Chapter 7: Differential

The next morning Susan was able to provide a list of the various bacterial and viral contaminates from the specimens Thirteen and Taub had brought to her. All of them were ruled out for one reason or another. She had not been able to find evidence of any toxins from the material either. Dr. Taub didn't seem impressed by her contributions, but she ignored his inference. She stared at the chemistry report in front of her. She knew what it said because it was her report and knew the doctors should be seeing something. While the doctors were contemplating several options for what was ailing their patient, Dr. House noted the expression on her face. "Spit it out Susan," he said

"Does the low potassium level mean anything?" Susan asked.

Dr. Chase replied, "The potassium level is normal."

"It shouldn't be," said Susan.

"Why?" asked Dr. Taub.

Dr. Foreman saw what Susan was referring to, "The specimen was grossly hemolyzed. The potassium levels should be high, but they're not. That means the patient has low potassium levels"

Dr. House said, "Good catch, but unfortunately it's not related. The potassium imbalance is due to the nausea the patient is experiencing. Thirteen, go hang a banana bag to get her electrolytes back in balance."

As Thirteen left the room, Dr. House continued. "The potassium may not mean anything, but we do have another symptom, hemolysis."

"Not necessarily," offered Susan. "There are several causes of hemolysis other than symptomatic ones. You need to rule out technique issues. Who pulled the blood?"

"Thirteen," offered Dr. Chase. "She said the patient was a hard stick."

"Then it's possible that the hemolysis is caused from technique," Susan said. Dr. Taub looked at Susan with disdain, it was obvious that he didn't appreciate Susan's presence, though Susan wasn't sure why. "I'm not saying she's a bad stick," Susan continued, "I'm saying that if the patient was a hard stick, then it's possible that the tourniquet was left on too long while she was trying to find a vein, or she had to use a very small gauge butterfly needle. If that's the case, then the hemolysis may not actually be a symptom. The specimen needs to be re-drawn."

Dr. House nodded, "Susan, go collect a fresh specimen from the patient and re-run the chemistries."

As Susan got up to retrieve her phlebotomy tray from the lab, Dr. House assigned more diagnostic tests for the rest of the team. When Susan arrived in the patient's room, Dr. House was standing just inside the room. "Why are you here?" Susan asked.

"I'm here to watch." He replied.

"You've watched me pull blood several times in the clinic. Why do you need to watch this one?" She asked.

"Just do your job." He said.

Susan, went over to the patient. She introduced herself and told her that her doctors had ordered more tests and that she needed to pull more blood. The patient said, "I hope you're better at it than that doctor, she had to stick me three times before she was able to get any blood."

"Well," said Susan, "you've been dehydrated from all the nausea and sometimes that makes it difficult." Susan continued, "I'm going to take my time looking for a good vein before we try any sticking, OK?" The patient nodded, and Susan started looking for a vein. Susan went to the arm opposite of the IV, and looked around the inside of the patient's arm. She saw several bruises where Dr. Hadley had stuck her arm and missed the vein. She didn't want to make those any worse, but it's always better to take from the arm than the hand if you can. She got out a butterfly, syringe and the vacutainer she needed for the draw. She put on her gloves, cleaned the area inside of the elbow with alcohol and put the tourniquet on the arm of the patient. She put the butterfly in her right hand positioned for the draw as she started feeling for a vein with her left hand. As she felt the vein under the skin, her eyes went wide with surprise. She was expecting not to feel much of anything, or if she did that it was a rolling vein, but instead she felt a large easy vein. She glanced over toward Dr. House as she put her butterfly down and reached for a larger gauge vacutainer needle instead. She didn't want to make it obvious, but it was better to draw with a large gauge needle whenever possible in order to minimize damaging the red blood cells in the specimen. When she finished the draw the patient said, "That was much better than last time, I hardly felt it." Susan smiled at the patient as she gathered the specimen and her things.

Dr. House watched the entire process. Susan had no issues pulling the patient's blood. He knew she was a good stick, but he also knew that Thirteen was a good stick. Artificial hemolysis shouldn't even have been an issue to rule out. As he watched her draw the blood, he once again couldn't get over the feeling that there was something familiar about her. He followed her out of the room. "She wasn't a hard stick," Dr. House said more than asked.

"She was probably dehydrated or something earlier," said Susan. "Who knows, everybody has good and bad days. About the time you start getting cocky and thinking that you can hit anybody's vein, somebody comes along and humbles you. Perhaps today was just not Dr. Hadley's day."

House didn't say anymore, but he was worried. He'd noticed Thirteen was showing more nerve damage from her Huntington's. This may be the start of her having limitations on what she could and couldn't do as a physician.

Back in the lab, Susan spun down the blood. The serum was clear – no hemolysis. That meant that hemolysis was not a symptom. Susan texted the news to Dr. House and started the chemistry analysis. When she was finished, she took the results to the diagnostics conference room for the team. When she arrived, the only team member there was Dr. Taub. She handed him the results and started back to the lab. Dr. Taub started to follow her. Susan turned around and asked him if he needed anything, he didn't but it was obvious he wanted to say something. Finally, he said that he needed to apologize for his behavior. When she first came, he thought that a lab tech did not belong on House's team, he was wrong. Susan had as much right to be on the team as anybody. As he said this, he put his hand on her arm. Susan ignored the gesture, thanked him and started away, but something in Dr. Taub's demeanor made her hesitate. She looked at him and suddenly she became very uncomfortable. She excused herself and went to the lab.

A couple of hours later, Dr. Hadley stormed into the lab. "What did you say to Dr. House?" she demanded.

"I told him that the hemolysis wasn't a symptom." Susan replied.

"No, what did you say to him about my blood draw?" She clarified.

"Nothing. He watched me do the second draw and came to his own conclusions. I only told him that everybody misses and it's not that big of a deal." Susan said.

"You're not a doctor, you shouldn't even be involved in the differentials, next time you keep your mouth shut." Dr. Hadley exclaimed.

Thirteen's condescending manner angered Susan. She felt her temper starting to rise, "Look," she said, "I don't know why you are so upset; I saw something with the lab results that you guys didn't see. As you are so quick to point out, I'm not a doctor so I don't know if it's important or not, but I think it's in the best interest of the patient that if I see something that I mention it. I'm sorry you're upset, but I'm not going to stop so deal with it."

Dr. House walked in the lab. He'd heard the entire exchange. He wanted to see the microbiological specimen's results again. He told Dr. Hadley to gather the rest of the team. As Susan started to go to his office, he stopped her. He wanted her to stay in the lab and run a confirmation test on the blood she had drawn. As he left the lab, Susan wondered how bad she had screwed up her position on the team. Her temper had gotten her in trouble before and she wasn't looking forward to the repercussions this time.

Susan ran the test Dr. House ordered. The test confirmed his suspicions and they had their answer for the patient. Instead of taking the test results to Dr. House, she sent them to him electronically. She didn't want to go upstairs; she didn't want to face anybody just yet, especially Dr. House. She'd already had issues with two of the doctors and Dr. House had just heard her lose her temper.

No sooner than these thoughts were crossing her mind, Dr. Taub entered the lab. He just wanted to see how she was doing. He'd heard about the exchange she had with Thirteen. He wanted her to know that he supported her position, that she was a very good lab tech etc. Susan had heard enough. "Dr. Taub," she said, "Stop it right now. You have a patient and a job to do, start doing it and quit flirting with me. Go away." Dr. Taub left.