Chapter 44: Racing Heartbeat, Cardiac Arrest
Seeing the Sister's condition, House immediately grabbed a stethoscope and began auscultation.
After hearing the heart sounds, House quickly assessed:
"You're having an asthma attack. Try to relax."
Then, while rolling up the Sister's sleeve, House turned to David:
"Get me point-one milligrams epinephrine. I need to inject her to open her airways."
With the epinephrine injection, the Sister's asthma clearly improved.
House's expression immediately relaxed:
"Likely an allergic reaction. I'll switch her to steroids to prevent recurrence.
Sister, feeling better?"
The latter question was directed at Sister Augustine, who replied breathlessly:
"Much better, but my heart feels strange now. Is that normal?"
House nodded:
"Epinephrine naturally accelerates your heart rate. Completely normal."
Just then, Sister Augustine's face became increasingly flushed.
Seeing this abnormality, David—who'd been observing—suddenly placed his fingers on Sister Augustine's wrist and said to House with grave expression:
"Something's wrong. Her heart's racing."
House, also sensing the abnormality, checked the pulse himself and quickly said:
"Heart rate's definitely too high. Get the crash cart. We might need CPR!"
Just as David retrieved the defibrillator, Sister Augustine had lost consciousness and collapsed.
House was performing emergency chest compressions, but clearly this level of intervention wasn't sufficient to save Sister Augustine.
Without awaiting House's instruction, David had already charged the defibrillator.
Then House opened the Sister's habit and began electrical cardioversion on her chest.
David, managing the defibrillator nearby, wasn't distracted but instead keenly noticed the Sister also had a skunk tattooed on her left shoulder.
Soon, under defibrillation, Sister Augustine's heart was stimulated by the shock and began beating strongly again.
House wiped cold sweat from his forehead and instructed David:
"Admit her, then come to the Diagnostics conference room for differential."
David nodded and began admission arrangements.
By the time David returned to Diagnostics, the atmosphere was tense.
Foreman was standing before House, confronting him. Apparently they'd just argued about diagnosis.
As soon as Foreman spotted David, he immediately sneered:
"I told you not to trust him.
That drawer contained point-one milligram and one milligram epinephrine vials.
This kid must've made a mistake and handed you the one milligram dose, which caused cardiac arrest!
For this incident, Wells must bear primary responsibility!"
Hearing Foreman attempting to shift blame onto David, House frowned:
"No. The Sister likely has cardiac history, which the epinephrine exacerbated.
This has nothing to do with David."
Foreman raised the chart:
"But the medical record never indicated cardiac history!
Everyone makes mistakes, and a newcomer's error probability is only higher!
If you continue employing Wells, I'm definitely reporting this to the medical board!"
Observing the aggressive Foreman, Cameron was first to intervene:
"Foreman! This already happened. Shouldn't we focus on treating Sister Augustine?
Arguing about this pointless matter only delays her care.
I think the reason for Sister Augustine's dermatitis might be skin infection—cellulitis or similar—which can also cause tachycardia symptoms.
Moreover, she has no fever, her CBC doesn't indicate infection, but her eosinophils are slightly elevated with mildly increased ESR.
I think this is systemic allergic reaction."
Cameron's words successfully redirected from David to the patient.
House also didn't intend entanglement with Foreman over David's alleged error:
"Not allergy. Allergy wouldn't cause cardiac arrest like this. Possibly vasculitis—Churg-Strauss syndrome.
Blood vessel inflammation in heart, lungs, and skin leads to asthma, rash, and cardiac problems.
This explains all symptoms, so nothing to do with epinephrine dosage.
Give her chest CT and high-dose dexamethasone, forty milligrams TID."
Foreman shook his head and directly challenged House's diagnosis:
"She presented with rash, but now you're diagnosing symptoms caused by forced excessive epinephrine as Churg-Strauss?
I think you're covering for Wells's mistake.
I don't understand why you're willing to risk a patient's life protecting an intern.
Even after five years treatment, Churg-Strauss survival rate is only 62%!
Are you genuinely certain she has Churg-Strauss?"
Just as House was about to respond, David spoke first.
"I also don't think she has Churg-Strauss syndrome."
Hearing David actually agreed with his assessment, Foreman was instantly shocked.
He was arguing to ruin David's medical career.
This kid actually agreed with him? What was his angle?
While Foreman reeled, David continued:
"I noticed when she took diphenhydramine, she didn't use our provided water.
Instead, she used tea they'd brought. As far as I know, many herbal teas have stimulant properties.
They often achieve stimulating effects by increasing lung capacity, elevating blood pressure, and accelerating heart rate.
When we administered point-one milligrams epinephrine with identical effects, it caused tachycardia, leading to cardiac arrest."
Clap, clap, clap.
Applause sounded.
House looked over with approval:
"Excellent deduction. You're genuinely observant, kid.
If your reasoning's correct, she wouldn't have Churg-Strauss, but rather the systemic allergy Cameron mentioned.
So, Foreman, did you hear David's deduction clearly?"
At this proximity, Foreman naturally heard David's words clearly.
He finally understood why David had agreed moments ago.
Turns out David had determined Sister Augustine's cardiac arrest had nothing to do with epinephrine dosage.
Instead, regardless of dosage, any epinephrine at that moment would've inevitably caused cardiac arrest!
But until they actually examined the tea, this remained speculation!
So Foreman still argued stubbornly:
"I heard clearly, but I disagree. Tea can have various effects.
How do you know their tea has stimulant properties? Maybe it's just calming chamomile?"
Seeing Foreman's continued obstinance, even Chase couldn't tolerate it.
He proactively offered:
"Then I'll make the trip. Whether cardiac arrest was caused by excessive epinephrine dose is critical for subsequent diagnosis.
We need to rule this out first. Wait for me—I'll be right back."
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