(I still don't own House and this is just for fun)
"We've got a problem."
All eyes shifted back to the gurney. The residents were currently viewing portable x-ray results and looking at House's thigh.
"There is a femoral shaft fracture. When you splinted it on scene it was stable. The damage muscles in his thigh have started to spasm – something shifted." Mathis's residents seemed capable as they summed up their findings.
The doctors realized that the remaining muscle was creating a vibrating ripple effect and the leg was turning dark – like blood rapidly filling beneath the skin.
"We think bone fragments have shifted onto a blood vessel and it is now bleeding profusely into the surrounding area."
Cuddy jumped in, "He's been on mild blood thinners ever since the infarction."
Mathis calmly stated, "Then we've got a definite problem. Is he allergic to any medications?"
When no response came, Mathis continued, "Felt, inject a targeted paralytic directly into the scarred area. We don't want to paralyze him systematically, but we've got to get that muscle still. We don't have time for further testing. Book an OR, we're opening him up."
Wilson was in a panic and his medical sensibilities were obviously out the window, "Based on the external evaluation, his hip may need surgery as well. Should we wait and do it all at once?"
Mathis and her residents were already guiding the gurney out of the ER.
"No time, for all we know the bleeding will continue and a fragment could be pinching a nerve. The last thing we need is for him to have more nerve damage to his right leg. I'm sure he already has enough nerve pain from the debridement after the infarction," Mathis explained as if this was obvious.
It should have been obvious to all the doctors present.
Rationally, Wilson knew that enough pressure to break the femur could also cause substantial vascular, nerve, and soft tissue damage.
House was high risk for this type of damage because he had little protection or "cushioning" because of the missing muscle. House was so slim there certainly wasn't any "padding" from fat!
House's luck certainly predicted what came next. House's eyelids began to flutter. The sudden trauma of the spasms must have triggered him awake. With a series of whimpers he began to shift on the gurney. He was trying to turn and reach for his right thigh.
All of this movement was a disaster waiting to happen. Mathis grabbed House's hands and stopped the gurney.
"You're okay. Squeeze my hand. We're going to get you fixed up, deep breaths."
House was so out of it that he blearily attempted to obey through the pants and whimpers. Everyone knew it was bad because House never attempted to obey or let people touch him when it wasn't totally necessary.
Mathis immediately regretted asking him to squeeze her hand. Adrenaline was not always a good thing!
With the hand not in House's clutches Mathis ripped the sheet off of House's lower body in the middle of the hall.
House would be mortified if he knew his manhood was exposed in the open air for all to see. His greater fear would probably be the fact that his scarred thigh was also visible.
He was way too out of it to even notice.
From where Foreman was standing he saw House's pelvic bone shift underneath his skin.
Foreman heard it scrape in his mind. Just the thought was like fingernails on a chalkboard.
Mathis turned to the residents, "He's doing more damage! Grab a damn sedative before he shifts everything out of whack."
Dr. Felt had already run for a syringe before Mathis even ordered it.
He reappeared and plunged the medication home.
House began to droop and cease movement.
"Let's go!" Mathis ordered as the gurney began to move. "Somebody get several units of blood ready in the OR."
"I'm on it." Taub sprang into action.
Wilson, Foreman, Chase, and Cuddy all followed like some sort of procession.
A funeral procession flitted through Foreman's mind, but he quickly squashed that thought away.
His mental image changed to a bridal procession with House as the bride, Mathis the father of the bride, and himself, Chase, and Cuddy as bride's maids. Of course, Wilson brought up the rear as ring bearer. Foreman shook that image out of his head – now that was distressing.
House's gurney was now being pushed into the OR. Mathis and her residents broke off to get scrubbed in.
Mathis ran everything smoothly, "Get a scope set up for me – I want a look around so I know where I'm cutting."
Several techs scurried to get everything set up.
Mathis yelled out, "Foreman, scrub in! I want you available to look for neurological damage."
Foreman rapidly shook the image of his boss writhing in pain out of his head and replaced him with a faceless patient. He couldn't allow himself to think that they were about to dig into House's thigh.
This must become a random patient in Foreman's mind. People like Wilson could never create that separation, but Foreman thought he could – for a while.
Mathis began to talk as they scrubbed in, "A fall like this never should have caused this much damage to his femur - it's one of the strongest bones in the body. Even with his muscle damage, this is weird."
