Chapter 38

We like to think that we are rational beings; humane, conscientious, civilized, thoughtful. But when things fall apart, even just a little, it becomes clear we are not better than animals. We have opposable thumbs, we think, we walk erect, we speak, we dream, but deep down we are still routing around in the primordial ooze; biting, clawing, scratching out an existence in the cold, dark world like the rest of the tree-toads and sloths. There's a little animal in all of us and maybe that's something to celebrate. Our animal instinct is what makes us seek comfort, warmth, a pack to run with. We may feel caged, we may feel trapped, but still as humans we can find ways to feel free. We are each other's keepers, we are the guardians of our own humanity and even though there's a beast inside all of us, what sets us apart from the animals is that we can think, feel, dream and love. And against all odds, against all instinct, we evolve. Where The Wild Things Are; Meredith Grey

In that moment, Meredith's pager beeped loudly. Mrs. Karolinska looked at her in apprehension. "If you need to take this, go. I'll be fine on my own." She assured her as Meredith glanced onto her pager. 911 ER. It was Burke's pager number, Meredith realized as she looked over the screen of her pager. She put her stethoscope away and said shortly toward the patient: "I'm sorry, I need to take this. It's an emergency." Meredith said her before sprinting out of the room and toward the emergency department. 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. "It must be something big." She added knowingly. "Yeah, probably, do you know whether the others are on call as well?" Meredith asked a pretty normal question. "Why? Are you scared to face Izzie after what she thinks about you?" Cristina said sarcastically without really thinking. Meredith hadn't reckoned with that kind of question she was taken by surprise.

"I don't care what she thinks of me." Meredith replied, her voice quavered slightly and Cristina could read her like a book.

Meredith didn't scare easily and currently, Meredith Grey was panicking by the mention of Izzie Stevens who was out to make her life hell. "She'd probably freak out at the mere prospect of me getting paged to this trauma instead of her. But you know I'm fine. I am perfectly fine. Also, Derek is having her doing his patient charts because she was disrespectful toward him." She rambled, had a hard time stopping if no one stops her. She mumbled under her breath.

"However, we have more important things to worry about such as this patient."

Meredith was flummoxed by Cristina's comment.

She was aware that she hasn't meant to be insensible but she couldn't say that it hasn't affected her. But she and Izzie weren't exactly on good terms. For some reason, Izzie couldn't stand with her. "Yeah, let's just worry about that." Cristina quickly backpedaled as she sensed that her comment has let Meredith backfire. Then Cristina and Meredith entered the emergency department. They walked in on Burke attending to patient as two paramedics pushed the gurney to the nearest trauma room. From the sound of the heart monitor it was clear that the patient was on the verge of collapsing. He was bradycardic and hypotensive, probably in shock. His airway was maintained and a tube was breathing for him. "Grey, Yang, I need some hands." Dr. Preston Burke called out. Meredith saw that they were already letting fluids running wide open to keep up with the extensive blood loss.

Burke was awaiting them impatiently. There was a trauma they needed to attend. This was not going to be a quiet night. It was more like going to be hectic. "There you are." He led them to a trauma room. "What do we have?" Cristina prodded. She was looking forward to spending the night in the operating room as did Meredith. "Triple-A? Is this involving Traumatic Aortic Disruption? Injury to heart or / and lungs? Pulmonary contusion or contusion of the heart, did the patient arrest on the way to the hospital? Tear in the ventricle? Does the patient have to go on bypass to repair the underlying damage?" She spilled possible injuries of a patient with chest trauma. Burke didn't say anything to Cristina outburst of possible diagnoses. Instead he gazed over to Meredith. He'd heard from Cristina how Izzie treated her as if she was unable to do her job but hell, she was wrong when she thought so. He was with Bailey and Shepherd on this one. Maybe they needed to have a serious talk with Stevens who only seemed to have a problem when it comes to Meredith. The paramedic walked over to them and gave them a quick overview of the status of the patient. He told them he'd coded once when they were on their way but they have been able to resuscitate him very quickly. They entered the trauma room. "Patient is 23 year old male, was in a high-speed MVA, he has sustained thoracic aortic injuries and injuries to the heart and lungs." He told them the details of this case.

"I need a hand, or more both of you. Dr. Grey?" Dr. Burke said her name harshly as he was her superior. Meredith didn't seem surprised that she was being asked.

