Chapter 37

At any given moment, the brain has 14 billion neurons firing at a speed of 450 miles per hour. We don't have control over most of them. When we get a chill ... goose bumps. When we get excited ... adrenaline. The body naturally follows its impulses, which I think is part of what makes it so hard for us to control ours. Of course, sometimes we have impulses we would rather not control, that we later wish we had. The body is a slave to its impulses. But the thing that makes us human is what we can control. After the storm, after the rush, after the heat of the moment has passed, we can cool off and clean up the messes we made. We can try to let go of what was. Then again … Meredith Grey; I Am A Tree

Lexie wasn't in a good mood. She was sitting in her old room. Nothing changed. Her parents had left everything as it was when she left. She stared at the smiley posters on the wall. She can't imagine Meredith growing up having smiley faced creatures on posters on her walls. She has been looking forward to meeting her. After she'd cooled down she wanted it. Even if she told her in the elevator that she didn't want to meet her. Maybe this was the reason for her sister rejecting her offer to get to know her. Lexie let her thoughts free room. She had nothing else to do. In this moment, Molly knocked against the door. "Get out." Lexie called as she opened the door but Molly did it anyway. "I told you this wasn't a good idea." She said tentatively. "What do you want from me, Mol?" Lexie said back. "The satisfaction that you were right and that I shouldn't have gotten my hopes up." Lexie ranted. "I just had this picture in my mind. I liked the thought having a big sister but now …" Lexie continued. Molly came in and closed the door after entering.

"She probably just needs time to warm up, Lex. This isn't the end of it. You wait a few days and then you try again, maybe you'll fail and maybe not. It's all open in the cards. You can do it, Lex. You just need to keep on faith." Molly assured her.

"You really believe this, Molly? Or are saying this to cheer me up?" Lexie answered grumbling.

"Stevens, you go first." Dr. Bailey said, her voice was intimidating to Izzie who just nodded. Meredith waited for her question which will probably be asked after Izzie got hers. "But you said that Meredith gets a question." Izzie asked in panic. She didn't want to go first. "She also said you'll get a question for attacking your co-worker." Cristina interjected in a snarky tone. "Yang." Dr. Bailey chastised her by saying her name warningly. "Sorry for that, Dr. Bailey." She apologized, not wanting to be like Izzie with her somewhat childlike behavior not only toward Meredith but all in all everyone.

"So, now that we've established that Stevens and Grey both will get a question to show off their talent, does anyone else want a question?" Dr. Bailey looked around questioningly. But everyone else stayed quiet.

"Here we go, Stevens." She introduced. Izzie shifted nervously.

"What is the procedure to repair an anterior spinal cord compression at C4 and central canal dilation?" She asked. "You're a general surgeon. I thought you'd ask me a question concerning general surgery …" Izzie stuttered a bit in over her head.

"Are you questioning my expertise in other specialties? Stevens, a well-rounded education is necessary. So yes, I know the answer to that question. If I didn't I would not be asking that question. You just earned yourself two days in the pit in a row. It's presumptuous to maintain that I haven't undergone a solid and well-rounded education including, Stevens, the basics. It's important to remember the basics. Remember this the next time you question my ability to do my job." Bailey ranted, her interns held their breaths, they feared that there was an eventual crackdown to come.

Izzie held her head down for the time being. "Grey, do you know the answer? Or any of you?" Bailey questioned her other interns after Izzie failed to answer that question. "Reduce fracture with a halo device, you follow with a C4 vertebrectomy and with a C3-5 plating." Meredith answered quickly. Cristina also attempted to answer it but Meredith beat her to it. Meredith remembered Derek telling her about this when they were learning. She was using his flashcards, the flashcards he used when he was learning for his boards. This was an advanced neuro question and Meredith was able to answer it.

Meredith had no idea why her questions were always way harder than the others but she seemed to think that it was because she had more to prove.

And apparently, she aced it.

"But Bailey, this isn't fair, she's spent way more time on neuro than any of us." Izzie complained, it appears she hasn't learned from what just happened. "Had I spent more time on neuro I would have been able to answer that question." Izzie stated, trying to save her reputation.

But everybody knew it was a lost cause.

She was acting like the enemy of Meredith without having a proper reason for it and that is what nobody understands. She is stirring up problems out of the blue.

"Did I just hear you complaining about my decision, my questions?" Bailey enquired the blonde intern.

"Uh, no." Izzie stuttered. "I just think that it isn't fair that Grey is assigned to a surgery and …" "You're not?" Bailey interjected harshly. "Is that what you wanted to say?" "It's not fair, I haven't spent as much time in neuro as she has." Izzie told her. "Boohoo, Stevens, in case you haven't noticed, life and especially work life is never fair. You might as well get used to it." She advised. "Well, she's got a boatload of reasons for being favored. For starters, she's Ellis Grey's daughter, second Shepherd and her, they are in a relationship – sue me if I start thinking of him pitching her extra surgeries. And for one, there is the whole heart thing." Izzie pointed out, her voice dripping with jealousy. Meredith was too shocked to say anything coherent. Izzie stole a heart for a patient, for god's sake. She's not getting any special treatment. There is no way she was getting surgeries due to one of her relationship with two word-class surgeons.

"Is that why you think Grey is being favored?" Miranda eyed the intern. She couldn't believe this. She personally makes sure no one is being favored and now rumor has it that Grey is being favored. Just because the girl went through something, does that mean that everyone thinks she is being favored? She needs to set these interns straight. But maybe not today, for today she'll watch them closely.

"Yes. I do." Izzie said confidently.

Meredith gasped when she heard what Izzie thought about her. When has she been favored by anyone? She has been on charts a few times after she came back. She only got the adrenalectomy 'cause she saw something pathologic on the labs. She had a reason for scrubbing in on that surgery.

"Dr. Stevens, I can assure you that none of my interns is being favored, not in any way. Also, Shepherd outranks me, as much as I don't like it, so he can make certain requests and it is my job to make sure none of you are being favored." Bailey's voice was ice-cold. Izzie scoffed. "Whatever you say, Dr. Bailey." She retorted gruffly and not in her best mood. Meredith couldn't believe this was happening. Izzie had been acting the same way when she got to know about her relationship with Derek in the first place.

