Cuddy: I'm sorry you lost Amber. I cannot imagine what it is you're going through, but it will not get better by you walking away from everyone that cares about you. Do you think Amber would have wanted you to walk away?

Wilson: Nobody at this hospital even liked Amber.

―Dying Changes Everything

Dying Changes Everything is the first episode of the 5th season of House which first aired on September 16, 2008.

The team treats the assistant of a powerful woman and Thirteen starts to see something of her own nature in the patient's subordination to her employer. In grief over Amber 's death, Wilson contemplates resigning from the hospital. When House reacts by telling him to get over it, their friendship is strained to the point where Cuddy has to be called in to do the equivalent of couples counselling. However, when push comes to shove, it appears that House may have to choose between his friendship with Wilson, the life of his patient, or his job at Princeton-Plainsboro.

The fifth season premiere used the natural break between seasons to naturally build the tension over the ramifications of Amber's death. When we return to PPTH, just as much fictional time as real time has passed, and Wilson is still at an impasse. Like House, we've been anticipating what would happen after House and Wilson parted without a word.

Certainly, this isn't the only episode where Hilson, the eternal bromance, has been threatened. However, it's one of the ones that posed the greatest challenge to the relationship between the two men. Cuddy, probably far too late, tries to mediate between the two, but her motives are far from clear - and Wilson knows it. Ostensibly, she wants to keep Wilson at the hospital. However, her hidden agenda is that she knows that it's unlikely that she will be able to handle House without Wilson's help. Throughout the series, it's usually been Wilson suggesting ways to Cuddy to keep the brakes on House's more excessive behaviors, and neither of them have been above using House's relationship with Wilson to manipulate the hospital's resident mad genius.

Meanwhile, the character that gets developed the most is Thirteen as her reaction to her Huntington's diagnosis finally gives us more insight into her personality. Like many of the others on the team, we find out that she wants to work for House so she can become her own version of House - a person who makes a difference in the world. Her disclosure of the diagnosis to the patient mirrors House's own disclosure to the patient in Pilot and shows that House and Thirteen have something in common - they both feel vulnerable when reaching out to other people and draw much of their strength by keeping their pain, fear, and feelings bottled in.

A boss and her assistant arrive at a meeting. The boss starts speaking to a meeting about the audience's lack of women in the executive office. Suddenly, her assistant starts screaming that she's covered in ants.

Meanwhile, House is enjoying a video game (Ninja Gaiden II) in the coma ward. Cuddy comes in to say Wilson has returned after two months away. She pulls out his video game. House says he hasn't spoken to Wilson since Amber died. Foreman comes in with a new case - the assistant ripped off her clothes during the meeting. House thinks it's a mental illness, but Foreman tells him she has real physical symptoms. House is interested, but Cuddy wants to give the case to someone else, so he can deal with Wilson. House takes the case anyway.

House starts a differential with the team. They wonder why he isn't speaking to Wilson. They note the assistant travels a lot, so it might be malnutrition. When Thirteen suggests an insulinoma, House discloses that she probably has Huntington's. He sides with Taub that the patient has B12 deficiency.

Thirteen denies to the team that she has Huntington's. She then goes to see the patient to tell her about the B12 deficiency, then tells her to get back in bed because she needs rest. Suddenly, the patient feels a sudden urge to go to the washroom, but Thirteen finds that she's bleeding.

House goes to see Wilson to talk about Thirteen. Wilson tells House he's resigning. House tells him that his reaction is typical of bereavement. When Thirteen comes in to talk to House about the rectal bleeding, House sends her away. Wilson rejects House's advice and goes to wrap up his practice.

Taub is not as concerned about House's indifference with the case as Thirteen is and concentrates on why she is bleeding. However, he can't find a bleed anywhere in her digestive tract. However, Kutner finds that one of her routine tests shows she is pregnant, which explains her symptoms. However, when they do the ultrasound, they can't find a fetus.

They inform House of the inconsistency - positive pregnancy test and no pregnancy. Foreman wonders why House isn't more interested. House finally starts a differential. He tells them to keep going while he sees Wilson. He once again confronts him about leaving, but Wilson thinks House is being insensitive. The team comes in and finds out Wilson is leaving. House ignores his team and tells them that the patient must be pregnant.

