Chapter nine

Part two

House rose to his feet, leaning heavily on the cane. He limped forward, his already ponderous gait made more pronounced by his time sitting uncomfortably in the padded chair. Luckily, she'd handed his laptop off on their arrival; so he didn't need to carry it up with him. He approached the base of the stage, only to freeze before the three small stairs that led up to it. Those three stairs, Cuddy realized, must have seemed like Mt. Everest as there wasn't even a railing for him to hang on to. She assumed she was giving off the right vibes with her gaze, because Scott looked her in the eye and then moved to the stair's edge and offered House his hand. After a long moment in absolute silence, House took Scott's hand in his left and hop-stepped up the first stair. He was doing everything he could, Cuddy could see, to avoid weight-bearing on his right leg at all. He took the next stair in the same way, pausing to regain his balance before moving onto the next stair. But as he lifted his left foot to try the next step, his foot was caught between the stair and the riser and he lurched forward. She didn't need to see his face to imagine the pain that sudden movement sparked in his leg; and she closed her eyes as House sprawled forward on the stage with an involuntary cry of pain. The room was silent; save for a few whispers here and there. Cuddy leaned forward in her chair anxiously; arresting the desire to get to her feet and rush to his side. She stayed the motion, knowing House would not welcome her help in this moment. Scott spoke to him quietly as House lay where he had fallen on the took House's left elbow as he used his hands to push himself up, abandoning his cane. He stood heavily on his left leg, his right hand clamped around his other leg protectively. Scott held him up; reaching to put an arm around House's waist to steady him but was brushed aside.

"Greg, if you want to—" Scott's soft voice was pitched low, but still readily picked up by the microphone clipped to his lapel.

"No, I'm fine." House muttered tersely. He wasn't fine, Cuddy could tell from the way his hand clutched at the leg. But he was upright, and that was more than she expected at this point. "Just...just get me to the podium."

"Greg—"

"I'm fine." House ground out, and gestured at the stage. "I need to do this."

"Do you want a chair?" Scott asked, and Cuddy closed her eyes as House drew in a deep breath and let it out slowly.

"No."

Scott helped him along as House stepped with the left and dragged his right. It was likely that he wasn't able to lift the foot any more. Scott walked him to the podium and House latched onto it, leaning heavily on his left leg with his right foot lightly touching the floor. He lifted one shaking hand to the microphone and raised it slightly so he could speak without stooping.

"The first identified cases of human infection with the H5N1 virus occurred in eastern China during February and March of 2004 and were characterized by rapidly progressive pneumonia, respiratory failure, acute respiratory distress syndrome and fatal outcomes." House began without preamble. "Within the past year, a taskforce on Biohazardous Threats and Emerging Diseases was assembled to analyze data from field investigations to characterize the descriptive epidemiology of laboratory-confirmed cases of avian influenza. Today, I will be sharing with you the summary of our preliminary findings: our investigations into confirmed cases of H5N1 virus infection that have been identified to date, the nature of the virus' transmission, symptoms and pathogenicity. This is an ongoing investigation." his voice quavered; his hands gripped the podium as pain surged through him in waves. Cuddy caught her breath and held it, watching House intently; certain that he was going to collapse at any moment. He doggedly continued his presentation, however; his words coming in fits and starts and increasingly faster.

"The human incubation period of H5N1 is two to seventeen days. There is as yet no human form of H5N1, so all humans who have caught it so far have caught the avian strain. Avian influenza HA differs from human influenza in that it binds alpha 2-3 sialic acid receptors while human influenza HA binds alpha 2-6 sialic acid receptors. Highly pathogenic, H5N1 in a human appears to be far worse: killing over fifty percent of humans reported infected, although it is unknown how many cases go unreported." House paused to shift himself again with one halting hop-step and then resumed leaning heavily on the podium, with his right leg bent at the knee.

"Our studies into the H5N1 pathogenicity began by assessing the levels of cytokines in humans infected by the H5N1 strain. Of particular concern are elevated levels of tumor necrosis factor alpha, given the protein's association with tissue destruction at sites of infection and increased production of other cytokines. Flu virus-induced increases in the level of cytokines is also associated with flu symptoms including fever, chills, vomiting and headache. Of note, the inflammatory cascade triggered by H5N1 is best likened to a cytokine storm, because of the damage to the body resulting from immune system stimulation. H5N1 type flu virus induces higher levels of cytokines than the more common flu virus types such as H1N1. Tissue damage associated with this pathogenic flu virus infection can ultimately result in death…" House's voice trailed off again and Cuddy looked up at him sharply, half afraid this was the moment he would finally collapse. Sweat bathed his face, and soaked the collar of his shirt. He was squinting in the overhead light; face pale, trembling visibly. She considered getting to her feet and ending his presentation then and there; but he rallied himself and continued bravely.