Foreman had spent so much time considering the prostate tumor and the tumor in the pelvic girdle that the femur had barely crossed his mind.
He figured he should tell Mathis, "Whenever I did the MRI this morning, there was a substantial shadow near the right femur. I figured it was associated with the damage from the infarction."
Mathis jumped in, "His infarction site should not have shown up like that. There must have been damage to the femur before the fall."
It seemed that no matter how much medicine Foreman studied or how many patients he treated, there were still so many things he didn't know. He had just assumed the shadow had something to do with House's infarction. I guess he should stop making assumptions - he thought he was past that point in his career!
By the time the doctors were scrubbed in and entering the OR, the nurses had already cleansed House's leg with iodine and draped him. The anesthesiologist nodded that House was ready to go.
"I'm going to cut in through the side of the thigh and take a look. I want to avoid cutting through the depression and scarring from the infarction if we can. "
Mathis smoothly made an incision less than an inch long and inserted the scope. Foreman looked at the screen and immediately saw the problem.
Mathis saw the problem as well. "The problem is actually being caused by a tumor on the femur. When the muscle spasms started, it was the tumor that shifted causing the blood loss. We've got to get the tumor out. Foreman, keep checking the pulses in his leg."
Foreman felt for pulses. "Nothing here"
Mathis nodded and replied, "The blood flow was blocked when the tumor shifted and the bone punctured the artery. All the blood is flowing from the puncture because it has to go somewhere and it can't travel through the artery that the tumor is blocking. Once we get the tumor away from the artery, blood should flow that way again and slow the spilling through the puncture. Path of least resistance – it's physics."
Mathis was still searching with the scope. "We need the best angle for getting the tumor out. You can see the area of bone erosion it has caused. The eroded bone essentially caused the fracture. Even if he didn't fall, this was a time bomb waiting to go off – or rather break."
Foreman was amazed how focused Mathis was even though she was talking away. She was the perfect Doctor for a teaching hospital.
Felt, the more involved resident, asked, "Can we even get in without cutting through the scarred area?"
Mathis grimaced, "Nope. This is a mess."
She requested a scalpel. "Here we go."
Foreman watched as she started about 3 inches above his patella (or kneecap) and cut for about 6 inches.
When Foreman heard her ask the nurse to grab another oncologist to help evaluate the tumor he suggested, "Don't get Wilson. He can't be objective. Get someone else."
The nurse nodded and left.
Mathis continued, "Dr. Felt, suction this blood off. Hang a unit, blood is still spilling."
Even though Mathis was an oncologist as well as an orthopedic surgeon, Foreman was glad she was calling someone else in as well. He suspected that Mathis wanted to move on to help her residents with the artery damage as soon as the tumor was away from the artery.
Foreman knew he had a tendency to be a control freak. Sometimes he had trouble calling others in. He knew sometimes you had to, but he still hesitated to bring others in on his own cases.
House solved that problem by employing a team of competent people and then getting oncology consults from Wilson.
Foreman was amazed at how quickly Mathis was cutting and moving the tumor out of the way. He was very impressed with Mathis.
Foreman felt a pulse and snapped out of his thoughts. "I've got a pulse down here!" Foreman didn't know how long they had been operating.
Felt chimed in, "The blood spill is slowing."
"Almost got the tumor away from the artery," Mathis replied. "Hang more blood, I'm not happy with his blood pressure."
Blood was now flowing where it should be and wasn't spilling out. The puncture caused by the bone was actually quite small now that blood was no longer spilling from it. It was amazing such a small hole could result in this much blood loss.
Mathis had gotten the tumor away from the vessel to stop him from bleeding out, but Foreman saw that there was still a good bit of tumor to remove.
Foreman now found his eye drawn to the messy fracture in front of them. He felt relief that the immediate crisis and bleeding was under control, but it felt artificial in light of what was right in front of him.
"That's one crisis under control, but we need to get the rest of this tumor out and then deal with the fracture." Mathis seemed to read Foreman's mind.
"What about amputation?" Felt asked.
Foreman cringed at the word.
"Amputation wouldn't stop the spread of cancer because we know that this tumor is a metastasis from the prostate." Mathis started. They could already tell from testing that the cancer had started in the prostate.
"House would freak out anyway." Foreman had heard enough of the lecture House delivered to the med students that he had a pretty good understanding of the story behind House's infarction. He had grilled Wilson for the rest of the story later. House wouldn't want his leg amputated.
"Let's get the rest of this tumor."