She thought it was about getting ahead, him pitching her some really cool surgeries, that she was using him or he was using her … which had been complete crap.

This wasn't about getting ahead.

"Grey?" Dr. Bailey called Meredith's name. Meredith was glad she was being fair.

All the others fell silent as they held their breaths and watched the scene unfold for their very eyes. "Since you're interested in neurosurgery, I'll ask a neuro question." She said. Meredith nodded. She was ready. Cristina looked at her, she was sure Meredith would be to answer that without any difficulties.

"She gets to choose about which specialty the question will be? It's not fair to any of us." Izzie exclaimed in jealousy.

"She does not get to choose."

Bailey scowled angrily, before she once again reaches her rope with her.

Cristina groaned quietly, only for Izzie and Alex to hear. Alex Karev shot her a knowing look.

He'd been watching this. In that moment, Cristina had to suppress the urge to scream at Barbie. When anything was unfair it was the way Izzie treated her person ever since the truth came out. And Cristina wasn't the type of girl who gets angry over nothing but this was hard to watch. Meredith wasn't sure if she wanted to know what this was about. This was somewhat high school-like. Seriously, she thought to herself. "What are the differences between anoxic and hypoxic brain injury?" She asked with a straight face. Meredith knew if she wouldn't be able to answer this question it would be a satisfaction for Izzie. So she needed to be able to answer this question.

"Hypoxic brain injury is caused by a reduction in oxygen supply to the brain and Anoxic brain injury when there is a complete lack of oxygen to the brain. Both conditions can occur despite sufficient blood supply to the brain. The brain consumes 20 % of our oxygen supply so damage can happen very quickly and despite sufficient oxygenation." Meredith answered with an unwavering voice. She was completely sure of the rightness of her answer. And everybody felt it.

"What causes anoxic brain injuries?" Bailey wanted to test the young doctor.

"Do you know the answer to that?" George whispered over to Izzie who seemed to ponder what she just did. She undermined her fellow surgeon's ability to do her task with her actions and now she was being proven otherwise. That Meredith was in fact qualified of being on Derek's service. In no way she was getting extra treatment out of her heart defect. "No, I don't." Izzie mumbled back, she was obviously ashamed. "Stevens, care to fill us in?" Dr. Bailey said in booming and intimidating voice.

"Have you something to add?"

Stevens was caught off guard by the general surgeon with furrowed her brows. "Uh no, Dr. Bailey." She stuttered, she was wringing her hands nervously. "Since you don't seem interested in listening to what Meredith has to say

Alex, Izzie and George were gaping at her. Meredith really could answer all these questions.

"Grey?" She asked Meredith to continue answering the question.

"Stroke, near drowning, heart attack, drug overdose, strangulation, severe asthma event/s, accidents involving anesthesia, carbon monoxide inhalation and poisoning can be causes of those conditions." Meredith replied, she didn't see that Derek was watching the scene of Meredith answering difficult neuro questions.

"Hypoxia can also occur as a secondary injury following a traumatic brain injury, for example, when there is serious blood loss resulting in low blood pressure or as a result of brain swelling that restricts oxygen supply to areas of the brain." Meredith told her, feeling completely in her element. She loved neurosurgery. "Oxygen is crucial to the brain as it is used to metabolize glucose, which provides energy for all body cells. Most of the brain's glucose is used to send impulses and keep cells alive. Brain cells are sensitive to the effects of restricted oxygen supply and may begin to die within minutes of oxygen restriction. Therefore it's important to re-establish blood flow. The immediate outcome of severe oxygen restriction is often coma and in very severe cases brain death. Long term outcomes can be problems with cognition, emotions and movement." She summed up.

"Dr. Grey, I have to say after all the problems you put us through that I am incredibly proud of you. I have no doubt that you'll pass this test hard and with flying colors. Good job, Grey. You should think about specializing in neuro." Bailey remarked. "Well, I do." Meredith grinned happily.

"You have thought about it?" She asked.

"I have." Meredith confirmed, surprised by the turn things were taking. "You have a real talent, that's hard to come by. Don't squander it." "I just answered a few questions right, Dr. Bailey. I am not allowed to take a scalpel and operate all by myself. Only then, we'll see how much talent I have."

"Geez, you can't really accept a compliment, can you Grey?" "I just don't want people to think I got here because of my mother's legacy, simply because it's not true." Meredith knew she was talking too much. In this moment, Derek was walking forward toward Bailey and the group of interns summoned around her. He's saved her unknowingly. "Good morning, everybody, may I be able to borrow one of your interns for the day?" He said, flashing on of his McDreamy smiles. But the other interns were immune against that glance. Only it happened that Meredith wasn't. She saw that Izzie was gawking at the neurosurgeon with wide eyes.

Mine. Meredith couldn't help but think as she saw the way her colleague was looking at Derek.

Derek ignored the staring doctor and waited for Dr. Bailey's reply.

"Grey, you're with Shepherd. He's requested you for the day."

Meredith suppressed the urge to jump up and down. Derek had kept his word and she was on his service. "Thank you, Miranda." Derek Shepherd said. As Meredith walked up to Derek, Alex took her aside and whispered: "Wow, I wouldn't have been able to answer the question Izzie got asked and you just …"

"Thanks, Alex." Meredith smiled shyly.

Alex was a good guy under the harsh surface. But reality it was all just a defense mechanism. "What was that about?" Derek asked after Alex walked away. "Bailey questioned me and Izzie. I practically answered every question. I mean the first one, to be fair, was difficult. A question a fifth year neuro resident would get but I was able to answer it." Meredith told him.

"Don't make me regret it." She called back. "You won't." Derek replied. "Dr. Grey, follow me please." When Miranda was out of sight, Derek stopped and turned to Meredith who looked at him expectantly. "Did I do something wrong?" She asked awkwardly. "No, you didn't. I just heard the questions. They were pretty hard. I mean, can you tell me …" "You again with the questions?" Meredith moaned slightly. Everywhere she went, questions were following her. She would be so happy if the intern test was already over and done.

