Chapter 4

When exposed to trauma, the body deploys its own defence system. From the first second the brain receives the signal that a catastrophe has happened, the blood rushes to the organs that need help the most. Blood floods into the muscles, the lungs, the heart, the brain. The brain makes a decision for the rest of the body.

Either face the danger or run away. It's a mechanism designed to protect the body from harm. From knowing that what has happened might be irreparable, we call it 'shock'.

When shock wears off, when the body can accept that a trauma has happened, when it can let down its defences, it's a scary moment. It's vulnerable. The shock response had protected us, and it just might have saved us. Meredith Grey; Where Do We Go From Here

"His pulse is up 194 and still going up, he's tachycardic. Damn it." One paramedic called out as they just went up. There were airlifting him to Grey Sloan Memorial Hospital, it was the nearest level I trauma center and they were properly equipped for cases like Derek. They were properly trained and had the resources to save even the severe cases …

Derek was drifting in and out of consciousness at that point, barely stable, vaguely he could make out the voices from around him. Everything was a blur. An oxygen mask was covering his mouth and nose, providing extra oxygen.

He felt his racing and he knew he wouldn't stay awake for long.

They've been in the air for only ten minutes and they've got still twenty minutes to Grey Sloan Memorial then, his oxygen saturation dropped below eighty. "Pulse ox is dropping. I'm starting to bag him. Get me an Ambu bag, I am going to ventilate him manually until they get ready for intubation." The paramedic grabbed the Ambu bag and started bagging him.

"Why does he keep going into arrhythmias?" He then asked himself after he has stabilized the patient as he continuously monitored his saturation, blood pressure (that was more on the low side than at a point where it could be considered as stable) and his other vital signs.

Then they were descending. Just then, he started going into v-fib again.

"He's in fib. Paddles."

After he pressed them onto the patient's chest, he yelled: "Clear."

The shrill beeping of the machines could be heard, also the roaring of the engines of the helicopter.

Derek's body jerked up and fell back on the gurney. The paramedic looked over to the cardiac monitor. After the second round, there was a reaction. His heart was coming back, they could hear the faint but regular beeping of the cardiac monitor. Derek Shepherd was going back into Sinusbrady. "We got him back." One paramedic said in relief.

Then he turned around, calling over to the pilot while the other paramedic was constantly checking his vital functions.

"How many minutes do we have to go until we reach Grey Sloan Memorial Hospital? He's barely hanging on now. Is there any chance we could fast-track this?" The paramedic asked, his eyes were on Derek's heart monitor to check for any rhythm disturbances. But for now, there weren't any. But since there was bruising on Derek's chest, he assumed there might be trauma to the chest.

"We're two minutes out." He got the answer over the headphones.

After they got his rhythm back, they have almost reached Grey Sloan Memorial Hospital, the trauma team already waiting for them on the helipad. "Get ready for landing." The pilot warned before starting to descend.

Dr. April Kepner waited along with Dr. Bailey and a few other surgeons for the landing of the helicopter that was bringing in Derek Shepherd, neurosurgeon at former Seattle Grace Mercy West, now Grey Sloan Memorial Hospital. "Okay, they're landing. We need to as fast as effective."

"We're going to descent. Please fasten your seat belts." The drone of outside noise grew louder.

The MedEvac landed with rotating propellers on the helipad. Once the rotors were fairly stopping to rotate, a His injuries were severe. Dr. Hunt, Dr. Bailey and the other doctors ran quickly toward the Medevac. "What do we have?" Dr. Miranda Bailey asked and glanced at the portable heart monitor which recorded the heartbeat. "What do we have?" The first paramedic jumped out and pulled out the gurney with Derek lying on it.

"Dr. Shepherd, severe injuries resulting from car crash, suspected chest and abdominal injuries and a head lac. BP's tanking and low." The paramedic told them in a hurry.

"Okay, you've heard it all people. He's in bad shape so let's move it." April has taken over commands.

"Let's get him in."

It's a beautiful day to save lives.

After the Grey Sloan staff got him into the nearest trauma room, they quickly began assessing his state. "How come he isn't intubated?" First comes Airway Management with cervical spine protection, and they did stabilize Derek's spine at the crash site so they need to secure his airway.