Ever since her surgery she has to work doubly so hard to prove that she can do this than before. "What's a cardiac tamponade and how do you treat it?" He questioned her. Cristina raised her arm. Pick me. Pick me. Pick me. Burke's eyebrows furrowed amused. But he said: "It's Grey's turn, Dr. Yang. You'll get your chance to show off your talent as well." He noted. Cristina smiled and then turned to Meredith, waiting for her to answer. "Pericardial Tamponade is accumulation of blood in the pericardial sac of sufficient volume and pressure to impair cardiac filling, resulting in reduced ventricular filling and subsequent hemodynamic compromise. It's a medical emergency. Leaving it untreated, it would result in death. Patients typically show signs of hypotension, muffled heart tones, Pulsus paradoxus, and distended neck veins. Diagnosis is made clinically and often with bedside echocardiography. The Treatment for this kind of condition is immediate pericardiocentesis or pericardiotomy." Meredith answered quickly as her eyes darted to the patient's heart monitor.

He was hypotensive and he had bruises on his chest. There was evidence of chest wall injury. He was intubated and ventilated using the PEEP mode that was more protective to the lungs. Meredith answered that question correctly, as Burke said: "Order a CBC and an arterial blood gas, Dr. Grey. We need to place a chest tube to avoid complications such as ..."

"… tension pneumothorax, hemothorax." Cristina was quick to answer.

"You're placing the chest tube, use one with a large lumen." He advised her. Cristina quickly put on sterile gloves before reaching for the chest tube that was lying on the tray among other instruments.

"Hemopericardium with a cardiac tamponade, he's showing signs of Beck triad and other symptoms related to an acute tamponade which means he's most likely tamponading, get me a crash ECHO to confirm this." Burke spurted out during the initial evaluation. The ECG was additionally showing a "low-voltage" rhythm. A nurse got a portable ultrasound and Burke reached for the transducer. The chambers were getting progressively smaller and diastolic compliance is reduced, he immediately noticed that, the patient's skin was getting cold and clammy due to hypotension.

He was preparing to do an emergency subxiphoid percutaneous drainage or also known as pericardiocentesis which is done in unstable patients when cardiac tamponade is suspected. He knew that that kind of procedure has a mortality rate of approximately 4% and a complication rate of 17%. Meredith was holding the transducer to monitor everything during the insertion, making sure that there is no ST segment elevation that's indicating contact with the epicardium and the need to withdraw the needle. He was coming with the needle, carefully so that he wouldn't puncture the heart. This is a life-saving bedside procedure. The subxiphoidal approach is extra-pleural; hence, it is the safest for blind pericardiocentesis. Dr. Burke inserted a 16- or 18-gauge needle at an angle of 30-45° to the skin, near the left xiphocostal angle, and was aiming towards the left shoulder to drain the excess fluid around the heart. Cristina and Meredith were both looking at the monitor, holding their breaths as the rhythm slowly stabilizes.

When they got the patient stabilized, they were going to do the chest radiographs and also plain films of head, abdomen, neck and pelvis to make sure there are no other injuries they might have missed. But all films came back clear which was a huge relief. "So there's no need for other consults as the films came back clear." Burke noted as he moved on.

"Grey, I'm gonna need your help with the chest radiographs. We need to make sure that the patient has no aortic injuries, or we're looking at rapid deterioration. If that happens …" Meredith looked up as she pushed the portable x-ray toward the gurney and placed it correctly so they could take pictures of the man. "… They are dead man walking." Cristina said bluntly. "The patient's sedated but we don't know how much they feel and hear of all of this. This is a patient, Cristina. Do not talk like that over the patient." Burke scolded her. Meredith was occupied with taking the radiographs of the patient's chest. When they did that, they saw the extent of the injuries. The mediastinum was wide and kind of funny-looking, there also was deviation of the trachea the right and there was depression of the left main bronchus. There was no clearly visualized aortic outline. While many signs of aortic injury have been reported, the most sensitive indicator of blunt aortic injury remains an 'abnormal mediastinum'. Meredith also noted that there was a lot of bright blood in the chest tube. "Dr. Burke, look, there is extensive blood loss via chest tube." She said as she held up the chamber that was filling with blood. "Let's save that patient. Time is …" "… everything." Both of them replied in a chorus. The patient had suffered significant trauma to the chest. His chest rose and fell in an accelerated pace, Meredith noted after they finished the primary exam. After they got him stable for transport, they were taking him down for a CT to confirm damage to the aorta and surrounding tissue.

His lungs were also bruised, he had fractured a few ribs, meaning, he'd be in for a painful, excruciating recovery. If a normal recovery after a sternotomy was painful, she can't imagine how it is to have to recuperate from an injury like this. This has to be particularly painful. "Prepare for moving." Cristina and Meredith helped Burke getting the patient down to CT. "We need to be quick." She said to Meredith. "Most patients with aortic transection are dead on arrival. We're incredibly lucky that this isn't a transection."