"You have a problem with that, Dr. Grey?" Derek said coolly.

Meredith flinched slightly and quickly shook her head to tell him no. "Okay, we're good to go then. What's stagnant ischemic hypoxia?" Derek looked at her expectantly. "So again about anoxic and hypoxic brain injuries?" Meredith said. Derek nodded.

"Yup. Again." Meredith thought about it for some seconds before giving him the right answer.

"It's also called hypoxic-ischemic injury and it means that there is inadequate oxygen supply to the brain due to reduction of cerebral blood flow or blood pressure and can be localized or generalized, but typically causes general, diffuse damage to the Cerebral Cortex and Cerebellum. Causes of this type of brain injury include stroke, heart attack and brain hemorrhage. Pressure on the brain caused by hydrocephalus or brain hemorrhage can also be a cause of stagnant hypoxia." Meredith rattled down everything she could think of. Hopefully it was right. It'd be embarrassing if she wasn't. But when Derek's face lights up like a Christmas tree she knew her answer has been right.

"You've earned the spot on my service, Dr. Grey. Enough with the teaching, we have a patient to see." Derek as he walked down the hall in high-speed. Meredith accelerated her pace as well to be able to catch up with him.

"The patient who is here for the aneurysm clipping?" Meredith asked.

"Yang, Montgomery needs a hand in the N.I.C.U. Go. And the others, you will spend your day in the pit and if there is not much to do you will learn for this test. This test is important, it'll determine the direction of your career. Some of you still have some serious deficits." She was looking at Izzie Stevens, hinting that she was the one who still has a lot to learn. "Dr. Bailey?" Izzie raised her hand. "You have a problem?" "Why aren't Grey and Yang here, listening to this?" She asked, Bailey felt like her intern was demanding to know that. Bailey frowned at Izzie who didn't seem to notice that and answered with: "Grey can answer the questions, Yang as well. Karev probably can too but him I didn't ask. Yang, you're on Montgomery's service, Karev, Stevens, O'Malley, ER, hustle." Izzie saw that it wouldn't work. She would have to work in the pit this day.

Her interns walked off to the ER.

"But I've got the tonsillectomy, Dr. Bailey." George warily protested. Dr. Bailey just replied with: "The tonsillectomy isn't until 12 AM so go, ER now." She ordered them. With protesting and moaning, Izzie and George followed their resident's request. Alex was already on his way down.

Yang was on her way to Addison Montgomery who said that she'll met Cristina in the N.I.C.U. Dr. Yang entered the neonatal intensive care unit after putting on a special gown for the neonatal intensive care unit. She walked through the room, past incubators with more or less premature babies or babies with severe medical conditions until she saw Addison standing over an incubator with a seemingly very young baby. "Dr. Montgomery, you requested me for today's case?" She said, coming as always straight to the point. Addison turned around as soon as she heard the young doctor speaking to her.

"I did." Addison cleared her throat.

"This little guy is Jeremiah Johnsen, gestational age is 26 weeks. He was born four days ago, has spent them in the N.I.C.U. due to difficulty adapting the changes. We have detected a *Pulsus celer et altus* meaning a large blood pressure amplitude with high systolic and low diastolic pressure." "The PDA hasn't closed yet." Cristina remarked as she heard what Addison said about the baby's pulse. "It hasn't and since he doesn't need it anymore, we need it to close. Yang, what are the factors of a not closing patent ductus arteriosus?" Cristina looked over to small baby in the incubator before attempting to answer: "A PDA normally closes within the first days of life. If that doesn't happen it can be due to low O2 partial pressure and elevated prostaglandin levels since prostaglandin is known to keep a PDA open. Therefore it's often used in babies with ductus-dependent babies to keep them stabilized before they go into surgery."

"Symptoms?" Dr. Montgomery was aware of the intern test and wanted to prepare her for it by asking her several questions about her field. "Symptoms are fatigue, sweating, rapid breathing, heavy breathing, congested breathing, disinterest in feeding, or tiring while feeding, poor weight gain." Cristina answered easily.

She loved cardiology and this was cardio. She was excellent at everything cardio-related.

"But in his case, the PDA does more harm than good and isn't closing itself. I'd treat it with ibuprofen and if that does not work, I'd opt for surgery." Cristina ended. Addison called over to a nurse so she can administer the ibuprofen. Hopefully, the PDA will close. "He'll need an echo, and an x-ray to confirm this. But sadly, this isn't his only medical problem. He's got underdeveloped lungs. Poor guy's got RDS." Addison added after a look in his chart. "Isn't Respiratory Distress Syndrome quite common in preemies this size?" Addison nodded. "Most preemies have this kind of respiratory problems. His sats are pretty low so probably it's for the best if we put him on oxygen as well. Yang, can you tell me what RDS is?" "Respiratory distress syndrome, it's also known as hyaline membrane disease, occurs almost exclusively in premature infants. The incidence and severity of RDS are related inversely to the gestational age of the newborn infant." Cristina told her in her Cristina-tone. "Treatment for RDS?" antenatal steroids to enhance pulmonary maturity, immediate use of continuous positive airway pressure and the use of gentler modes of ventilation including early use of "bubble" nasal CPAP to minimize damage to the immature lungs, it's also important to early administer surfactant, then there's fluid and electrolyte management, trophic feeding and nutrition, and the use of prophylactic fluconazole you can do to better his chances."

"Good. So what about treatment options for the PDA?" Montgomery asked.

"Well, for one there's PDA ligation and there is also the option of closing it using a catheter but since the patient's a preemie, I'd go with treating it with a dose of indomethacin since it's known to close those defects. Indomethacin is related to aspirin and ibuprofen and works by stimulating the muscles inside the PDA to constrict, thereby closing the connection. But as for diagnosing I would do an echocardiography, maybe chest x-ray and ECG." Cristina said.

"Well, let's do that. Will you please order the echocardiography?"

They did the ECHO and the chest x-ray. On the radiograph, they saw the shows poor lung expansion and an air bronchogram but no cardiomegaly due to the PDA. So that's "good". After confirming the underlying condition with those procedures, Montgomery administered the medication intravenously, hoping it would work and he wouldn't need surgery.