House goes to do the ultrasound again himself. He finds the patient is 37, and then he finds the fetus has dropped too far - it's taking blood from her intestines to cause the bleed and the neurological symptoms. He tells them to remove the fetus. Thirteen confronts him in the hall about trying to save the fetus, but he reminds her it's too dangerous. He then reminds her she can't let her Huntington's color her every diagnosis - people die. Thirteen goes to see the patient, who readily agrees to the abortion.

House goes to see Cameron about Wilson. She reminds him how grief is unique to everyone. He tells her that everyone suffers grief, but you have to get over it. Cameron tells House that when her husband died, she too moved and got a new job.

Chase operates to remove the fetus. The patient starts bleeding. Chase orders them to squeeze the spleen to start platelets flowing, and the crisis ends. He successfully removes the fetus.

House tells Cuddy that she has to get Wilson to stay. Cuddy tells House he can't just be dismissive of Wilson's feelings. She tells him to apologize, but he doesn't feel he has anything to apologize for. Cuddy agrees, but asks him if he has any guilt at all. She tells him if he wants to keep Wilson, he has to find a way to do it himself.

The patient isn't recovering well from surgery - she keeps blinking and her heart slows dangerously. The team realizes that the pregnancy may have been just a coincidence.

House goes to see Wilson again, threatening to stay home until he agrees to stay. House gets a page that the patient is in cardiac arrest, but he leaves the pager with Wilson and says he's going home until Wilson agrees to stay. House's team wonders where he is.

They fit the patient with a pacing wire. Cuddy takes over the case and tells the team that she has confidence in them. Thirteen thinks they can do it themselves and suggests multiple sclerosis. Foreman orders interferon.

Cuddy goes to see House. He says he told Wilson he was sorry, but Wilson didn't believe it, probably because House didn't mean it. He tells Cuddy to fire him if she doesn't like the fact he left the patient. When Cuddy confronts him, he slams the door in her face. She tells House that he's running away too, just like Wilson.

The patient admits to Thirteen that her boss would get along just fine without her. Suddenly the patient starts shivering and has a fever. That means it can't be multiple sclerosis.

Cuddy has House's cable TV cut off so House goes to confront her. Wilson arrives and Cuddy threatens him with not telling anyone else what his salary is, making a job search impossible. She welcomes them to couples counseling.

The team is arguing while watching the surgery video, but Kutner spots something. He thinks it might be a ganglioma, a broken bundle of nerves. Foreman realizes that could explain her symptoms and they have to do a biopsy.

Cuddy tells Wilson and House to talk it out, but they both refuse. When Cuddy confronts Wilson, he walks out, reminding them that no-one but him even liked Amber.

Chase doesn't want to do a second major surgery because he doesn't think she has a ganglioma and she won't survive the general anesthetic. Thirteen says Chase would do it for House. He agrees he would, but still won't do it. Kutner comes up with another idea - coming in through the intestine - painful but no surgery risk. The patient wants to speak to House and reveals that she's been fired. However, she doesn't seem to care about being fired and Thirteen wonders why she agrees to be treated like a doormat. The patient says that's its better to be close to the birds than to wish you had wings.

They perform the procedure on the patient and find the suspected site for the biopsy. Foreman cuts off a piece.

Cameron finds Wilson to tell him he shouldn't go. She says she first refused to talk to him when House asked, but also agrees that House is right. She tells him the pain doesn't go away, but making a big change doesn't help either. She keeps thinking of her husband all the time. She tells him to do something, but not to leave.

The biopsy shows it might be amyloidosis. However, they still have to find the cause. Foreman asks Wilson to call House. Wilson thinks it's impossible to rule out lymphoma. Foreman agrees to start chemotherapy. He then tells Wilson he thinks he should leave if he wants to because everyone else is just afraid to lose him and don't care what he wants.

The patient starts to feel better on chemotherapy. Thirteen apologizes for getting angry with the patient. The patient thinks Thirteen might actually have her own wings, but Thirteen reveals that she has Huntington's and will start to deteriorate soon. The patient realizes Thirteen wants to make a difference. The patient tells Thirteen that she's applied for a new job.