"What is going on, I need to be with him." Someone entered the room, frantic. "You can't be here Meredith." Bailey tried to tell her. "He needs me to be here."

That's right.

Derek was vaguely conscious, he heard the familiar voices around him, figures hovering over him-

"Mer …" He tried to get out, his voice barely audible.

Meredith and Derek were both lying in their bed, wide awake. "You want to go again?" He asked, panting. Meredith and Derek both smiled 'cause it was so damn good. Then they heard cries coming from their son, Meredith and Derek turned their heads in direction of Bailey's room. "I guess not, Bailey's up." Meredith said as she hears the cries of her youngest child.

"Oh." Derek said. "What if I cancel my flight …" Derek suggested, leaning towards Meredith, they were happy, they were a happy couple again ... "I could come to the hospital before I go to the airport and we could find an empty on-call room …" Derek smiled at her dreamingly. "I have work to do." Meredith replied smiling, not wanting to show him how much she actually liked that idea - even if it wasn't realizable. "Aw, you know as much as I like that idea, it's just not feasible, Derek. I have work to do at work and I can't do you too."

"Okay, then it's settled, let's could go again …"

He was ready to start, when Meredith loudly exclaimed: "No, you are terrible influence, absolutely not." With that she gets up, saying with determination in her voice: "We're getting up now." Derek looked at his absolutely hot wife. But Derek stayed in their bed, smiling to convince her to come join him … "I know." Meredith said smirking, eyeing that husband of hers.

"Why don't you make yourself useful and go change Bailey's diaper." Meredith's eyes sparkled when said that. "Uh-" Derek sighed when Meredith threw a Bailey's baby-phone at him. "And you are terrible." Meredith's voice slightly raised. She threw one of their pillows at him. Derek just laughed in reply, pushing the pillow away from him.

"Have fun changing your son's diaper." She mouthed.

"I am gonna go shower." She smiled at him, obviously trying to seduce him. And it worked. Derek shook his head chuckling while he watched his wife disappear for the bathroom. While he is the one to change Bailey's diapers when he could have joined Meredith in the shower which was far more appealing than changing dirty diapers – but hey, McDreamy, changing diapers is part of parenthood!

After Derek had changed Bailey's diapers he put his son in the high chair. Meredith already prepared the breakfast for their little one. It was carrots. Then Derek Shepherd walked into the kitchen, fully clothed.

"Have you seen my phone?" Derek asked as he walked into the kitchen. Meredith glanced at him while mothering Bailey, frowned and then she said: "Well, Derek, it's in your hand." She was pointing out the obvious but what she didn't know at the time that Derek didn't meant that phone, he meant the phone he got from the president. "Not this one. This one's mine, the government wants theirs back, I need to return it and I don't know where I put it." Derek explained the ongoing situation to Meredith. "Have you checked the couch cushions?" Meredith asked as she started searching for Derek's other phone.

While doing that, she called out for Zola: "Zola, hurry up honey or you won't have time to eat breakfast."

Then she asked Derek if he was nervous. "Are you nervous?" "Well, maybe I end up going to prison if I don't return the phone. I mean I don't go to prison for that, right?" He wanted his wife to reassure him that he won't go to prison even if he can't find the phone. "No, I meant resigning." She told him with a wide smile, unable to contain the happiness about Derek resigning and coming back to her and their kids and the dream-house that Derek built for their family to live in.

"I mean giving your job up isn't a small thing to do …"

She didn't complete the sentence.

"Oh it is …" Derek replied, still searching for the phone. "… in comparison to everything here, it is." Derek said reassuringly, while Bailey was face down in his food what nobody seemed to notice what Bailey was doing.

"But Derek …" Meredith tried to say something. "Meredith, I meet with the president's council in the morning and give them my final report and official accommodation and then I am done. I'll be home before you even know it." He said, coming toward her. She smiled at him, catching herself thinking, that this was too good to be true. Her husband, the love of her life was finally coming home.

"It's time. It feels good." He said, feeling relieved about the fact that he can go home to his wife, that isn't obligated to stay in Washington D.C.

It's unbelievably freeing – for both of them. He took a big sip of his coffee. "I just wish you could be home already." Meredith said longingly. "I know, I feel that feeling too. But you know, I'll be home before you know and then you know we'll have a lot you know, Starting-fresh-sex." Derek smiled at his wife. "Derek." Meredith scolded. "Little ears in here."