"I know." Meredith answered as they got their patient to CT.

When their patient was in the machine, Dr. Burke, Dr. Grey and Dr. Yang were impatiently waiting for the results to come up.

"C'mon, hurry up computer." Cristina mumbled impatiently as she whipped with her feet. Burke and Meredith were watching her as suddenly the images plopped up on the screen. "We have images." Burke suddenly announced.

"Okay, what do we have?" He asked as he gazed at the image very closely as did Meredith and Cristina who were as concentrated as he was. "I see a pseudoaneurysm on the aortic arch." Cristina pointed with her finger at the plain film. "There is damage to the ascending aorta, there is also a mediastinal and in addition a periaortic hematoma which is much more suggesting an aortic injury than an aortic injury alone, and the motion artifact." Burke somberly ran his fingers over the defect. Meredith was looking at the image closely before feeling the need of noting something. "Most blunt aortic injuries are at the proximal descending aorta and are visible on axial CT as a pseudoaneurysm bulging anteriorly or antero-medially at the level of the left pulmonary artery." "I have to say, Grey, you are right with that." Burke said, he had the right interns for this case. "But what we also need to do, is getting him out of that machine and to an OR. Time's a wastin', guys." Meredith pressed the button to get the patient out of the machine. They were definitely opting for an open surgical repair. After they did a CTA chest, they moved the patient to the OR to get this taken care off. "I need the hands meaning you're both scrubbing in with me on this one." Meredith and Cristina looked at each other. They knew what the other one thought about the possible prospect of scrubbing in on this kind of surgery. A distinct smile was forming on both of their faces. Burke's mouth twitched amusedly. Then he cleared his throat but neither of them seemed to hear him. The patient was being prepped for emergent surgery, so he used the time for teaching since intern exam was coming up and they needed to be prepared for that.

"Yang, options for TAI repair?" Burke directed his question to Cristina who seemed to be taken by surprise, at least in the first second. But she recovered very quickly from her shock and was able to answer her superior's question: "Treatment options for TAI can be divided into three categories which are open surgical repair, endovascular repair and medical management." Burke nodded. As the patient was being prepped for surgery, he used this time for asking complex questions about pleural effusions and other complications. "What are the common causes of cardiac tamponade?" Burke asked as Cristina put on a surgical mask. "Malignant diseases are a common cause of this, also pericarditis, post-pericardiotomy syndrome …" Cristina listed. "It also occurs in Type A aortic rupture."

"… which might be the reason our patient suffered from cardiac tamponade." Burke noted.

Cristina nodded eagerly. "What can you tell me about the different procedures of relieving a cardiac tamponade." Burke started.

Cristina grinned as she told him the answer. "Removal of pericardial fluid is the definitive therapy for tamponade and it can be done using the following three methods to relieve the pressure that's building up around the heart: emergency subxiphoid percutaneous drainage, echocardiographically guided pericardiocentesis and then there's percutaneous balloon pericardiotomy that's very similar to echocardiographically guided pericardiocentesis. As for surgical Care in hemodynamically unstable Patients can a surgical creation of a pericardial window be useful." Cristina answered his questions.

"Where is Grey?" Burke suddenly asked. "Maybe you should let one of the nurses page her." Cristina offered.

Meredith on the other hand got caught up in talking. "Meredith, wait." Derek jogged so he could keep up with her pace. "I can't, I'm supposed to be in the OR by now. I have a patient who's critical and hemodynamically unstable." "You were too." He said silently, thought Meredith didn't hear him. But she can't remember a point where she was hemodynamically unstable. Was this before or after her surgery? She asked herself that but she didn't say anything. It could wait. Her patient can't wait. If he would have to wait he'd be dead in what, a few hours? Meredith walked toward the ORs but stopped at the OR rotation. Due to the sudden stop, Derek bumped into her accidently as he wasn't able to stop before. "Meredith." He got out. "Why did you stop in the middle of walking?" He asked, as he ran his hands through his hair in a stressed mode. "Derek, I am about to scrub in on a sternotomy to repair a heart and an aorta that is almost ruptured. Cristina and I are scrubbing in so I am gonna be awhile." Meredith gushed enthusiastically, she loved doing this.

Derek smiled warmly. He loved seeing Meredith lighting up at a possible surgery.

"Well, Mer, you're incredibly lucky. All I am looking forward to is paper work, some bureaucratic traffic, something that needs to be signed right away." Derek sighed, Meredith is in the OR while he has to catch up on paperwork. "I am going to get coffee. You want too?" He asked her as they made their way toward the vending machine.