Cuddy is standing at the nurse's station outside the patient's room. House comes up and reaches under the counter, grabbing the remote, saying the nurse's remote works in the doctor's lounge too. Cuddy wants to know why House is afraid of losing Wilson, but he ignores her. Instead he is staring over her shoulder at the patient. He walks away from Cuddy and into the patient's room and tells her she actually looks thirty-seven now, her actual age. He comments that she looked twenty-seven the last time he saw her and that was only a few days ago. He realizes her bruises are lesions and that she has diffuse lepromatous leprosy, which they also call "pretty leprosy". The chemotherapy is killing some of the bacteria, but it will also wipe out her immune system. This type of leprosy makes her skin look younger, which is why she didn't look her age. House tells them to treat her with antibiotics and Prednisone and she'll be fine.

Thirteen comes in later and explains that the test for leprosy confirmed House's diagnosis. The physical stress triggered the common complication of leprosy and caused all the other symptoms. The patient makes a joke about prescribing skin cream and Thirteen says she'll need it for those job interviews. The patient then reveals her boss is hiring her back because her replacement couldn't handle it. Her boss even told her she would be able to handle some things on her own, so that she can have a bigger role.

House tells Thirteen not to feel so bad about being wrong about lymphoma - at least she had a good theory and stuck to her convictions. She's upset that the near-death experience didn't make the patient leave her boss. He reminds her that dying changes everything, but almost dying doesn't.

House goes to apologize to Wilson and admits Amber is dead because of him. However, Wilson doesn't blame House for her death. He then admits that he's not leaving because of Amber; he's leaving because of House's manipulation and because he's been enabling House's behavior. He claims he wishes House had been alone on the bus, and he learned from Amber he has to take care of himself. He didn't tell House before because he didn't want to hurt him, as he's always tried to protect him. He leaves saying they are no longer friends, and maybe they never were.

Wilson then leaves his office with his box and rucksack as House stands completely stunned. In the final scene, Wilson walks down the hallway as House remains in the office.

Leprosy is rare even in people with an extensive history of worldwide travel. Most people are naturally immune to it.

• The video game House is playing on the Xbox is Ninja Gaiden II.
• The Salvation Army is a Protestant religious denomination and charitable organization founded in 1865.
• More about Pewaukee, Wisconsin.
• A Tantō is a short-bladed Japanese samurai sword.
• "Miss Steinem" is a reference to feminist Gloria Steinem.
• Newark is the largest city in New Jersey and lies across the Hudson River from Manhattan, New York. It's the home of Newark International Airport, one of the three major airports serving New York City.
• Another reference to a "pine box" as a euphemism for a casket.
• Training wheels are a pair of small wheels attached to the rear wheel of a bicycle that holds the bicycle up while it's stationary. They are used for new cyclists to keep them from falling over when their speed drops too low. As in this episode, they are often used as a metaphor for someone who works with a lot of guidance.
• The episode ran one minute longer than its scheduled time slot. As a result, many people who recorded the episode missed the last scene.

Responsibilities of an attending physician:

On the show, the medically responsible physician for an individual patient is referred to as an "attending". The actual term for such a physician changes from place to place, but their responsibilities are pretty much the same no matter what hospital you're in:

• Approve all treatment and testing plans for the patient.
• Be available for junior staff (usually a resident, but possibly a fellow), either in person, by phone, or by pager.
• Delegate tasks the attending isn't capable of performing themselves to other qualified physicians.

Whether or not the attending actually does these things is irrelevant in determining whether they are responsible for the patient's care and the actions of the junior staff - the attending is deemed to be responsible even if they abandon the case (without finding a new attending), they don't see the patient, or they fail to respond to their junior staff.

Obviously, in this episode, Cuddy should have found the patient a new attending physician while House dealt with Wilson. Attending physicians usually report directly to department heads (who don't often act as attendings themselves because they often have to deal with administrative and educational tasks) but since House is also technically a department head, he answers directly to Cuddy.

Residents and fellows generally don't have a duty to report to the department head if the attending isn't following through. As such, responsibility for House's actions falls directly on Cuddy once she knows he isn't doing his job. House's team is clearly not following proper protocol by ordering tests (particularly invasive procedures) and approving treatment without getting his approval first. Cuddy does have a lot of faith in House's team, and deservedly so, but she would still have to discipline House if his team screwed up in this situation (see, for example, The Mistake, where House is suspended for Chase's mistake).

