Fourteen-year-old Della performs to cheers at a skateboarding exhibition, a benefit to raise money for muscular dystrophy research. She confidently navigates the ramps and grinds. When she skates over to the adoring crowd of mostly wheelchair-bound kids asking who wants a turn, her teenaged brother, Hugo, eagerly raises his hand, so she grabs hold of his chair and begins racing him up and down the ramps.
"Fast enough for ya?," Della asks. Hugo's loving it but can't help giving his sister a hard time. "I'm already in a wheelchair - what are you so afraid of?" Della speeds up. Then, suddenly, she's no longer behind him. Hugo stops himself and turns around. Della has collapsed.
Cuddy tells House that she wants to formally report their relationship to the hospital's human resources department. "OK. You get them. I'll cover everybody else," he tells her. But she wants House to keep quiet until they have the meeting, which also means no public ass-grabbing, much to House's dismay. He reluctantly agrees - or at least he seems to.
Fortunately, she has a case for House: it's Della, and the EMTs say that her heart stopped at the skate park. House gathers the team, plus Wilson, to discuss the case, and immediately announces that he's seeing Cuddy. Wilson assumes it's a prank and promptly leaves, Taub cautions House against "yanking on the chain of command," Foreman gives a sort-of congratulations - while Chase ignores it all and plows on with the case. With the male perspectives summarily gathered, House wants a woman's point of view. Where's Thirteen?
Foreman tells House that Thirteen asked for a leave of absence, let the team believe she was heading to Rome for a Huntington's Disease study, then vanished. Her phones have been disconnected, and she's vacated her apartment. House moves on.
"Conditions that cause intermittent heart arrhythmia?," House asks them.
Chase wonders if maybe Della has a latent case of muscular dystrophy? Doesn't explain the sudden onset, though. Foreman and Taub are curious about House's non-reaction to Thirteen's departure. But if he knows anything, he's not telling.
Chase suggests long QT syndrome, thinking maybe Della was startled in the skate park, triggering the arrhythmia. "Scare the patient to death to confirm long QT," House tells the team.
House visits Wilson in his office, determined to prove that he's dating Cuddy, who, at that moment, joins them, furious that House ignored her request and told everyone about their relationship. But Wilson still doesn't buy it. Even as Cuddy tries to drag House away to their HR meeting, Wilson isn't convinced. Cuddy tells Wilson it's true. He doesn't believe her. Cuddy kisses House, and Wilson still doesn't believe. Cuddy exasperatedly grabs House between the legs and looks at Wilson. "We done here?" Wilson is convinced.
"How would you describe the exact nature of the relationship?" They're in the human resources manager's office. "You ever see 'Wild Kingdom'?," House offers. This isn't going well. Cuddy says that she can still supervise House effectively but that they want to follow hospital procedure. Which in this case is a "love contract," a consensual relationship agreement that they both must sign. And there must be no favoritism from Cuddy toward House, nor bias against him. One last question: "Are there any supervisory issues with Dr. House's current case load?"
"Nope, her case is solved. This patient has long QT, and we're going to scare her into cardiac arrest to confirm," House says. Cuddy's hearing this for the first time. "No, we're not," she tells him. They sign their contracts but continue the argument in the hallway.
"The patient is nowhere near sick enough to justify the risk. An angiogram and an EP study are much safer, and very effective," Cuddy tells House. He knows the "scare test" is more conclusive, but agrees not to do it.
In Della's room, with her parents and her brother at her bedside, Taub and Foreman prepare her for the tests. They're concerned that she's been taking in lots of fluids but hasn't had to go to the bathroom recently. Foreman thinks her kidneys might be failing.
Back in House's office, the team tries to figure out what could cause a heart arrhythmia and kidney failure. Taub thinks that House's relationship with Cuddy is already causing problems, because they should have done the riskier - but more conclusive - test on Della, despite Cuddy's wishes. House wastes no time in turning that around on Taub: he says Taub just wants House to be as unhappy as he is.