Dr. Derek Shepherd and Dr. Meredith Grey entered the patient room where an elderly woman waited for them. Meredith had the chart. "Good morning, Mrs. Karolinska. Dr. Grey, please present the case." Derek ordered. "Tanya Karolinska, 46, came into the ER complaining of persistent headaches and vision changes. An ordered MRI revealed a large saccular aneurysm on the basilar artery with a warning leak that needs to be fixed before it causes further damage. She's now scheduled for an angiogram and as soon as we get the results, for surgery." Meredith presented the case. "Aneurysms rupture at about 1-2% per year but it varies with the size, location and history of previous aneurysm rupture. Unfortunately, most aneurysms present because they have ruptured." Meredith said, remembering her first case with Derek, Katie Bryce with the subarachnoidal bleeding after a ruptured brain aneurysm. She presented with seizures and at first they couldn't figure out what was wrong with her. "Can you please operate before this thing in my head explodes?" The patient interjected worriedly. "Sure, we will clip the feeder to aneurysm before it causes any problems." Dr. Shepherd replied in a calming voice. Meredith started to examine the patient before she gets prepped for anything.

"These are just questions for a teaching matter. In some way our doctors have to learn too. Before they start cutting they need to be ready for it." The patient laughed, she seemed comfortable with the young doctor doing her pre-op exam.

While Meredith did the exam, the woman told them some things about herself. "Everybody needs to start at some point. I teach little children. I am an elementary school teacher. I know what you're talking about, I am very happy to teach you." She added as she looked at Dr. Grey who smiled before looking over to her boss. "I'm flattered." Meredith smiled sympathetically at the patient before continuing the exam. "Look up." Then: "Down." The patient followed her orders.

"Good." She said, she felt Derek watching her intently.

After she'd completed it, she made a quick note in the chart and put the pencil aside. Derek watched her. "Dr. Grey, symptoms of aneurysms, go." Derek surprised the young doctor but Meredith had no problems answering them. "Occasionally, large aneurysms can present with vision changes, pain above and behind the eye, nerve paralysis, localized headache, neck pain, nausea and vomiting, or other neurological symptoms." Meredith answered his questions. "How do we diagnose this kind of condition, Dr. Grey?" Derek asked his intern. Meredith cleared her throat before answering that question as well. "CT (computed tomography) and MRI (magnetic resonance imaging) are used commonly to assess patients with these complaints. These are noninvasive methods but most patients with aneurysms need cerebral angiogram for definite diagnosis and to determine course of treatment." Meredith retorted.

"What procedure is better when wanting to detect active bleeding?" Derek asked.

"MRI does not involve radiation or contrast risks, while a CT produces better resolution and is better for operative planning. Patients suspected of having a ruptured aneurysm typically undergo a CT scan of the head and a CT angiogram, which shows subarachnoid hemorrhage and the aneurysm." Meredith answered that question. "You seem to be very good." The patient noted. "She was able to answer all your questions." Derek grinned. She knew Derek was asking her all these questions because it's a teaching hospital.

"Good, prep Mrs. Karolinska for an angiogram. We'll clip this this morning after the angiogram." He said. "Go, book an OR, Mere … Dr. Grey." Derek told her.

The patient noticed his mistake and blinked as Dr. Grey left the hospital room. As she was sure that Meredith had left the room she gazed over to her surgeon. Derek was scribbling something in the patient's chart. "You love her, right?" She exclaimed with a laugh. "Is it that obvious?" Derek chuckled in reply. "It was." Mrs. Karolinska chuckled a bit, causing Derek to look away. He just couldn't hide wanting to be with Meredith. He was happy when she'll finally agree to others than his mother, Mark and Cristina about the upcoming wedding. He was looking forward to the day where Meredith would become his wife-officially. "I really can't keep a secret." He muttered to himself. The patient heard that as well. "Oh, well, dear maybe you should …" "What?" Derek smiled as he played with the pencil he was holding in his hand.

"Did you ask her out?" She pressed, wanting more information. "If you like her you should." She said, giving dating advice. Derek chuckled slightly as he revealed the truth about him and Meredith.

"Well, we are together. Meredith and I, we are involved." Derek told her. "Oh that's pretty amazing. I can tell you fit well together. How long have you been together?" "Almost for a year, at first it was more like on-off-on again but eventually we found each other and I am glad that we did and I am glad for every day I get to spent with her." Derek told her, his blue eyes sparkled with life. "Is it a secret, your relationship?" "Well, we like to keep our work life and private life apart. But our relationship is not a secret. We're just being strict professional at work. Anyway, I need to get back to work." Derek tried to find a way to get out of this interrogation.

"Marriage?" The patient asked, looking for distractions.

"We'll get married soon. We just wait for an appointment at City Hall." Derek explained. He had no idea why he was sharing all these intimate things about their relationship with his patient. "Oh, come on. It's a wedding. You think about doing it in a church."

"Meredith wants to keep it small. And I love her to death." Derek confessed. "Oh, this is so sweet and romantic." The patient beamed happily. She was trying to take her head off the surgery. "I want to build us a house on my land." He even prepared blueprints for their imaginary house in the woods. He can't wait to show her. "How romantic." Mrs. Karolinska exclaimed.

Derek continued after looking to the hallway. Meredith Grey wasn't back yet so he still had some time to discuss things with his patient. "I haven't told her yet. I will tell her when she's ready. I need to find the right moment or she flees. She scares easily."

"She loves you, right?" "She does." Derek replied with an easy and honest smile. "Then she won't run. Or maybe she will but she'll come back at some point."

"You think?" Derek felt awkwardly comfortable discussing Meredith and their relationship with this woman. She seems wise and like she's lived. "Yeah."

"So I don't have something to be scared about?"

"No. Have I?"

"No." Derek answered short out.