Medically necessary abortion:

Ectopic pregnancies are extremely dangerous. They are the leading cause of death in the first trimester of pregnancy worldwide, and are almost always fatal in the absence of treatment. Death usually occurs when the fetus outgrows the space it occupies and caused uncontrolled bleeding.

Fetal survival in an ectopic pregnancy isn't unheard of, but is very rare, and only happens when the fetus is allowed to come to full term. Even then, delivery of the newborn must be performed surgically.

As such, ectopic pregnancy is clearly a condition where abortion is medically necessary. If the condition is found early enough, methotrexate can be administered to chemically abort the fetus. Otherwise, the fetus has to be removed surgically.

House, unlike usual on ethical questions, is totally right here. It's difficult to understand Thirteen's position (which House totally, if inelegantly, demolishes in rebuttal), although the issue of attempting to save what appears to be a non-viable pregnancy was explored in Fetal Position. Luckily, the law appears to be clear - removing an ectopic pregnancy isn't defined in any way as an "abortion".

However, that doesn't seem to have stopped a small number of anti-abortion activists from trying to tie the two together. The American Right-to-Life Association (an anti-abortion group) has tried to point to successful full-term ectopic pregnancies. Although they don't oppose removal of ectopic pregnancies (as long as the physician takes no overt action to damage the fetus after removal) they have tried to oppose other forms of medically necessary abortions which are often referred to as "late-term", even though that term isn't a medical term of art. The chill on such procedures makes doctors reluctant to undertake them. They also oppose abortions in rape cases (see One Day, One Room) and incest cases (luckily not a possibility in Skin Deep).

Although Roe v. Wade is now well over 40 years old, its rationale is still deeply misunderstood. The law in question in Roe did allow abortions to save the life of the mother, but the majority felt the constitution required more to avoid trying to second-guess the decisions of physicians. One of the physicians intervening in the case made the point that it was difficult to determine, under the statute, which abortions were medically necessary. The court agreed:

"This means, on the other hand, that, for the period of pregnancy prior to this "compelling" point [the end of the first trimester], the attending physician, in consultation with his patient, is free to determine, without regulation by the State, that, in his medical judgment, the patient's pregnancy should be terminated. If that decision is reached, the judgment may be effectuated by an abortion free of interference by the State."

• Although it was probably correct that a patient in Lou's condition could not survive the general anesthesia required for surgery, she most likely would have been able to tolerate other pain management such as intravenous sedation, local anesthesia, or even painkillers during the hunt for the ganglioma.
• There are several different types of lymphoma and each requires a targeted approach with a different chemotherapy agent. A doctor would not just start a lymphoma patient on chemotherapy without confirming what type it was.
• Primary amyloidosis (which is the type generally seen on the show) cannot be distinguished from secondary amyloidosis without further testing.
• B12 deficiency cannot be cured with a single shot of the vitamin. In most forms of the deficiency, the patient may require a lifetime of ongoing injections, changes in diet, or a regimen of supplements.
• The blinking green light on the XBox controller House is using shows that the controller is either not physically connected to the XBox, or isn't properly connected. Either way, he couldn't be playing a game while the controller was in that state.
• The man in the coma constantly moves his hand as House uses it for a cup holder.
• The team initially rules out an infection because of the lack of fever, but doesn't put it back into the differential once she develops a fever.
• During the scene where House apologizes to Wilson, the reflection on the television frame in the background changes position, showing the source of the lighting or the position of the television has been changed.
• In the scene where Lou is sitting in the chemotherapy chair, her ankles are crossed when shot from one angle, but uncrossed when shot from other angles.
• The team only notices bruises just before making the final diagnosis, but they must have existed from the beginning and the team didn't mention them.
• It's stated that Lou's pregnancy caused the rest of her symptoms, including the scarring of her fallopian tubes that caused the pregnancy to become ectopic. But this implies that the scarring was somehow instantaneous.
• A reverse goof, something that isn't a goof in this episode but is done wrong in almost every other episode - the surgical team is all wearing eye protection.