Foreman brings up Fabry disease, but her father's history was clean. Foreman says protein deposits wouldn't show up on a history, suggesting amyloidosis. House wants Della to have a marrow transplant to treat it. Her brother Hugo is a match.
In the clinic, House is talking to a 102-year-old man complaining of fatigue. His son tells House that normally his father is as strong as an ox, and that in addition to the fatigue, he's got tingling in his feet and legs. He wants a battery of tests to figure out what's wrong. "You have a bad case of 'natural causes,' " House tells the father. But both men are adamant. They want the tests.
Taub and Della's parents are in her room, and she doesn't understand why Hugo isn't there, too, since the surgery obviously affects him, too. Taub assures her it's a standard, harmless procedure, with almost no pain. "No, I'm not taking my brother's marrow," Della tells them. "His life's hard enough as it is."
Taub tells House that Della won't consent to taking Hugo's marrow and they're looking for another donor. "Boys' sports, science club - she's living his life, not hers. It makes sense she's being a self-denying moron," House says. Taub doesn't understand: Della's acting selflessly, because she loves her brother. "You're right. If everyone were more selfish, the world would be a better place," he tells House sarcastically.
Wilson greets House in the hall. He's happy for House - but can it work with Cuddy as his supervisor? House says nothing's changed. Wilson tells him everything's changed now that they're sleeping together. House showed up for clinic duty, voluntarily, and then there's the issue of Della's "scare test"... "I'm not doing anything differently. She changed my mind about one diagnostic test. She was right. Even though it's your emotional default, stop worrying. I can handle it," he tells Wilson.
Taub is talking to Della about her "boyish" interests. "Some people might think you're trying to live his life for him." "I am, sort of," she tells him. "I got into skateboarding when some of Hugo's classmates did, and he realized he could never do it. It's the same with a lot of things. We live through it together." Suddenly Della starts throwing up blood. Chase rushes in and they take her to an O.R. It's not amyloidosis.
"She's bleeding to death - out of her lung. I want to fill a quarter of it with foam." House is asking Cuddy for approval on another risky procedure. House says it's the best way to stop the bleeding. To his amazement, Cuddy agrees, but after she leaves House tells Chase to suture the lung instead.
"I can't handle it." House is in Wilson's office. He's convinced Cuddy really wanted to say no to the foam procedure. But why does he care, since what she actually said was yes? House thinks he's screwing up the relationship already. Wilson tells him all hope isn't lost, but he and Cuddy need to set some ground rules from the beginning, but what House gets from the conversation is that he needs to just avoid Cuddy at the hospital altogether.
Chase tells House that the lung stitching worked, but Taub says there's no guarantee it'll work next time. They get back to diagnosing Della's condition: heart arrhythmia, kidney failure, and now bleeding lung.
Foreman thinks multi-system involvement centered in the lung suggests sarcoidosis. Chase and Taub say no. What about Goodpasture's? Foreman says it explains the lungs and kidneys, and House agrees that an autoimmune disorder would explain the sudden arrhythmia. He orders immunosuppressants and plasmapheresis to treat, and a kidney biopsy to confirm.
House is on his way out of the hospital when he's stopped by the son of the elderly man he saw in the clinic. "Don't tell me - your father's hairline is receding and he needs more tests?" But the man says he knows running a slew of tests on his father is crazy; he just wanted to get him out of the house. He needs to put him in a care facility but doesn't know how to tell him. But if a doctor told him ... he slips House some cash. "Pretend to run the tests. And then tell him he can't live with me anymore."
House and Cuddy are in bed. Cuddy's noticed that she hasn't seen much of House at the hospital. The phone rings: Foreman and Chase say the kidney biopsy was clean so they re-checked a piece of Della's lung. It's not Goodpasture's. There's intimal thickening of the blood vessels, and lymphocytic infiltrate. Della tested positive for LAM lung disease. Plus, her lung is destroyed. She'll need a donor lung to live, but that's the only treatment for LAM anyway. Taub has approached the transplant committee, and they may have found a donor lung. "So this call is purely expositional?" House hangs up on them and gets back to Cuddy.