In this moment, Meredith entered the room again. Derek and the patient were talking but fell quiet when Meredith entered the room. "OR is booked for this morning." She said, she could barely get a word in edgewise. "Oh thank god, this ticking time bomb really scares me. I mean you said it could rupture." The patient changed the course of the conversation. "Yeah, that is one of the complications." Dr. Shepherd replied. "Complications? What are the complications of not fixing a warning leak?" The patient demanded to know. "Rupture, bleeding, death." Meredith answered.

"How soon can we fix it?" "I know you're scared but Dr. Shepherd, he is the best there is. You are in very good hands." Meredith assured the patient. "So, I still need to take some blood for the pre-op labs and then you're good to go." Meredith said as she prepped the syringe. "I'll be done in a whiff." She said. Soon, they patient was being transported to the OR that's already been prepped for that kind of procedure. "Okay, Mrs. Karolinska, I am going to inject a sedative which means you won't feel anything. You will be sleepy during the procedure." Derek told his patient. Both he and Meredith were wearing those special aprons since they are being exposed to radiation when doing this. An angiogram is an invasive procedure during which a neuro-interventional surgeon, in this case, Dr. Shepherd, guided a flexible catheter through an artery over the hip to the vessels of the brain. After they injected liquid dye or contrast agent into the vessel, they could see the structure of the blood vessels more clearly. "What do we do now?" Meredith asked her attending as she looked at the monitor where they could see the vessels. "Look, you see that form on basilar artery?" "That's the aneurysm." "It's not bleeding." Derek said. "So we're still good." The heart monitor was beeping rhythmically in the background. "Now we take pictures with the fluoroscope." He explained. Meredith nodded to signal him that she understood. This gives the highest detailed pictures of the location, size, and shape of the aneurysm which is used to determine the best treatment option." Derek added as he removed the catheter.

After completing this procedure, Meredith asked her attending if she could go grab a snack before heading to surgery. "Sure, I'll speak to the patient. I will see you in the OR, Dr. Grey." Derek smiled her lovingly as no one looked.

Meredith hinted him a smile before disappearing. Meredith saw Cristina and her other fellow surgeons sitting at a table in the cafeteria. "Hey." Meredith said as she stopped on their table. "Hi, Mer." Cristina acknowledged her presence. "I don't have much time, I am scrubbing in on an aneurysm clipping with Derek." "You're just scrubbing on an aneurysm clipping?" Cristina asked bored as she looked at Mer. "And you can't let us forget it." Izzie mumbled under her breath- Meredith raised her eyebrows as she fixated her gaze on Izzie. "What the hell is your problem with me?"

"With you? I don't have a problem." Izzie never really replied.

"I just spend the whole damn morning in the pit with treating patients with minor medical issues while you got a good neuro case just because you answered some idiotic questions every idiot could have answered." "And still, you couldn't answer them, Izzie." Meredith couldn't not say it. She had too. "So you're more of an idiot than you think." Izzie never replied. Meredith enjoyed the silence before Izzie started up again. "You always get extra time with your hubby." She said. "I just wanted a place to eat my meal in peace before going back to work. But it seems like every person I know is determined to make my life hell. I have to work doubly so hard after everyone got to know about my CHD. So what is it, Izzie?" Meredith asked her as she carefully laid her fork next to her plate as she fixated her gaze on Izzie.

"You always get the neuro cases, you are always on neuro rotation. And we others are stuck doing sutures in the pit." Izzie complained about the "unfairness" of the situation.

"So this is about me working with Shepherd?" Cristina watched the bickering between those two as she was eating her apple. As Izzie doesn't reply, Meredith groaned exasperated. This really was like high school. "Oh come on, it's a simple aneurysm repair, nothing big." Meredith downplayed it. "At least you get to see the inside of an OR. Look at us others, we're stitching up idiots in the pit. Well done; Meredith." "Oh, come on it's not all it's cracked up to be." Meredith answered, not getting down on her level. Alex and George were just sitting there, being mature and all and were eating their lunch. "Today's spaghetti on the menu, isn't it?" Meredith asked. Cristina nodded with her head in reply. "I'll be right back." She said as she walked over to the counter to get her portion spaghetti. That meal is at least eatable considering it is hospital food. Meredith returned to the table. "Have you already told people about …" Cristina asked curiously. "Cristina, not now." Meredith hissed annoyed. They weren't even alone.

"Have you already told people about what?" Izzie jumped in causing Meredith to jerk up. "Nothing." Meredith avoided. "Well, you've had your share of things you kept in the dark." Izzie grumbled as Meredith wouldn't tell her.

When Meredith has finished her spaghetti she went to find Derek. He was in his office, catching up on paperwork. She opened the door without knocking. Derek had allowed her to do that. "Derek, I'm ready." She said as she sat down on his sofa. "I have to get through this today. It needs to go out today. Will you wait for me till I'm finished?" He asked without looking up from his desk. "Sure." Meredith replied, she snatched one of his neurosurgery journals and skimmed through it. "Yeah, of I will. I am hiding." "Hiding?" Derek replied with a frown. "Why are you hiding?" He put his pencil aside as he looked at Meredith for a moment. He saw that she has problems with one of her colleagues that is supposed to be her friend but doesn't act like it. "I'm hiding because Izzie is out to make my life hell." "Jealousy. She knows you and Yang are the interns to beat and has no way to change that." Derek told her. "Are you okay?"

"I'm fine. Why wouldn't I be?" Meredith replied. Derek sighed. Meredith was shutting him out. He just hoped she'd come to him later on when she can't do it anymore.

Later, as his patient got prepped for the surgery, he walked into the operating room. "See you afterwards." Derek told his patient as he put on his lucky scrub cap. Meredith was still in the scrub room scrubbing in. When Meredith entered the operating room the patient was already under and they were ready to start. Meredith noticed that Derek was wearing his ferryboat scrub cap. He said the exact lines he always says before cutting someone open.

"It's a beautiful day to save lives. Let's have some fun."

They were doing a keyhole craniotomy. They were clipping the aneurysm. He started by making an incision in the skin over the head, Meredith was watching closely. The neurosurgeon continued to make an opening in the bone with the needed instruments and dissect through the spaces of the brain, he mobilized the posterior communicating arteries. Meredith stood next to him with the suction and irrigating the spot so that he has clean visual field. "I am placing the temporary clip on the basilar trunk." He said as Meredith watched his precise moves. She could only dream on this herself, maybe she'd do something like that in her third year. She could only watch, take in the thrill of the cut.

