this isn't like that.
I know it's scary, Ian, but you can do it.
You're getting to be so grown-up.
So just hold perfectly still, just for a little bit.
Mommy, are you crying?
No. No, honey, I'm just tired.
Okay. I'll try.
The base of his brain's been infiltrated by a small mass. We think...
- Pituitary? - Looks that way.
Explains the low blood pressure.
And pretty much confirms the lymphoma.
If we'd started Ester on prednisone...
Did anyone see the lymphoma?
No, we saw a mass. The location is consistent with...
Didn't see any in the blood either.
White blood cells show no spindling or abnormal nuclei.
Nothing on immunochemistries either. It's not lymphoma.
House!
It's a train.
- We don't know what kind of train... - Whoa. Whoa. Whoa.
- I'm thirsty. - It's closed.
It's not now.
We got one advantage. We know where the tracks are going.
The fact that the end of the line is death is an advantage?
The fact that we know is an advantage.
It means maybe we can get ahead of it.
Next station is the liver.
We got about 90 minutes before it gets there.
Maybe we can cut down a tree across the line just outside of town.
I'll do an ultrasound.
No, treatment will tell us more, faster.
How can we start treatment if we have no idea what we're treating for?
Treat him for everything.
Give him acetylcysteine, and interferon, and silymarin,
and whatever else you can think of to protect the liver.
What's going on?
Oh, just catching up on some TV. How're you doing?
Well, thanks to your last consult, the patient has improved dramatically.
Tell House the patient is about to kill the doctor.
- She says the patient... - I heard.
- What've you got? - Well, Cuddy just raised and...
- You're paired. - What?
Nines.
How do you know?
Anything lower, you wouldn't sound so excited.
Jacks or higher,
your voice sounds like Debbie from accounting is sitting in your lap.
Ask Cuddy if she can beat a pair of threes.
What's going on? If you're gonna mess with me,
wouldn't it be more fun to do it in person?
Yes, it would.
Can you beat a pair of threes?
What'd she do?
I left orders for PO fluids, Doctor.
Enough with the codes. She obviously knows it's me.
She's drinking her seltzer.
Did she stop?
- Yes. - Go all in.
- But... - Just do it.
You couldn't care less about this charity event.
You claim not to be messing with me.
You're either trying to keep me...
Shut up.
Look, last time I wanted the game to go on. I still do.
It means that this time you get to win.
Hold on.
I fold.
House, are you sure you're okay?
Meds seem to be working. Liver's holding its own.
Good.
- But the platelets are dropping. - Even better.
Why? It means he's getting sicker.
It's new. New is good.
Because old ended in death.
I can't breathe.
Chase!
What's happening?
Ian, come on.
Honey, just relax.
Ian, breathe. Come on, honey. Please.
Please, honey.
We had to put him on a ventilator.
He's back on Ester's path
and we managed to make the train skip a few stations.
Which means that instead of 12 hours, he's probably got less than two.
Which begs the question, why? What did we do?
Acetylcysteine could mess with the lungs.
Mess with them, not shut them down in 20 minutes.
Interferon modulates the immune system.
It could affect a cancer of the blood, like one of the leukemias.
It doesn't speed them up. It slows them down.
It slows down all 500 of them?
Anybody know where we can find an oncologist at this hour?
What effects would interferon have on leukemia?
Depends on what type. Could make it better. Could make it worse.
A four-year fellowship to learn that.
Tell House if he wants to play cards,
he can get his ass back down here and play.
You hear that. She wants me off the phone.
Means she's vulnerable. Go all in.
But the party's over in less than three hours.
It's over in less than two hours,
which means you either have
three of a kind or just threes.
I'm guessing threes.
I bet $500.
- Go all in. - You obviously want to bust me.
Why would you...
Either you go all in,
or I tell everybody in the building that you wear toenail polish.
I'm all in.
I'll call.
I'm betting you have a pair of threes,
but even if you have three,
it's not gonna beat trip nines.
Oh! Oh! Oh, no!
Oh, no! Oh! Oh, that's gotta hurt.
What happened?
I just killed two birds with one straight.
Goodbye.
Fine, keep playing. But I need you to recommend a good oncologist
because if I don't get one up here in the next few minutes,
I got a dead six-year-old.
If you need help, ask. These games are insane.
The games have a higher success rate.
Well, I don't see anything that looks like leukemia.
- You do a bone marrow biopsy? - No time.
Even if there is an occult blood cancer,
you wouldn't expect interferon to make it worse.
Certainly not this fast.