"The NS1 protein of the highly pathogenic avian H5N1 viruses circulating in poultry and waterfowl in Southeast Asia is currently believed to be responsible for the enhanced pro-inflammatory cytokine response. H5N1 NS1 is characterized by a single amino acid change at position 92. By changing the amino acid from glutamic acid to aspartic, our partners in research were able to abrogate the effect of the H5N1 NS1. This single amino acid change in the NS1 gene was noted to greatly increase the pathogenicity of the H5N1 influenza virus."

Cuddy took a moment to locate Sir Richard Scott, only to find he had never left the stage. He was standing only a few feet behind House, hands out in front of him as though he anticipated having to scoop House up off the stage. There was something like envy and something like regret in his expression, Cuddy could not tell which. But as she surveyed the room she could see that most of the audience were paying rapt attention to House's recitation of the medical aspects of their research. A select few could be seen staring at the white-knuckled grip House had on the podium; but they seemed more concerned with the man himself than the medicine.

"In short, this one amino acid difference in the NS1 protein produced by the NS RNA molecule of the H5N1 virus is believed to be largely responsible for an increased pathogenicity because of its hemagglutinin type which allows it to grow in other organs and can manifest itself by causing a cytokine storm in a patient's body, often causing pneumonia and death. Neuraminidase inhibitors have proven to be a class of drugs that proves most effective in preventing the virus from spreading inside the body. Zanamivir and Oseltamivir are the most effective in this class. Antivirals which include amantadine and rimantidine target the M2 protein but have become ineffective against most strains of H5N1, due to overuse. Research also indicates that therapy to block one cytokine to lessen a cytokine storm in a patient may not be clinically beneficial in the long run." House had rushed through this last part in record time and turned abruptly away from the podium so fast that Scott had to scurry to catch him by the arm. Cuddy rose to her feet and walked quickly to the edge of the stage as Scott helped House stand beside the stairs. In the absolute silence of the room, she reached up tenderly and took his other arm and a good deal of his weight as she helped guide him down the same three steps that had felled him earlier. They stood together, House swaying unsteadily between them for a long silent moment.

"Greg?" Scott asked aloud; even as House finally slumped in their arms, and Cuddy forced herself to reach with trembling fingers to House's carotid. His pulse hammered quickly beneath her fingers and she sighed sadly.

"He's out." she murmured faintly. Scott nodded his acknowledgement, and together they set him down as gently as they could manage on the floor. Lifting House's feet, Scott settled them in his lap to elevate them, and within a minute or so he opened his eyes and started to come around.

"House? Are you all right?" she asked quietly. She looked down at him tenderly as the fog of confusion slowly lifted from his piercing blue eyes. She could see the exact moment awareness returned; his gaze was pained, and she suddenly understood how much more deeply his fall affected his spirit rather than his leg.

"I'm fine." he whispered softly, and Cuddy gave him a strained smile. Scott leaned in close, and spoke confidentially.

"Do you need an ambulance, Greg?"

"No." House muttered angrily. "Just—just get me a wheelchair."

"Are you certain? Perhaps we should consider—"

"No!" House cried, and Cuddy looked away from the pain in his eyes. "It's fine. I'm fine. I don't need an ambulance." he whispered brokenly.

Scott looked at her helplessly, his expression pleading for her to intervene and Cuddy shook her head sadly."House knows his leg better than anyone here. There's nothing a hospital could do for him that we can't take care of ourselves."

"What if there's something broken?" Scott demanded. "Or—"

"Nothing's broken." House muttered as he tried to push himself into a sitting position. Cuddy helped, easing him up and sitting behind him in case he needed someone to lean back against. Scott remained kneeling beside House for a few more minutes before arriving to a decision and climbing to his feet. He stepped away, and spoke quietly to a young man near the wall before waving him out the door. Cuddy focused her attention on House; noting that he was still sweating profusely despite the cool temperature of the room.

"Can you give me a number?" she asked, and House shook his head. He was biting his lip, and she could tell it took everything he had to keep from crying out. Scott returned and knelt down beside House once more; leaning in to whisper quietly.

"Robert will be by in a moment with a wheelchair; I've asked him to help Dr. Cuddy return you to your room. If you have need of anything, you have only to ask." Scott rose to his feet and strode smoothly toward the stage. He bounded up the three steps quickly and crossed to the podium. His energy and presence captured the attention of most everyone in the room, and Cuddy noted in relief that the audience allowed itself to be distracted from House's predicament.

"Ladies and gentlemen: I would like to introduce our next speaker." Scott segued easily into conference leader once more; as if House had never fallen. As though his presentation had gone off without a hitch.

"Dr. Xiang Chen is a virologist working in the Szechuan province in China. His research into—"

oOo

The young man had returned in short order with a wheelchair, as Scott had promised. Cuddy had risen to her feet as Robert locked the brakes on the chair and slid the leg rests out of the way. Their eyes met, and Cuddy wordlessly shifted to House's feet as he moved to take House's upper body. Robert wasn't a muscle bound man; but despite a slender build he had at least five inches on her and would more readily take House's upper body weight than she could. Without uttering a syllable, he slid his arms around House's chest as she took his feet and together they hefted him into the chair. House grunted in surprise and not a little pain as his butt hit the seat and jarred his leg. Cuddy remained in place, staying as straight and still as possible until Robert got the leg rest in position before she eased his foot down.