"Can you believe this?" Sometime into the surgery, Izzie's persistent voice said. Meredith heard it over the intercom. They forgot that when the red light blinks, it's on speakerphone. So Meredith was able to listen to their conversation. "Just because she can answer every damn question in the book it doesn't mean she's superwoman." Izzie made a snide remark, stirring up trouble. Alex tried to ignore the sneering remarks of the blonde intern. Only Alex, Izzie and George were there. Cristina was down in the pit, working on patients or in the N.I.C.U., working on the preemie case. She was working as in really working. "I mean, I accepted that has this fling going on with Derek and all but does that mean she gets all the good cases? I don't care what she does with him. That's her problem but it is my problem when it interferes with my surgical career and education. She's constantly stealing my surgeries as she did with the adrenalectomy." Izzie complained non-stop. Meredith swallowed and turned her view to the side, focusing back on the surgical field. Derek glanced up as well. He'd heard them talking. When he heard Izzie saying that his relationship with Meredith was just a fling his blood started to boil.

She's not a fling. How dare she say that? How dare she?

Derek closed his eyes for a second, only to open them a second later and continue with the surgery. He felt Meredith's presence next to him and tried to block everything else out.

When Meredith looked up to the gallery, she saw her peers sitting there and watching her. "She's the only one who got a surgery today. Those daddy issues are working for her. And she's got her neurosurgeon boyfriend who lets her scrub in on all the good cases." She said with enviousness. Meredith felt her chest tighten in anguish. She couldn't believe how some of her so called friends slowly turned against her. It was like a stab into her body as she realized that. Meredith slowly looked up to them, keeping a straight face and not letting them know how much these words hurt her. She tried to cover it up.

Alex groaned repressed, rubbing his hand over his face.

"I got a surgery too, she's not the only …" He was cut off by Izzie: "Just because Robbins needed a hand, Alex. Otherwise you'd be stuck in the pit as well." "Well you don't look like you're stuck in the pit, Stevens. Just stop trying to crush Mer!" He exclaimed. "Why are you taking her side? She hid this from all of us." "What this?" Alex snorted at Izzie's ignorance. He's grown fond of Meredith and just couldn't explain Izzie's unexplainable behavior. "Well, when looking at your extraordinarily immature behavior it might have been the correct choice. So yeah, I'm choosing hers. She's like a sister to me and brothers protect their sisters when they need it." "Sister? You're not her sister, she's an only child, asshole." Izzie just scoffed. "We might not be blood-related but she is and don't dare question that. You have absolutely no right to do this." "Zzz, just because everyone's become worried about her and all, she …" Alex got up from his seat in the observation room and faced the blonde doctor. Izzie continued to sink in his esteem.

"You do this to her just because she's suffering from a CHD? Are you freaking hare-brained?"

Before Alex could go on ranting, his pager shrieked. "It's Robbins, I have to go." "Dr. Karev, would you mind turning off the intercom so we could get a little piece and quiet down here?" He asked.

"Sure, Dr. Shepherd." He said as he got up and turned off the intercom, glancing for one last moment down and then left. He walked toward the pit where Robbins was waiting for him. "Alex, there you are. We've got a ten year old with a possible tibia fracture in more than one place." She told him. "Ambulance is four minutes out?" "Should I call orthopedics for a consult?" Alex asked, now fully in work mode. Arizona nodded. "Also secure an operating room just in case." She said as Alex nodded in understanding. He ran off to the nurses' station and paged orthopedic surgeon Dr. Callie Torres who came within the next two minutes.

Izzie has fallen silent after Alex left and Meredith was thankful for that. Meredith's breathing has been accelerated a bit after hearing what Izzie thought about her. Derek felt her sucking in air, trying desperately to concentrate on what's important. She can't give Izzie this kind of satisfaction. As Meredith felt Derek's concerned glance lingering on her, she gave him an imperceptible nod telling him she would be okay and that she wasn't on her way of hyperventilating. Slowly her breathing eased up and slowed down. "Let's continue." Derek noted as he saw that Meredith would be okay. "This prevents the blood flow from entering the aneurysm." Meredith said as he placed the clip across the aneurysm where it arises from the blood vessel. "Correct." The scrub nurse handed him the Penfield 4, the neurosurgeon carefully navigated through the mess of perforators so that he wouldn't nick them and followed the PCA back to the basilar tip. Soon he had located the neck of the aneurysm. "Continuous suction, Dr. Grey and I am going to need a straight seven millimeter clip, Bokey." Derek ordered as he concentrated on clipping the aneurysm. "It's berry-shaped." Meredith suddenly noted."It is." Derek confirmed.

He then applied the clip and both he and Meredith held their breaths. But nothing happened. "Clip is on, there's no bleeding. How are the patient's sats?" Derek asked, looking up from the microscope.

"BP's holding steady, 112 systolic and heart rate's 77." The anesthesiologist noted.

"ICP's in the normal range." Meredith looked at the monitor. "Good. Get ready for matador move." Derek announced. The scrub nurse handed him the needle to make sure he'd completely ensured the aneurysm. He inserted the aneurysm dome and only a little blood trickled out of it, meaning he had done his job right. He released the temporary clip to re-establish normal blood flow to the brain.

"Meredith, you want to close up?" Derek asked her.

"Sure." Meredith replied as she glanced at her superior. "You can do it." He encouraged her. "I know. And I like you breathing down my neck like this. Sorry this was inappropriate." Meredith said, he was hovering as she did what has to be done. Meredith put the piece of the skull back where it belongs. When they finished the surgery, the patient was moved to PACU to be monitored. "I'll stay the night." Meredith said. "I want to have to pull an all-nighter." She said. "Maybe then someone will respect me."She said defeatedly. Derek noticed that something was wrong by solely looking at her and listening to her words.

"Don't work yourself into the ground." Derek, as always, was concerned about her.