- What would move this fast? - Autoimmune diseases.
If his body's own defenses are attacking him,
beefing them up is just gonna put fuel on the fire.
Sarcoidosis could be in his brain and lungs.
No. No enlarged hilar lymph nodes on his chest x-ray.
The systemic nature suggests Juvenile Rheumatoid Arthritis.
Or Kawasaki's Disease.
Can't be Kawasaki's.
That doesn't affect the elderly.
This is a kid's x-ray?
House had another patient.
Who may or may not have had Kawasaki's.
This kid on the other hand,
he makes antibodies that are eating the inside of his arteries,
choking off blood to his major organs, one by one.
First the GI tract, then the kidneys, then the brain, now the lungs.
Can anyone think of a reason why Kawasaki's can't affect the elderly,
other than that it doesn't? Nice.
We can confirm with blood work.
We need an ANA, sed rate...
Labs will take two hours.
What was the old lady's sed rate?
Elevated, 98.
You can't use another patient's labs to diagnosis Kawasaki's disease.
Is that like a dare or something?
You don't have time to be wrong.
Fine. We'll look for Kawasaki where he lives,
Ian's coronary arteries.
This other patient,
the old lady, Ester?
Have you read Moby Dick?
It was a book?
- It was ten years ago. - Twelve.
Obsession is dangerous.
Only if you're on a wooden ship, and your obsession is a whale.
I think I'm in the clear.
You do realize it's a metaphor.
You realize the point of metaphors is to scare people from doing things
by telling them that something much scarier is gonna happen
than what will really happen.
God, I wish I had a metaphor to explain that better.
Go back to the game. Don't worry, I'm not gonna get eaten by witches.
Coronary arteries clear. No aneurysms.
Flip the mode. Let's see the flow.
How did that other woman die?
She went into respiratory distress.
- Her heart and liver were already... - No.
Did she suffer?
Was she in pain?
I don't know.
Laminar flow. No blood clots, no ragged edges.
Damn. Shut it down. We're just wasting time.
Look at the right atrium.
- That's not Kawasaki's. - No.
It's small, but it's there.
Ester didn't have a mass in her heart.
Ian's younger. He can take more of a pounding.
Ester died before the disease reached her heart.
The disease made a mass and made it fast.
- Could be bacteria. - Muscle.
Connective tissue.
The kid can't take any more theories.
Only thing we know is that whatever that mass is,
that's what he's got.
We need a piece of it. I'm doing a biopsy.
I'll shut the blinds.
No, let them watch.
I do my best work on the big stage.
Passing through the superior vena cava.
You're in the atrium. Pull back.
You've hit the wall of the heart.
These procedures would be so much simpler
if you could do them on healthy people.
And out again.
- V-fib. - Cardiac arrest.
Call a code.
Come on, paddles!
- Come on. - Charge.
Clear!
Code blue, ISO room.
And again.
- Nothing. - Again.
You got a clock on this?
How much longer you gonna keep doing this?
Clear.
Wait. I've got something.
He's back.
- What are you doing? - I'm doing what we came here to do.
- It almost killed him. - I know. I was right here.
I need a Vacutainer.
His brain's been oxygen deprived for over eight minutes.
There might be nothing left. He might...
Tell the parents. Where the hell is that Vacutainer?
- So, what's he got? - Brain damage.
Good chance. I was talking about before that.
- You're not worried about... - Things I can't do anything about?
- I try not to. - Yeah.
Things just roll off you like water off a duck.
Histiocytosis.
Very unlikely in a 73-year-old.
Whatever this is, it's very unlikely.
Come on. More ideas. Let's go, people.
Genetic disorders could cause masses everywhere. Tuberous sclerosis.
If it's genetic, he's had it all his life.
- Why now? - I don't know.
It sure fits nice enough.
We haven't ruled out leukemia yet.
Or sarcoma. He could have multiple soft tissue tumors.
Or sarcoidosis.
Multiple neurofibromatosis.
Chondrocytomas.
How's it going? You win?
I got called away by the angry parents of a patient.
There are three of you here.
None of you had the sense to stop him, to pick up a phone and call me.
I told them you'd signed off.
The parents are mad because their kid is dying.
It's understandable.
But if he doesn't die, they won't be mad anymore.
If he's brain damaged, they might still be a little ticked.
Had to do it to save him.
You had to do it to diagnose Ester.
You may have killed a six-year-old
because you're obsessed with a woman who's been dead for 12 years.
Sometimes you lose, House! You're not God!
He's not dead yet.