Robert busied himself with getting the other foot rest in place before he took up the wheelchair's handles and pushed House carefully out of the room. Cuddy trailed behind, her eyes defiantly meeting sympathetic looks as House departed. House didn't want—didn't need—pity from his peers. He needed understanding. He needed space. And he needed heavy pain medication. For the first time since the infarction, she found herself wishing she had IM morphine on hand. After the Tritter fiasco, she knew better than to think House would have brought any. She kept pace as Robert pushed him past hotel guests who eyed him warily. The elevator came promptly when called, and before she could even think about it they were safely back inside their shared suite and Robert was helping settle House on the bed in his room. His bottom lip was clenched between his teeth, and Cuddy would have bet anything that House was reaching the end of his legendary endurance.

"Thank you, Robert." she murmured tersely, even as she began to root through House's suitcase on the bureau.

"You're welcome." he said, and let his gaze flicker to House and back to her. "If you need anything else, let me know." Robert turned and left then; just as Cuddy's questing fingertips came across the Kadian bottle House had tossed into his bag. She grabbed it triumphantly as House deflated; unable to hold back the agony any longer. His white-knuckled grip grew tighter and he groaned loudly; swallowing over and over against the tide of nausea.

"Can you give me a number, House?" she asked, even as she opened the bottle and poured two pills into her palm.

"Nuh-uh." House gasped; his breath coming faster. His groaning gave way to panting; agonal grunts of pain that indicated his pain levels were finally beyond his ability to withstand. She sank down beside him and slipped the pills into his mouth.

"Need IM." he panted, even as he used his tongue to shove the pills between his back molars and began to chew. "Gonna puke."

"We don't have anything injectable." Cuddy replied. "This is all we have."

House chewed and swallowed; his eyes closing as he willed his stomach to behave long enough to absorb the opiates. Cuddy reached for House's leg, only to be stopped by the cold fury in his voice..

"Don't." House said sharply.

"I just want to help."

"Don't touch it!"

"Maybe I can help—"

"Just don't—" he mumbled; "—it doesn't—" the fury dissipated, and his voice caught as he began to wretch; Cuddy rose to her feet and raced to the bathroom and back with the ice bucket again. House had somehow managed to position himself so that he puked over the edge of the bed instead of on it. He lay, gasping; though with every breath came the distinct grunt that indicated the pain had accelerated away from him again.

"Oh, House." she said softly, and sat down beside him. "What can I do?"

"Noth—" he started to say, only to pause when he retched again. This time, she was ready and had the bucket in place as he brought up what was left of his meager breakfast and bits of the undigested pills he'd chewed up. He retched again and again; until nothing but bile was in the bottom of the bucket. Cuddy shook her head sadly as she dumped the contents of the bucket into the toilet and rinsed it out before returning to House to study him clinically. He was half-curled on his left side; both hands clamped firmly around his upper thigh as he writhed in pain. His breathing was still fast and erratic; sweat soaked his dress shirt in great patches and his tie was stained with a spot of vomit. She shook her head sadly; he'd already brought up the only medication she had to offer him. Anything else he truly would need an ambulance and a trip to the hospital to get.

"House—I think we need to consider elevated care." she said carefully. He shook his head emphatically, and Cuddy grimaced. "I know it's not what you'd like. But I don't have anything injectable, and you need something to break the cycle."

"No."

"House—"

"Dramamine."

"What?"

"Dramamine." he grunted. "Plane. Anti-emetic."

Cuddy blinked at his request before a memory was jarred loose. She rose then, darting into the common room where she'd dropped her purse. With trembling fingers, she withdrew the vial of Dramamine she'd procured for herself. As a child, she'd been prone to motion sickness, and had gotten the script on the off-chance it returned during the long flight. House was right; it might take the edge off his nausea enough for the Kadian to be absorbed. She shook out both the Dramamine and Kadian and slipped them into his mouth one at a time. House chewed each pill in hopes of absorbing them faster.

"When this is over you're going to tell me how you knew I had them." she muttered; touched when House somehow found enough energy to quirk up a corner of his mouth in reply. He worked to swallow each chewed-up pill and then let his head fall back to the mattress. She set the pill bottles aside and gently sat down beside him on the bed. House continued to sweat and writhe and shake; swallowing over and over again as he tried to keep the pills down long enough to help.

"Breathe, House. Just breathe." Cuddy murmured over and over again. She remained seated beside him; running her fingers through his tangled, sweaty hair. She couldn't tell how long she sat there; awkwardly leaning over House until the Kadian kicked in. His shudders turned to shivers against the sweat soaking his clothes, and his heaving breath slowed and shallowed as he finally sank below the pain and fell asleep.

Cuddy sighed shakily as she leaned forward to press her fingers to his carotid. His pulse was slow but steady; the pain tempered at last by the morphine racing through his veins. It had been years since she'd seen House in such agony—not since the initial infarction had she seen him so lost to it. Defeated by it.

Selfishly, she hoped she never would again.