He knows she'll work until she can't anymore if no one stops her. She is that stubborn. "Derek … Dr. Shepherd, I assure you there's absolutely no need for being concerned. I can pull this off, an all-nighter. Everybody does, I am an intern, I need to log more hours in the OR and that is the right way to it." Meredith told him as she walked toward the post anesthesia care unit where her patient was being monitored until the anesthesia's wearing off. "Just remember to make sure that you make breaks whenever possible and eat and drink on a regular basis. We don't need to add dehydration to the list."

"Well, that sounds somewhat familiar." Meredith noted.

"Derek you don't need to hover all the time. I'm okay, I really am. Stevens' words don't hurt me." Derek knew she meant the opposite but he didn't let on that he got the real message behind her sayings.

"Okay then, Grey, you page me she makes up. Do a neuro exam every three hours." Derek said. Meredith was familiar with post-surgery protocols but he said it anyway. "Derek." Meredith called after his retreating back. "I will monitor her but is it possible that I could find Cristina for a minute? Then I can go back to my doctor duties." Meredith really hoped he would agree. But maybe he'll play the attending card and won't let her. Derek nodded, taking in Meredith's expression. He could read defeat and silent anger in it.

He figured it was due to the cold and harsh treatment she was getting from Izzie albeit with no good reason for it.

"Ten minutes coffee break." He told her but suddenly his features changed noticeably. He was more like the Derek she knew outside the hospital and less the attending Dr. Shepherd. "But …" He began and after glancing to the right and left, he pulled her with him into an on-call room and closed the door behind him. Meredith looked at him, not knowing what he wanted.

"Is that how the others treat you?" He said in a serious tone.

Meredith pressed her lips together before nodding resignedly. "They hate me. At least Izzie does."

"She lives in your house, Meredith." Derek noted. "I know." Meredith took a deep breath. "But I don't get it. Why is she so determined to make my life hell?" Meredith asked helplessly. "She just humiliated me and us in front of an entire OR team." Meredith shook her head, she didn't understand why she was suddenly Izzie's enemy. "She'd been complaining about me being your service. She thinks I'm … that you favor me." Meredith told him. "I know, right now you're not my fiancé, you're attending. I can't keep doing this." Meredith said. "You can't keep doing what?" "I'm good at what I do." Derek nodded in affirmation. "But she makes me feel like I am not deserving this. That I am not able to do this, the last she acted like she does now was when she found out." "Found out about what?" Meredith let go of whatever held her back and spilled what was on her mind. She paced up and down in the small room. "Our relationship, you remember, we've been hiding it at first. I am talking about the time before your wife …" "Ex-wife." Derek cut her off. "Before your ex-wife came into the picture. She asked me why I was doing this. I had the respect without doing anything. She thought I always had easy which I hadn't. She was asking why I was letting the respect taken away just, if this was about getting ahead and for some surgeries … she didn't realize that I was falling for you." Meredith told him, she was avoiding looking at him.

Derek sat down on one of the bunk beds. He motioned Meredith to sit down as well. Meredith listened to him without questioning him. She stared straight ahead. He could tell that this was hitting close to home for whatever reason.

"I had their respect, Derek, without having to do anything and now I have work my ass off, not that I am complaining. But she's got no respect for me, no respect at all."

"Izzie?" Derek asked, frowning.

Who else should I be talking about?" Meredith said back, strained. "I can answer as many questions as they ask me to but she still treats me like crap. And the worst is, Derek, I think she does it because of my medical history. I mean, why else should she do it?" She asked. "Meredith, stop pacing." He stopped her by putting both hands on her shoulders. "I don't know." Derek honestly replied. "I've never given her a reason to do all this. Why is me being born with a CHD such a problem for her?" "Conflict of interests maybe?" Derek pointed out. "She thinks you get the easy way out or she wants to attract attention." He thought loudly. "You think? I mean, when she wants to attract attention, the right way to do that is learning for the intern test and pass it hard. That's how you earn respect and so on."

"Are you scared of it?" Derek asked silently. "The test? No, I don't." Meredith answered, as she looked over to him for a slight moment. They paused for a moment. Meredith said for another time, emphasizing what she didn't get: "I just don't get it how she can do this. How can she treat like this when she lives in my house?" "I can't have her doing that. She can't continue treating you like this." "How bad is it?" Derek asked concernedly. "Do you need to hug it out?" He asked. "Yes, please." Meredith's voice quivered a little bit. Derek pulled her small frame into a loving hug. "'s better." Meredith murmured softly. After some time, she slowly released the grip with what she held onto Derek's body. She gazed up to him as she asked: "How do you think this will be when we're married, actually married?"

"I don't know. Let's just see what will be." Derek said. "You can't do anything anyways so why spending time wracking your mind about something that you cannot necessarily influence."

"This is exactly why I didn't want to say anything." Meredith suddenly said.

She couldn't help but feel anger toward the all-in-all situation. "But I didn't think it would as bad as it is now. I'm lucky to have friends like Cristina and Alex and my very supporting husband." "We're …" Derek noted but he didn't end it. He liked it that she referred to him as husband. He liked that even if they weren't – for now.

"I think we need to go, do our doctor stuff." Meredith mumbled.

"Doctor stuff, Meredith, really?" Derek asked, he couldn't help but grin at the absurdity of the choice of words. "What? It doesn't matter if it isn't a real word. You understand me anyway. And if you're being honest you love me for it." She smiled at him. Time with Derek was making up for the time she spent with judge-y Izzie Stevens. "I do. But as you pointed out before, we've both got some stuff to do with our time, Dr. Grey." Derek said, his voice switching back into attending mode. Meredith rolled her eyes for a moment, luckily Derek didn't see it as she was following him out of the room.

To their luck, Izzie Stevens passed by.

"How sweet, attending and intern hanging out in one on-call room. Sure that that wasn't post-surgery sex?" She bluntly remarked as other nurses and orderlies passed by as well. They stopped and gawked of course. Derek felt his blood boil with anger. "Dr. Stevens, this is no way to speak to your attending. I forbid that kind of behavior. I demand to be treated with respect as does any other doctor around here." "Is 'any other doctor' by any means Meredith?" Izzie asked innocently.