In House's office, Foreman tells House that Della's lung transplant surgery went well, but the donor lung started failing shortly thereafter. They're sure she has LAM, which means either her body is rejecting the new lung, or it's infected. They can't biopsy to find out for sure because there's no guarantee they'd hit the right spot. If they give her steroids for rejection it would make an infection worse, and if they give her antibiotics for an infection it'd make rejection worse. "Which worse is worse?," House asks them. They decide steroids are the least bad option. House orders IV methylprednisolone for hyperacute rejection. If that fails, then go with antibiotics. They all get up to leave - except Taub.
"We just decided to give meds that could kill the patient based on a guess. You need approval from Cuddy, and she'll want to take the safer course, and you're going to fold like an origami crane. So I'll just wait here until we get our actual orders." Taub sits back, looking smugly at House. House tells him to go get approval from Cuddy himself, and tell her she's an idiot for always taking the safer course.
House is at his desk when the elderly man from the clinic walks in. "Forget the tests," he tells House. He loves his son, but the son can't let go. "I can't do anything without him helping me like I'm senile. If I go back there I'm going to rip his throat out." He gives House cash to skip the tests and just tell his son that he needs to be in a nursing home. With a private room. A suite, actually.
Cuddy storms in with Taub, who's relayed to her House's exact words. She disagrees with the decision to give Della steroids. House stops her. "I agree with you. That was our analysis from the start." He looks to an astonished Taub: "If you've got a problem with the team decision, you come to me." House apologizes to Cuddy and assures her that he'll deal with Taub later. Cuddy leaves. House tells Taub: "People who have not seen Cuddy naked should not throw stones."
They give Della antibiotics, and before long her blood pressure drops. The drugs aren't working, so they know it's rejection, not infection. Chase orders steroids for Della.
House is in the cafeteria with Wilson lamenting his situation. Wilson again says that he needs to talk to Cuddy to work something out. Taub and Chase come in to tell House that the antibiotics failed - and so did the steroids. It's not infection or rejection. "Unless it's not LAM," House tells them. But the test was positive. House says the test has to be wrong.
House is outside Della's room when Hugo approaches him. "I want to make sure you're trying everything to save my sister," he tells House. "I'm the one that's supposed to die first. I'm the damaged one, not her. She never even gets a cold. "Never?," House asks. He quizzes Della about the last time she's has a cold, or minor aches, swelling, anything. She says sometimes her ears ache a little ... and she has some chest soreness ... and congestion. But she barely noticed any of it until a skateboard tournament in Denver a year ago. She says it's nothing when she thinks of what Hugo goes through every day. "Yeah, we get it. The brother the saint. The sister the martyr," and House leaves her room, confident he has the answer.
House orders Taub to go back to the transplant committee while he gets confirmation. Of what? "What causes low-level cold symptoms for a year, can ruin two lungs, is immune to drug therapies and gets worse in cities nicknamed 'Mile High'?" She has a clotting disorder: sickle cell trait. "The heart arrhythmia wasn't sudden at all. The screwed-up blood cells screwed up the blood vessels, which gave us a screwed-up 'positive' for LAM," he tells Taub. "If she'd told us about her symptoms sooner, like ever, she might not be dying. You were right after all: if everyone were more selfish, the world would be a better place."
Della will die without another transplant, but she went through the first one so quickly, there's no chance the committee will grant her another lung. House thinks for a second. "Unless we don't need their approval ..."
"You can't advise your patient's parents to take marrow and half a lung from their son," Cuddy informs House. But he's confirmed the sickle cell trait, and getting the marrow and lung from Hugo is the only treatment option. Cuddy says that with Hugo's disease, he'll die of respiratory failure by 25, and the transplant could cut that time in half. House still wants to give the parents the choice. "We don't compromise one life for another!," she says. He looks at her, then says OK and walks away. Is he deferring to her just because they're seeing each other? Maybe, he tells her. He's not sure.
"This is screwing me up. Why is it not screwing you up?," he wants to know. "It is. I don't know why I OK'd you foaming that lung. I realized it was wrong as soon as I said it," Cuddy says. "We are screwing this up. I'm going to call HR and find someone else to supervise you as soon as I can."
