At the beginning of the episode Cristina Yang was missing in action, having said simply 'that's how it goes' upon finding out someone else had won the Harper Avery award for which she'd also been nominated. She initially processed the loss on her own, going incommunicado after exiting the awards ceremony to the point of missing her original flight back to Seattle with Owen Hunt and Meredith Grey. Both Owen and Meredith worried about her and worked to find her via repeated phone calls to her or others who may have heard from her while the plane sat on the runway, to the point of delaying the flight until they ultimately and reluctantly returned to Seattle without her.
Besides personal concern about Cristina's whereabouts, there was a professional urgency as well when it appeared a transplant heart was now available for one of the pediatric cardiac patients she and Owen had been treating over the last several episodes. The tension in the OR was both cut and ratcheted up upon Cristina's abrupt reappearance, intent as she was on continuing her efforts to support this patient and her family. When she stepped in for rarely seen Cardio Chief Dr. Russell, Cristina maintained this was her patient and she would follow through on the course of treatment they'd started together regardless of her very recent professional disappointment. It was clear when she brushed aside all condolences on the loss at the awards ceremony with a terse 'it's an honor just to be nominated' that Cristina wasn't prepared to have any sort of emotional conversation on the subject just yet.
It's worth noting that we had to wait until the end of the episode again this week to see Cristina share her true feelings with someone and that she again chose Owen to be the person to whom she showed her true self in a callback scene to more of their shared history. This time, instead of sharing emotional intimacy on their secret hospital hiding place - the vent - the two of them stood sharing emotional truths fully clothed in a running shower. More on that later.
In true Grey's Anatomy angsty style, the heart transplant was too good to be true as even once Cristina skillfully placed the heart in their patient's chest it simply refused to beat. Leaving the patient on bypass upon finding out another donor heart was available in a nearby city, Cristina struggled with sharing this news with their patients' parents. It turned out the older daughter, though also struggling, was now at the top of the transplant list and would actually stand a greater chance of thriving post-surgery given the even more precarious nature of her sister who had remained in the operating room on bypass. While Cristina suggested a mechanical heart could temporarily be placed in the less stable sister to allow both girls a chance, the parents felt incapable of making the decision and put it in Cristina's hands.
Shaken by the situation, Cristina exited to evaluate all the data and make this nearly impossible decision as best she could. In a fraught round of scenes, we saw Owen and Cristina swing into action again on behalf of their very sick patients. We saw them prep for the heart to arrive by attempting to implant a mechanical heart into their younger patient in order to stabilize her. Initially the surgery seemed to have been successful, yet as they closed up her incision her weakened body began to shut down. Cristina was reluctant in the extreme to give up on their patient yet after almost an hour of attempts to save her life, Owen gently encouraged Cristina to step away from this patient as there wasn't anything more that could be done for her. As they shared a sad look it was clear they both knew they still had another young patient's life in their hands.
Later, the weight of their efforts hung heavy on both Owen and Cristina as they tried to express their sincere regret at the way things had turned out to their patients' parents. While they were able to share the good news that their older daughter's heart transplant surgery had gone well, they knew the news of their younger patient's death would tear apart her parents standing before them. The tears in Cristina's eyes betrayed her outward attempt at calm as their patients' parents cursed her from within their grief at losing their daughter. Owen backed up Cristina's efforts for the parents and also expressed his sincere regrets, trying to offer support to this family and to Cristina whom he knew had done everything she could for both patients.
At the end of an incredibly demanding day, Owen found Cristina standing fully clothed in a hospital shower, lamenting how her attempts to do what was right and provide her best professional efforts had resulted in such little direct result. It was again heartening to see that the one person who could just be there for Cristina, the one person she trusted to share her vulnerability with was Owen. As she questioned herself and all she'd tried to accomplish Owen chose to share with her news he'd received from Richard Webber who'd recently returned from a visit to Catherine Avery in Boston. Owen's news that Cristina had won the award based on votes and lost it due to politics broke her spirit and galvanized her all at the same time. We saw her look at him with both sorrow and fire in her eyes before purposefully striding out of the hospital into the night, a determined look on her face.
Elsewhere in the hospital: Jackson Avery was given the task of evaluating resources and results for all in-house research projects which earned him no friends among an already angered team of surgeons at the results of the Harper Avery award; Miranda Bailey struggled to reach the parents of her immune-depressed patient regarding her controversial treatment option; Alex Karev and Arizona Robbins faced the possibility of him accepting a private practice offer before he ultimately did just that and turned in his resignation to the board; Meredith and Derek Shepherd operated together while leaving their children in his sister Amy's hands for the day; Richard's surprise visit to Boston to propose to Catherine ended in sadness for them both; Callie Torres continued to mentor Jo Wilson in orthopedics; and April Kepner operated on a trauma case with Owen before going home to break news of her pregnancy to Jackson.