"I can't, I have a surgery in ten minutes." Meredith declined the offer of the neurosurgeon. "C'mon, one coffee won't hurt." Derek tried again.

Meredith had to laugh at his attempts to get her to go on a coffee date with him but Meredith didn't change her mind. At some point of all of this, her pager interrupted her conversation with her favourite attending. "See, that's what I am talking about, Dr. Shepherd." Meredith held up her pager. "OR 5 is ready 'n prepped. I need go, crash sternotomy."

She kissed him quickly on the cheek before disappearing down the hallway. Cristina was already there in the scrub room, her gaze was lingering on her as soon as she entered the room. "You're late." Cristina noted in a snarky tone. "I am not." Meredith replied while rolling her eyes. Burke isn't even here and I answered my page as soon as I received it." Meredith defended herself, knowing Cristina was an empty threat and not meaning any of this. And she was right. Only seconds, after she thought that, Cristina continued talking to her as if nothing happened.

"I was just kidding." Cristina grinned as she washed herself sterile. "Gotcha." She added with a smirk. "Fine, can we please move on?" She asked, hoping she'd let it go. "Sure." In this moment Burke entered the scrub room. "Patient ready?" He asked monosyllabic. "He's ready and prepped to go." Cristina was quick to answer. "Good, ready to save a life?" He asked both of them. "Yeah, we are definitely ready to save this man's life." "Then let's go." Burke announced as he entered the operating room. Meredith and Cristina followed him. They were greeting by the monotone beeping of a bunch of medical machines all to monitor the patient's vitals. The surgery was taking hours, the patient received at least four units of blood since he was losing very much due to traumatic aortic injury which is rare but frequently fatal, it's a condition that needs prompt diagnosis and immediate treatment.

"Scalpel." Dr. Burke was about to do a median sternotomy to gain access to the chest cavity. He needed clear visibility of the heart and the great arteries. When they had opened the patient up, they had clear view of the heart, the aortic root and the ascending aorta as well as the aortic arch where the injury was located.

"Prepare to do an interposition graft as soon as we get this bleeding controlled."

Suddenly, the heart monitor went off crazy. The patient was officially unstable. They were seeing the blood spilling from the injury. "He's losing too much blood to fast Sometime into the surgery, Dr. Burke was doing an interposition graft that is slightly higher in attenuation than the native aorta and will have a slight contour change at both the proximal and distal anastomoses. Meredith and Cristina watched him doing this. They were holding the clamps in place or suction when needed. All in all it was a good surgery. Suddenly Burke looked up. "When do surgeons decide to perform open repairs?" He asked both of his interns. "An open repair is still the procedure of choice to repair injuries involving the aortic root, ascending aorta and aortic arch. Open surgical repair may also still be the preferred option for repair of isthmic aortic injuries in stable or young patients. Open surgical repair is typically done Pre-contrast images can be helpful in identifying felt pledgets." Cristina answered quickly.

"Very good, Yang, what can you tell me about pledges that can occur and kinks in the graft?" Burke concentrated back on his surgical field. Cristina remembered reading something like this in the literature she's found in Burke's apartment. "Kinks can be seen within the graft material but are usually of no clinical consequence. Felt pledgets can be used to reinforce the anastomoses or to repair aortic cannulation sites. Felt pledges are high attenuation and can be confused with a small pseudoaneurysm." Cristina answered. Meredith on the other hand, looked at what Burke was doing at the moment. This was good. And what was good as well was that the patient is stable, for now at least.

They did, in fact, use one of the pledges to repair one aortic cannulation site. Besides the situation in the beginning of the surgery it has been completely okay.

After another hour, they were ready to close him up and get him to post anesthesia care unit for further monitoring until anesthesia wears off and they can start normal sedation to keep him from experiencing pain while recuperating. "Grey, you monitor his post-op status."

Meredith obeyed, what else is she going to do if not that?

"Yeah, I will do as you say." She said, taking the patient chart. After some time they decided it was time for him to be transferred to cardio intensive care unit.

Meredith was sitting at the nurses' station where she was able to monitor everything. The cardiac monitors were very good visible from point. The patient had a Swan Ganz Catheter to monitor his hemodynamics that can be left in place for now. Meredith's left the intra-pericardial catheter in place after securing it to the skin using sterile procedure and attached it to a closed drainage system via a 3-way stopcock that's going to be removed in 1-2 days. She knew they were supposed to a repeat ECHO tomorrow. She periodically checked for re-accumulation of fluid, but so far everything was okay. The only thing was that Meredith was tired. "Ugh, I am so freaking tired." Meredith groaned as she glanced at the clock. It was 1 AM. It seems like the clock is mocking her.