"Dr. Grey, would you please excuse us and tend to your patient in post anesthesia care unit and see if she's ready to be moved?" This was him treating her as any other attending. And that was okay.

She didn't want to be favored.

Not by him, not by anyone. It wasn't fair to anyone if she got the easy way out. But she didn't so that was good. Meanwhile, Izzie Stevens was facing a very angry Dr. Shepherd who looked at her in annoyance and anger. "Stevens, I am your attending. You're not authorized to speak with me like that. There is a pile of charts at the nurses' station that's needs to be done. I would have let Meredith go through that in all fairness but due to your undermining comments, I'm afraid your mind is occupied with other things. So, you're gonna be charting." Derek told Stevens off. "I want complete charts with ECG. If they haven't done one yet, it's you who's going to do it. Patient in 3472 needs a new IV access and he's a hard stick, dressing changes in post-ops 2367, 2456, 2136 and 1244. Got it?" Izzie was enraged, how could he punish her with putting her on scut? He should put his girlfriend on scut. That would be more fair. "Yes. I've got it. Derek." Izzie called him by his first name. "It's Dr. Shepherd to you, not Derek. It's not Derek, not here at work and not in the house. My name's Dr. Shepherd and you will call me that way." Derek managed to keep his voice down but this girl was sheer hell. "Sure, I will do that. Dr. Shepherd." Izzie emphasized his name unnaturally before walking down to the nurses' station.

After her surgery she told Derek, she would look what Cristina's doing. She is probably in the NICU. Addison had her on the preemie case. "Cristina." Meredith said as she walked next to her. "You just got out of surgery. I saw part of it. Shepherd let you close up." "He did." A huge smile graced Meredith's face. "How is your case?" "Barely holding on, it doesn't look good. Montgomery is looking into other options." Cristina told her as they walked up to NICU. "What about you?" "I am supposed to monitor my post-op patient but I have a ten minute coffee break right now." Meredith told her. "Ah, good." Both interns put on NICU gowns and were greeted by Arizona Robbins who had pulled out a stethoscope and listened to one baby's lungs. "Wait, we'll try liquid ventilation on her." Addison said, a determined expression was covering her features. Cristina listened in utter surprise. Liquid ventilation? Cristina stared at her attending who was about to do something brand new and experimental, very experimental in fact. But everything else they've tried to do before failed miserably. This was like their last chance of really doing something to help this baby getting better.

"That's highly experimental." She stated as she watched Montgomery taking the preemie's vitals and checking the breath sounds. "Yes." Addison answered shortly. "Have you ever done it before?" Cristina asked ambitiously, even though neonatology wasn't what she wanted to do for the rest of her life. She wanted to try this to give this newborn baby a chance. "No, but I am about to do it now, to give this patient a shot at living. The fluid will expand her lungs so that they don't collapse." Addison said as Cristina watched her perform this bedside. Meredith suddenly entered the NICU, Addison never looked up since she was focused on her patient, only Cristina turned around and acknowledged her friend's presence without much words. "Need a hand?" She asked as she saw what they're doing. "You're trying liquid ventilation?" She exclaimed. "Grey, be quiet please. I need to concentrate." The redhead scolded the eager intern.

Meredith nodded. She knew that that was better for the baby.

"We're simulating the womb. Keep an eye on her sats. If they go up it is working." Addison said to Cristina. "I'm going to watch this, this is a genius move." Meredith said as she stepped nearer to the incubator with a very little sick preemie with underdeveloped lungs and breathing difficulties to watch this bedside procedure. "This sucks." Meredith silently said. Cristina nodded. "Montgomery, sats are falling." Meredith warned, energy surging through her. "Give me a second." Addison retorted eerily calm. "Come on, come on." She was trying not to panic while fluid was expanding the baby's lungs. They controlled it via roentgenogram. The fluid filled the baby's lungs.

"There we go." Meredith said, a smile covering her lips as the saturation went up and the color significantly changed from cyanotic to normal baby color. "We got it." After the repeat chest radiograph after surfactant therapy demonstrates marked improvement.

Shortly after, Meredith was back on her way to post anesthesia care unit. Happily she noticed that her patient was very much awake at this point and ready to move to stepdown unit. "Welcome back, Mrs. Karolinska. I am just checking if everything is in working order before I can give the order to move you to stepdown unit." Meredith told her in a calming voice as she did a quick neuro check. "Can you move your arms for me?" Meredith asked. The patient followed her commands without any trouble. "Excellent. How about moving your feet?" After the patient did that as well without any problems Meredith moved on to next part of her exam. She was shining a light into the patient's eyes to see how the patient responds. "Follow the light, please?" "Good." and was taking her vitals and after asking the patient to pull up her shirt she pulled out a stethoscope to listen to her lungs and heart. After documenting everything she called for a nurse to get the transfer done. After the paperwork was done, Meredith's patient was moved. In that moment, Meredith's pager beeped loudly.

It Burke paging her and Cristina to the pit. Cardio trauma, sounds like this could be a long but interesting night.

"A trauma." Meredith said as she scanned her pager. Meredith turned and walked toward the emergency room, suddenly she had footsteps following her.

"You have been paged too?" Cristina asked as they jogged down the hallway and to the pit. "Must be something big." She added knowingly. Burke was awaiting them impatiently. "There you are." He lead them to a trauma room. "What do we have?" Cristina prodded. "Triple-A? Traumatic Aortic Disruption? Injury to heart or / and lungs? Tear in the ventricle? Does the patient have to go on bypass to repair the underlying damage?" Burke didn't say anything, instead he gazed over to Meredith. He'd heard from Cristina how Izzie treated her. "Dr. Grey?" Dr. Burke said her name.

"What's a cardiac tamponade and how do you treat it?" After Meredith answered that question correctly, they entered the trauma room. The patient had suffered significant trauma to the chest.

His chest rose and fell in an accelerated pace, Meredith noted as they started with the primary exam.

A/N: Sorry for not being able to post this earlier but I had things planned for the weekend. But now I am ready to post, obviously. I hope y'all like this chapter and review.