In the clinic, House meets with the elderly man and his son. He's got the test results, which in accordance with both their wishes aren't actually test results at all, but a piece of paper with the words "Test Results" written on it. House recommends that the man be moved to a home with round-the-clock care. Both men look at House approvingly, though they feign disbelief and try to argue against it. The son says, "There must be some other way. Just because he has a little tingling and some trouble feeling hot and cold ..." "Can't feel hot and cold?," House asks. Now he's curious. He wants to see the man's teeth, then his denture cream. House looks at the ingredients on the cream and diagnoses him with zinc poisoning. He's been going through a tube a day. It explains all his symptoms. To their shock, he says there's no medical reason for the father to go anywhere. House gets up to walk away, but before he leaves he gives them each back the cash they used to bribe him, as a "hospital rebate," suggesting they put it toward couples' therapy.
When House returns to his office, Della's father is waiting for him. "Transplant committee's never going to give my daughter another lung, are they?" House says no, but when the man asks if there are any other options, House just says they're looking into it. He begs House to tell him, to give him some kind of hope. But House won't talk. "If there's any chance you can save her, anything you can try," he tells House. Finally, House tells him they could take marrow and half a lung from Hugo, despite his conversation earlier with Cuddy. House tells him it'll likely shorten Hugo's life significantly. He asks House how long they have to decide. Morning, at the latest.
Taub is tending to Della, who doesn't know why her parents aren't there, and why it looked like they were arguing earlier. But she's already figured out that they want to take a piece of Hugo's lung as well as his marrow. Taub tells her not to worry about anything. In the hallway, her parents are agonizing over the choice they have to make. Suddenly, there's a rush of activity and they see Chase running toward a stairwell. Foreman is there, administering oxygen to Della, who's sprawled lifelessly on the floor. "What is she doing here?," her father demands.
Taub tells him that she figured out what was going on and must have yanked her tubes. She came there to die. They're able to keep her alive and bring her back to her room, but Taub tells them, "By unhooking herself from everything, she delivered a hypoxic insult to her body. It started a downward spiral." The parents must make their decision quickly.
Cuddy tells House that HR is unable to find him another supervisor. Apparently he's "unsupervisable." Two department chairs threatened to quit. Cuddy says she's not sure if she's making the right decision, but if he feels strongly about offering Della's parents the choice of taking part of Hugo's lung, he can do it. "Thank you. I will ... several hours ago," House tells her. "Well, I should probably be more mad at you," she says, as Della's parents walk up.
They've decided not to take part of Hugo's lung. Cuddy assures them Della is still on the transplant waiting list and they're doing all they can for her. But House is incredulous. "What ginormous crack pipe have you people been sucking on? Are you going to pretend that you're not choosing your own daughter's death?" Cuddy is horrified at House's behavior and they have a massive row in front of Della's parents. "Their son is a human being! You know what they are, right? Intrinsic value. We don't get to decide -"
"Come on, we do it every day! The two of them needed the same lung -" "He needs the one he's got! You don't get to play God by ripping out -"
"That train left the station when we learned to do transplants. The rest is just paper pushing. Of course, now we're on to your real area of expertise."
"Oh, I thought we were moving on to yours. Bullying your patients into embracing your own lack of a moral - Cuddy turns and see that Hugo has heard their whole argument. He leaves them and goes into Della's room. He tells Della he wants her to take half of his lung. "You do so many great things. I just watch. I get to watch, and coach and cheer. But that's not me out there. It never will be. If you take this piece of me, carry it with you, then I really can share in everything you do. This is the great thing I can do with my life. Don't make me live without you." Crying, Della takes his hand.
House and Cuddy head to the elevator. "We got lucky," House says. "I did give them an impossible choice. The kid took it away from them."
"That fight," she says. "It was the first honest interaction you and I have had since we came back to work. If we are painfully, brutally honest with each other, maybe we'll get lucky again." House agrees. "You've got a big ass," which he then grabs. Cuddy takes his hand and they walk into the elevator.