In three hours she was supposed to attend pre-rounds and she had no idea how to manage that, she was barely keeping it together now. But what put her through the night was her endless dreaming of Derek, their devotion to each other and fantasies of them lying in bed at their warm, comfy bed, intertwined. She tried to think of Derek and her. When she was with him everything was shining. He makes her rise when she falls. He says she gets the rest of them to move forward but as far as she's concerned, Derek was doing just as much. She needs him by her side. She wished that he was here now, assuring her she could get through this night shift. When it was just the two of them, enjoying their togetherness – but right now that wasn't possible.

She did want to do this, Meredith snorted lightly. She should remind herself of this.

This was torturous. She wanted sleep. Fatigue crept over her and for a slight moment she closed her eyes, telling herself not to doze off. She had patients relying on her.

But she figured she'd be no use to them in an overtired stressed-out mode when there is a medical emergency which can happen in trauma patients. She had to say she was horribly tired. So tired that she might sleep right there. She wanted Derek, an empty on-call room, him putting her arms around her and cradling her to comfort her. He kissing her until the world stops and it's only them blocking everything else out. But that was just dream thinking, not the reality she was in. Coffee, she needed coffee and a snack to keep her blood sugar up. Suddenly, she nodded off for only seconds only to wake up to the worried face of a neurosurgeon looking at her.

Derek was shocked at the view of her small, petite frame and instantly knew she was overtired and lagging due to the lack of sleep.

"Derek." Meredith got out and was getting up. Or at least she was making a motion to get up, only to lose hold. But now the overstress, the exhaustion and tiredness was all creeping up in her all at once. She swayed and Derek was there and catched her when her head landed on his chest. "Sit down." He ordered as he felt her pulse.

Meredith obeyed relentlessly. "When was the last time you actually ate, Meredith?" He asked quietly but in a tone that told her he was concerned. "Yesterday morning, I think." She answered warily. "Damn foolish girl." He cried out loudly resonating. "This is what I was talking about when I agreed to let you take night shifts, Meredith. Think about hydration and eating. At some point your body will give in, if you keep this up. Not to mention the fact that your blood pressure is going to bottom out, it's already low, Mer."

"I'm just really tired. Don't get carried away, I am fine." Meredith protested in a lame attempt, although she knew Derek was right.

She probably looked like hell on earth.

"Tired from the lack of food or what? You being fine is always alarming." He mumbled ironically under his breath. Of course he was concerned about her pale complexion that practically screams 'I need my sleep.' Meredith forced herself to keep her eyes open. She can't afford falling asleep when she was supposed to monitor this patient. "Stay here, in this chair and don't move. I'll be right back with a snack to get your blood sugar up and coffee." Derek watched her frail frame for a moment, before making sure she gets something into her stomach. Only minutes, if Meredith was honest it seemed like seconds, Derek was back carrying a stack of paperwork he needs to go through tonight and Meredith was stuck here he might as well do it here where he can supervise Meredith and trick her into eating to stop her blood sugar levels from getting dangerously low. He put a bottle of water, a power bar and a sandwich from the vending machine in front of her. He brought coffee for himself, water for Mer since he knew it was better for her. "Eat this." He ordered her.

"You're bossy. I like that." She smiled at him as her gaze went back to her patient's heart monitor. It showed a regular sinus. "Eat." He pushed the food to her. Meredith's brows furrowed at the view of the food. Her stomach rumbled, telling her to eat.

"I won't leave you prior making sure you're not passing out."

He seemed genuinely worried. "I'm not, Derek. I'm just tired, deathly tired and I'd love to sleep but if my patient codes and I am not here then I am done. I would look like a complete moron who can't monitor her patient. I'm supposed to be able to do this." Plus it would be a satisfaction for Izzie. But she didn't say the last sentence. He doesn't need to know that. But before Derek could reply in any way, Meredith unpacked the sandwich and started eating. Once again, Derek was amazed by her eating skills. After she finished, she offered him a small smile before saying: "I think I needed that. I didn't even know I was hungry until you shoved the food into my face." She giggled slightly. On Derek's face was a trace of smile visible, his eyes sparkled as he looked at Mer and put his around her.

"Derek we're at work." Meredith halfway protested. "You know you can't resist. We all know it and besides, no one's here besides you and me." Meredith relaxed when she felt him near her. "The patient maybe, you don't know if he can." Meredith blinked, slightly confused mixing with barely noticeable irritation coming from her.

"Who is conscious and able to see what we're doing here?" Derek made a pretty good point.

And so he stayed 'cause there was nothing better to do right now. The paper work he could do there too. That wasn't a problem. "Sleep if you want to." Derek offered. "I'm not going anywhere right now."