"Sorry." He apologized but smirked while he said that. Suddenly they heard a key in the door. Surprised, they looked up. Amelia entered the house.

"Oh, you're here?" Amelia said surprised as she opened the front door.

"We live here." Derek replied. "But you had a flight and you were going on and on about having an early surgery scheduled." Amelia was rambling, clearly nervous.

"My point is you're not supposed to be here."

Amelia first pointed at Derek, then at Meredith. She covered her nervousness with flashing a smile. Meredith and Derek were both looking at Amelia.

"My surgery got pushed back. Weren't you wearing that yesterday?" Meredith asked suspiciously but widely smiling.

Amelia gaped at them with a half - open mouth. Before Amelia had the chance to answer, Owen opened the front door. "Amelia, you forgot your ..." He stopped in the mid-sentence when he saw Meredith and Derek standing there and watching them. Amelia looked to Owen, then back to Meredith and Derek.

"Hey, ah …" Owen stuttered, taken by surprise.

He most certainly hadn't expected Amelia's family to be there when he came to visit her or whatever.

"I was just …" He pointed towards the door. Derek watched them, visibly amused by the scene. He turned to Meredith who just stared at them in shock. Even Bailey stopped eating his carrots and looked at Owen and Amelia. "I was just … her cell phone."

Owen handed Amelia her cell phone. "Thank you." She said widely grinning. "Yeah …" He said, turning to leave. But Derek had other plans. "Who wants breakfast?" He asked. "Anybody?" No answer. "We have coffee …" He offered. "I … I should probably go. I am gonna go." Owen suggested to end this awkward situation and with that he turned to go, closing the door behind him. Amelia didn't know what to do, this was really awkward. Then Bailey made some sounds, saving Amelia from her brother and sister in law.

"Hey, little guy." She exclaimed and went to high chair, taking Bailey, saying: "Let's find your sister and …" Bailey was babbling some incoherent words while Amelia carried him away.

When Amelia left the kitchen Meredith turned to Derek, making a face: "So your sister and Owen? Really?" Meredith asked and looked at her husband. "Yeah, she told me last night." Derek explained while putting on his coat. "You knew that your sister's doing Owen and you didn't tell me?" Meredith inquired him, eyeing him. Why did he hide that information from her? "I was supposed to tell you that?" He asked dumbfounded, not daring to look Meredith in the eye. "Yes." She replied, her eyes sparkling.

"I don't remember where I put my phone and now have to remember someone else's sex life?" He answered back flabbergasted. "Oh, I gotta go ..." But instead, Meredith came nearer to his body, Derek asking: "Oh you wanna go again? Huh?" Meredith didn't answer, in that moment she pulled Derek's lost phone from his pocket. She chuckled as she held it up.

"Oh. Hey, that's my phone." Derek replied and he and Meredith kissed.

Then they parted and Meredith said: "You know, I wish you could stay or I could come with you or something." Derek already opened the door. "I'll be back soon and you know that." Derek assured her. "I know, I know." Meredith followed him to the door. "I just feel like I just got you back and now you have to go and I have to stay here …" Meredith rambled a bit. "I'll be home before you know it, Mer." Derek smiled his McDreamy smile. Then they kissed - for real kissed.

„This is my last trip and then I'll be back for good." Derek said, smiling at her. Meredith smiled at him, the thought of Derek being back for good was amazing. "I love you, you know that, right?" Meredith looked at him as he came nearer and nearer and finally their lips met – they kissed, as in really must part ways with her now though. There's the little matter of resigning from a presidential post in DC.

"I just feel like I'm losing you again after I just got you back." Meredith told him her thoughts.

Derek replied: "You won't lose me, you won't ever lose me ..." Meredith smiled at him. Then Derek said smiling: "Wait right here. Wait for me. Stay here." It were the exact words he was saying before he went to break up with Rose, after she built the house of candles where their real house is now ... Meredith smiled as she watched Derek leave, already thinking about when he comes back to her.

Meredith heard him whispering her name in an effort. She was on his side in a second. She ignored the other doctors fussing around him, trying to get an i.v. access and a central line into his right subclavian artery.