No, but you're done with him.
It's my case now. Go home. Go ride your motorcycle.
Go brood in a dark room. Just don't go near Ian again.
So, anything else or is it just these seven?
Drop it, House. She's right.
No, she's not!
- You know she's not. - We should have called her.
I'm surprised you didn't.
You're gonna have to find a way to let this go.
We can't go near Ian.
We don't need to go near him.
We have his tumor.
Well, Cuddy may be right that we screwed up the protocol.
She may be right about my screwed up obsession.
But I'm right about the medicine.
How many tests can we do with that?
Look, we cure the kid, we solve everybody's problems.
How many?
Maybe two good pieces.
How many okay pieces?
Three would be pushing it.
Three tests, seven choices.
Okay, what's first?
Sarcoidosis seems most likely.
Yeah. So likely that Cuddy's gonna think of that all on her own.
She's got the kid's whole body to play with. Let her do that test.
What's next?
It's moving too fast to be spreading.
It has to be growing from something that's already there.
Genetic disorder. Tuberous sclerosis.
Or it's his immune system. Histiocytosis.
Well, there are more documented cases of Histio amongst older people
than tuberous sclerosis. Let's start with that.
Wing or drumstick?
Gonna need a little more than that.
A little more is more than a third.
If we have to repeat this test because you didn't cut us enough...
I'm adding one micro liter of the immunoperoxidase.
Make it two. I don't want House biting off our heads
because we weren't sure if it turned red or not.
That's definitely not red.
The problem could still be an abnormal cell growth
but a different cell line.
Sarcoma? Muscle cells are throughout his body.
It would explain the geography.
Genetic disorder is far more likely in a six-year-old. Tuberous sclerosis.
Pretty unlikely to cause a GI bleed.
The time course fits.
Mr. Foreman, you agree with both of them? Thanks for playing.
If we have enough tissue for two tests, why not do both?
Then we don't have to think as hard.
Taking the pressure off the choice makes us less likely to think critically.
Sarcoma is more likely to hit a six and 70-year-old.
Tuberous sclerosis, it is.
You think sarcoma is less likely?
It's more likely.
The test for it, on the other hand, is less reliable.
Test is negative. Well, that's okay.
If the tumor cells hadn't matured, the Ki-67 protein wouldn't have turned off.
- What happens if we don't solve this? - Kid dies.
I mean for the next 12 years.
Ki-67's negative.
And PCH antigen is negative.
Mighty Casey's down to his last strike.
Mighty Casey struck out.
Thanks a lot. I was gonna read that this weekend.
Chondrocytoma. Connective tissue's been in all the places we've been looking.
The kid is too sick for that. We're better off testing for sarcoma.
We would've seen signs of that when we tested for tuberous sclerosis.
The tumor cells looked like muscle under the microscope.
No, they didn't. They looked like fat.
I vote for neurofibromatosis.
- Why? - Because the other choices suck worse.
Give me a minute.
You want me out of here?
You come up with anything?
No.
Hey. We can talk about it tomorrow.
I...
I won the poker tournament.
I totally played this guy, Berman, from business affairs.
I got great cards. But I don't bet. Just call, no raises.
Berman pairs his king on the flop.
I keep calling, the river turns,
I check. He can't stand it.
He goes all in. He's sure he's won.
I call, I flip them.
Pocket aces.
I nailed his ass.
The aces were hiding all along.
Test him for Erdheim-Chester disease.
Erdheim-Chester? That's not even on the list.
Because we already did it. He tested negative.
- So did Ester. - The disease lied.
Yeah, the tumor's got it in for you. Diseases don't lie.
Fine, it didn't lie. It slow played us.
We biopsied the colon, it hadn't reached the GI tract yet.
It's there now. It's in his liver, his lungs.
You want it to be there.
Because then you didn't screw up 12 years ago.
We can't waste our one test on the one disease we know it's not.
Run the test.
You sure about this?
Wait. Let me think about that. Don't pressure me.
Just run the damn test.
Cells look like macrophages.
That's a good start.
Take your time, and say it loud.
CD 68 positive.
Start the treatment.
So, Ester can rest peaceful now, huh?
Yeah.
$40.
You got lucky.
You gonna call?
What I do
is not just based on the flip of a card.
You guessed. You got lucky.
It fit.
It could just as easily have been sarcoma or tuberous sclerosis.
No, not just as easily.
Maybe not. But it wasn't impossible.
Are you gonna call?
You know, relative to its size,
the barnacle has the largest penis of any animal.