The next morning, Burke was sitting in the cafeteria, a tray with food on his left side and he was concentrated on the paper in front of him. He was reading about clinical trials concerning the replacement of aortic valves via TAVI, Transcatheter Aortic Valve System in extreme-risk patients. He just happened to be treating someone like this, who wasn't a suitable candidate for a conventional repair with sternotomy. The risks were just too high for that. He was reading through the results of a clinical trial concerning Aortic Valve Implants without sternotomy. They've released the 24-Month results. They were good, good outcomes in extreme-risk patients, excellent and sustained hemodynamics and no significant post-procedural aortic regurgitation. Maybe he should contact someone who had done something like this before. But this might be an option for his 78 year old patient with severe symptomatic aortic stenosis.

He was so concentrated that he didn't hear Cristina coming to his table.

"What are you reading?" She asked as she tried to grab the booklet Burke was reading in, his laptop was also standing there, meaning, he did medical research about something.

"Cristina, I am working." Burke told his girlfriend whose gaze was lingering on him. "You're reading." She noted. "An article about Transcatheter Aortic Replacement in high risk patients and I need some peace and quiet to accomplish that. If you want to sit, fine, sit. But be quiet. I'm researching something." Cristina frowned, that sounded vaguely interesting.

If only she knew what he was researching, then it would be a hell lot more interesting.

"You are doing medical research about what?" Cristina wanted to know and slouched down on the chair, not letting her eyes off Dr. Burke. "Transcatheter Aortic Valve Implantations – I have an extreme-risk patient who isn't suitable for normal aortic replacement and now I am looking into other options." He looked onto his watch for a second. "Don't you have pre-rounds, Dr. Yang? Bailey isn't someone who lets people do whatever they want." He smiled lightly before taking a big sip from his cup. He rubbed his eyes for a moment. He had been here since yesterday.

He did a pulmonic valvuloplasty and a CABG before he was called to an emergency patient with extensive trauma to the chest, both aortic and lung injuries. Both Cristina Yang and Meredith Grey scrubbed in on that procedure. It has been a long and very bloody surgery.

But right now the patient was in CICU and Grey was monitoring his vitals.

He sighed.

This was going to be a long day and a longer night.

And he was on call for next night.

"Right, pre-rounds, but … are you doing this, a TAVI? I'd love to see you doing one in this OR." Cristina was out for surgeries. Burke let out a chuckle. This was so Cristina-like. "After I talk to some experts, I'll think about it." He said cryptically. "I have to go, as you pointed out before I have pre-rounds and Bailey will literally kill me if I'm late." Cristina got up and jogged toward the locker room.

Derek was sitting with Meredith but at some point he was paged to some patient of his. "Are you sure I can leave you alone, Mer?" He'd asked with glimpse of worry in his eyes. But her condition wasn't that worrisome was it? "Yeah, sure. I'll be here sitting and monitoring my patient." She shrugged it off. But she hasn't slept. "You have pre-rounds in thirty minutes, Mer. Bailey won't like you skipping pre-rounds." "If she doesn't like it, she should take it up with Burke who ordered me to monitor this patient." Meredith shrugged and suppressed a yawn. Twenty-five minutes later, Meredith was still sitting on a chair at the nurses' station and was monitoring the trauma patient. For now, he was stable but she was worried about his blood pressure. They barely have been able to get it to a point where it could be considered as stable.

In this moment, she noticed his BP was tanking, his ECG was going into a wide-complex arrhythmia. It means VT until proven otherwise.

She got up from her chair but before she could make it to the room, she heard the heart monitor beeping erratically in distress. He was going to go into cardiac arrest.

That's not how she imagined start her shift.

"Oh no, this can't be …!" Meredith exclaimed as it dawned on her what she was in for, of course this was happening during her shift. Then he started crashing, the patient's state took yet another dive downward. This was so not good. It was not good at all. But Meredith Grey can handle running a code without freaking out. Maybe he was tamponading again.

She jumped up, sprinted into the room at record speed, a nurse who watched this was following too and was pushing the crash cart into the room. "I'll get the crash cart right away." She called out. Then she pushed to button and a computed voice said over intercom repeatedly: "Code Blue, ICU. Code Blue, ICU." Meredith didn't listen anymore.

She had more important things to do right now.

She quickly analyzed the rhythm, seeing it was a ventricular tachycardia. Ventricular tachycardia (VT) is ≥ 3 consecutive ventricular beats at a rate ≥ 120 beats/min. Symptoms depend on duration and vary from none to palpitations to hemodynamic collapse and death. VT of short duration or slow rate may be asymptomatic. Sustained VT is almost always symptomatic, causing palpitations, symptoms of hemodynamic compromise, or sudden cardiac death.