But apparently, someone had heard him. Someone was touching his hand, it was ice-cold, due to poor circulation. "Derek, it's me, you gotta hold on. You need to stay awake , Derek." He knew that voice. He opened his eyes, tried to catch a glimpse of Meredith hovering over him.

Fear was covering her face. He wanted to tell her that he's going to be okay but he couldn't. "You really gotta pull through, Derek. Just remember that we love you."

Then, Meredith got pulled away from Bailey. She was being banned from the trauma room while they were working on stabilizing Derek. He's in hypovolemic shock. "What's happening to him?" Meredith asked with fear in her voice when she heard the beeping of the cardiac monitors. She wasn't able to think as a doctor would in a situation like that. Tachycardia. Dyspnea. Sudden drop in blood pressure. Symptoms of something bad.

They were all doctors in the room.

Meredith turned to Maggie. "Go, help him." She said, breathing heavily. "You're the cardiac surgeon and he keeps arresting." Without further questioning her sister, Maggie entered the trauma room. "Someone get me up on speed of his condition."

"Possible tension pneumothorax." Maggie said shortly, alarmed, Meredith looked up in shock.

They needed to relieve the pressure, otherwise this would send him into cardiac arrest.

"We need the portable X-ray machine, stat." Maggie commanded, she what not about to let her sister's husband on her hands and that's what Meredith makes go back to reality. "I need an emergency X-ray of the lungs in two levels. Move." Derek was getting heavier air and his skin took on a shade of blue. Cyanosis. He found it increasingly difficult to stay conscious.

Darkly, somewhere between consciousness and unconsciousness, he heard Maggie call out in fear: "Damn, tracheal shift and unilaterally revoked respiratory sounds. It's definitely a tension pneumothorax..."

Then she asked for the utensils for an immediate chest tube on the posterior axillary line in the 4th ICS. She immediately released the tension in Derek's chest, the entering of the chest tube made him grunt in pain.

"I'm sorry but we have to do this." Maggie told him, making eye contact with the injured neurosurgeon. But after they placed the chest tube, he was able to breathe again. "Okay, guys, let's prep for intubation." She then told them.

Circulation and hemorrhage control

After Amelia Shepherd did a brief neurological evaluation, she never let on how she felt, basically put her emotions and feeling aside to not obstruct her brother's care- he needed to survive ...

"Get the thermal blankets now. We need to prevent him from getting hypothermic by keeping his temp level." Bailey shouted, while palpating his abdomen. "Coming right up." Meredith stood on the other side of the glass and watched her colleagues and friends working on the love of her life. Although he had done mistakes in the past, they both had, she loved him with all her heart and she wasn't ready to stop doing that.

Hypothermia, acidosis and coagulopathy – the lethal triad.

Often watched in trauma patients like Derek. Triad of death. It could happen to him too. Meredith was struggling not to panic. Then she felt someone standing next to her. It was her sister Maggie.

"Come, you don't need to be here." Meredith never looked away from the glass.

She was looking distraught, almost white in her face. But she didn't care about how crappy she felt. She wanted to know what was going on with Derek, she needed it to know. Then suddenly, his heart monitor jumped into action. Meredith's eyes went wide as she saw the rhythm disturbances on his heart monitor. "Derek." She whispered, struggling to stay out of the room.

"No." Like in trance she watched Bailey apply the transcutaneous pacing pads to his chest, then she called: "Charge to 200. Clear."

"Ventricular fibrillation. We've shocked once, now preparing for the second round of ACLS." She explained, not taking her eyes off of the monitor. Luckily, they got him back after the first try. "We need to do a Head-CT, after you got him stable for transfer. I need to check for any bleeders and we need to place a device for ICP monitoring." Amelia interjected. She was the only available neurosurgeon.

She just hoped Derek's head scan would come back clear otherwise they'd have a real problem.

At the same time, they cross-matched his blood and ran his laboratory studies. "Someone get me a damn ultrasound." Bailey shouted into the chaos. She needed to do a focused abdominal sonography for trauma (FAST) ultrasonography examination to check for internal hemorrhage. She hated this day. "I think I speak for all of you when I say I hate this day." "Yeah." Owen said as he worked to get a second access into Derek. "He's lost a lot of blood, set up a rapid infuser." Then someone got Bailey's ultrasound.