It was a polymorphic "sustained" VT (lasting more than 30 secs) and the patient is hemodynamically unstable.

This wasn't good. Meredith would have to do an unsynchronized cardioversion or defibrillation on her own. Unsynchronized cardioversion (defibrillation) is a high energy shock which is delivered as soon as the shock button is pushed on a defibrillator. This means that the shock may fall randomly anywhere within the cardiac cycle (QRS complex). Unsynchronized cardioversion (defibrillation) is used when there is no coordinated intrinsic electrical activity in the heart (pulseless VT/VF) or the defibrillator fails to synchronize in an unstable patient.

Meredith grabbed the paddels, the patient already had percutaneous pacing pads applied to his chest.

"Charge the pads to 120." Meredith ordered, calmly.

"Charge. Clear."

The nurse pressed the button.

She pressed the paddels against the patient's chest and waited for the heartbeat to normalize itself. The shock sent the patient's body flying upwards. But the first loop wasn't successful, Meredith realized. She'd have to repeat this. She was using a biphasic defibrillator device.

"Anything?"

"No, nothing." The nurse replied as she focused on the monitor.

Meredith shook her head in desperation. "Charging. Nineteen seconds." The nurse pressed the button who is for the second round. "Charge them to 200." Meredith called out.

"200. Twenty-seven seconds."

And this time it worked. The patient was good. "We've got him back." Meredith said as relief was flooding through her body. The cardiac monitor showed a normal sinus rhythm. That was good.

After she got the patient stabilized, she put him on Amiodaron prophylaxis to keep it from happening again.

She singlehandedly saved this patient. She could be proud of herself.

Meredith was, she felt pride over her save. She did that, gave him a second chance. But what about his brain, is it okay? They would need to do further studies to find that out. He'd been oxygen deprived for a long time, the time in which his heart wasn't beating. Maybe he could have brain damage.

Maybe, there was a possibility. Meredith knew that. She was aware of the odds.

Anoxic brain injury.

Bailey asked her about that yesterday.

"Can you take over for me now that he's stable? Page me, Dr. Burke or Dr. Yang if there are any irregularities in his heart rhythm or change in hemodynamics etc. I have pre-rounds." Meredith explained and for once nurse Debbie just did what she was told to do. Meredith jogged to where she knew Bailey and the rest of her group would be. When Bailey heard her, she turned around, a bit agitated by her intern being late.

"Grey, where were you? You missed pre-rounds." Bailey accused her. The other interns were standing around in a circle as Meredith got her lecture. But she hadn't skipped pre-rounds just because she didn't want to attend to pre-rounds but because her patient had been flat-lining for a prolonged time. They would have to see whether her patient would be okay or if he had sustained anoxic brain injury due to the *Now-Flow-Time* that occurred even though Meredith tried to be as quick and productive as possible all at once. But she had been on her own. "I was just doing my job since a code blue always comes before pre-rounds or rounds." Meredith noted, she couldn't keep herself from smiling. "Your patient coded?" Bailey asked with furrowed brows. "And there was no resident to run the code?" She asked in a harsh voice. "I'm almost a resident." Meredith reminded her, before nodding.

"My patient coded and I was alone and I had to do every single thing all by myself, so sue me if attending to pre-rounds wasn't priority number one." Bailey made a hand motion that was telling her that she'd done everything right. Pre-rounds weren't as important as patient care and emergency bedside procedures, in her case. "How come he was coding? And why wasn't I paged?" Cristina questioned. "I would have dropped everything and come to help you." She said. "There was no time for me to page anyone. There were no nurses around and I needed to minimize No-Flow-Time because the brain does need oxygen."

"We know, Grey, we're all doctors around here." Bailey said.

"And the patient is stable again?" Bailey asked, her brown eyes were eyeing Meredith attentively. "Last time I checked, Mr. Brown was stable as was his blood pressure after some infusions to stabilize it. He seemed hemodynamically unstable." Meredith told her, she was able to assess and treat a patient on her own.

Cristina's mind shot backwards to a similar experience, but this time it wasn't some random patient it was Meredith. She looked at her friend, trying to replace the picture of lifeless, cyanotic Meredith with the Meredith who was standing right in front of her and was standing up to Dr. Bailey.

It worked and slowly Cristina's breathing returned to normal. Nobody noticed the change in her breathing and she was glad about it.

"So you will get your assignments." Bailey announced. "And you won't harass Dr. Bailey or any other colleague for that matter. I repeat, do not harass Dr. Bailey. Stevens, are we clear?" Stevens wasn't attentive and caught talking with George who didn't really reply but stayed silent in an attempt to listen what Dr. Bailey says. Stevens didn't answer. Bailey cleared her throat, loud enough for Izzie Stevens to hear. "What did ya say?" She asked back without much enthusiasm in her voice. It sounded like she was bored. Meredith couldn't help the feeling that Izzie wasn't cut out to be a surgeon. Maybe she didn't have what it takes.

"'kay, Grey and Yang, cardio with Burke; Karev is with Sloan on plastic."

"Wait, what?" Izzie interjected. Bailey frowned almost instantly, her body was practically screaming 'what the frigging hell is this girl thinking that she can't understand a simple sentence. "She's once again getting all the good cases …" She complained as she saw that Meredith was assigned to Dr. Preston Burke, cardiothoracic surgeon of Seattle Grace. Meredith really didn't get her. Meredith Grey was off neuro and she still was complaining. Dr. Bailey looked like she was absolutely thinking the same. "O'Malley, you're on Dr. Shepherd's service since he could use an intern. Stevens, pit." Bailey told her interns. Meredith and Cristina made their way to Dr. Burke who seemed to be headed to a patient room. "But Dr. Bailey, isn't it possible that any other attending needs a helping set of hands?" She practically begged for not having to spend a second day down in the pit. "Stevens, your job is it to make me happy. Do I look happy to you? You won't see the inside of an operating room before I look as happy as Mary-freaking-Poppins." Bailey gritted out through her teeth.

Stevens was a really challenging intern with less potential than others like Grey and Yang who always were on top of their game. Even Meredith never showed any weakness, not that that's good but it was less annoying and time-consuming than Stevens. Well, Meredith was challenging as well but that has other reasons Meredith can't do anything about. "Do you understand me?" She asked, seeing if Izzie was getting it with full clarity. "Yes, Dr. Bailey." Izzie said, deeply hurt in her ego. Shepherd had her doing charts and now Bailey was torturing her with a second day of stitching up in the pit. Izzie turned around and headed for the elevator. Alex was following her for a moment. Both of them entered the elevator, and were riding it in complete silence and Izzie appreciated this. Suddenly, the elevator came to a hold. Someone had pulled the emergency button to stop the elevator. Alex frowned, what does this mean? Who was she stopping the elevator? Alex knew from Meredith that she and Derek sometimes used that button to have some dreamily moments in the elevator but not for this … "This is not fair." Izzie vented, hoping Alex would be there to console her but since his outburst in the OR gallery she didn't think so. "Would you please just stop hitting the emergency button for no reason? I need to get to Sloan who will skin me if I'm late." He ranted, blended by Izzie's annoyingly persistent ignorance.

Izzie snorted. "All you're gonna do is pitching him muffins and his beloved coffee. It's all you're gonna accomplish." Izzie replied snarky. Alex was getting irritated.

"Just stop blocking the elevator. Here are lives that need to be saved. If I were you …" He silently completed that sentence. *I would not be complaining about such small things, especially with your history of being Drama queen and not to mention the heart you stole for Denny. Meredith always stood by your side despite everything. I suggest you do the same. But honestly I'd be surprised if she won't throw you out over short or long considering how you behaved toward her in the last few days, this kind of behavior isn't really acceptable.* But of course Alex didn't say that. To be frank, he didn't give a shit about Izzie and how this'll play out for her. She's been digging her own grave. "If I really wanted your advice or a lecture I'd say so but until then would you just shut it." Izzie snapped at Alex who just shrugged.

He didn't really care, maybe at some point he did but what she did to Meredith is the end of the straw. The way she was devaluating Mer who didn't do anything to provoke that kind of behavior. He was extremely thankful that the elevator started moving again and he was no longer forced to stay with Izzie in one place without a window and therefore without escape route. He then made his way to Mark Sloan who was waiting for him impatiently.

"Where were you, I've been waiting for you forever." Alex murmured something incoherent as he was reporting to his attending for the day.

"I was stuck in the elevator. I didn't initiate all of this." "Okay, then. It does not matter. I have a kid with a cleft palate, I'm probably scheduling that for tomorrow. You're scrubbing in, Karev." "I am actually scrubbing in on an actual plastics surgery? You aren't kidding, right? 'cause it's not fair to mess with someone's head like this." Alex answered. Izzie had been completely wrong and he was glad about it.

"I'm not kidding, Karev. Go prep. And I also have a Rhinoplasty scheduled later today at 4 PM." Mark chuckled at his surprised face expression. Alex couldn't believe it. Sloan was actually letting him scrub in on a surgery.

A/N: Please review.