"Here you go doctor." A nurse said.

Without any delays, the general surgeon pressed the transducer against his abdomen and then after a few looks on the screen, she was alarmed. "There's free fluid in the abdomen. He needs a trauma scan."

When he was stable enough for them to get him up to radiology, they began doing the scans and at Amelia's request also a head scan due to the fact that he has a head injury and they don't know the extent of it so they do the scan to make sure that they aren't missing something that might could kill him.

"We need to take him straight to the OR." Bailey said after taking one look at his trauma scans. "She's right." Owen said as he determined findings by analyzing Derek's x-ray images. "Move." He then said. Meredith stared at the images in shock. She had no idea how she entered this room but somehow she did. "Grey. Go wait by the attending's lounge. We'll meet you there when he have further information. Meredith didn't reply. She went with them until they reached the ORs.

"You have to stay here." Bailey said to Meredith who let go of Derek's hand when they rushed him into surgery. Meredith looked at his cardiac monitor, assuring herself that he was stable before she planted a quick kiss on his forehead.

Meredith looked at them, seeing the gurney with Derek on it disappear behind doors.

She couldn't be with him. She stayed behind, hoping everything would turn out alright. She wanted to be with him, seeing that everything was good to be okay. But she needed to. Although there was a sign: RESTRICTED AREA AUTHORIZED PERSONNEL ONLY. STAY BACK. DO NOT CROSS THE RED LINE.

Meredith began pacing up and down.

Maggie was with her, after all she was her sister. "He'll be okay." She offered, trying to be helpful. "You don't know that." Meredith said nervously. Just at that, Maggie's pager began to beep loudly. It interrupted the deafening silence. Maggie flinched at the sound of it as did Meredith and Amelia.

"Crap." She then said.

"I have to go, OR 1's paging me."

OR 1 - that was Derek ...

Amelia Shepherd silently went over to refrigerator, ignoring Meredith completely. Meredith had no idea what was going on. She took out an apple, turning to leave the room and then changing her mind. "Look, I appreciate that you want to look out for Owen but who I see is none of your business." Amelia stated, blindsiding Meredith with that.

"Wow." She said surprised. "Okay. I was only trying to …"

But she had no chance finishing that sentence because Amelia was cutting her off: "I moved here to start something, to build a new life. You don't know me... Not really. You don't know where I've been or what I've had to overcome, because you have never had to. You've never lost the love of your life. You have never cried over the body of the person you love most in this world. You... You don't know how that messes a person up. You've never had to claw your way back from that. But I have. I'm still trying to pull myself together, and I am doing the very best that I can, so... Until you've done that, until you've had to walk in my shoes, I need you to cut me some slack... And back the hell off." She said before leaving the room. Meredith only watched her going away …

But Amelia was wrong or at least partly wrong, she knew what it was like.

She had lost too many people in her life … for one, Lexie who she had grown to love, who was, is her little sister and then losing Derek on several occasions that had all to do with Seattle Grace Mercy West, now Grey Sloan Memorial … After all, she offered her life to a gunman so that he wouldn't shoot Derek for a second time (which he wouldn't have survived).

She was ready to take a bullet for Derek, anytime.

But apparently, Derek had never told her what happened in that OR and before that. Her fears that that nightmare she had would come true and that he would die before her eyes … that she would lose him, she almost lost him at too many occasions. The shooting, the plane crash … only to name two.

"Hey, can we talk?" Owen walked towards Amelia who was standing near the nurses' station, typing in her pad. But their conversation was interrupted by a nurse who called Amelia's name. "Dr. Shepherd, you have a call on line four." A nurse called Amelia over, holding a phone in his hand. Meredith was sitting there, looking for something in someone's patient chart. "I gotta get that." Amelia said to Owen. Amelia made her way over to take the call. "Hello." She said, waiting for whoever this was to reply.

"Oh, no, sorry, you want the other Dr. Shepherd." She stated, the cell phone pressed against the ear.

"Here's his wife." Amelia said concluding and handed the phone over to Meredith who was sitting there, working on the computer. "Hi, this is Dr. Shepherd's wife. No, he's not here. Can I take a message for him?" She asked while searching for a piece of paper, some post-it note or anything that goes that way and a pencil to write something down. She starts writing something on a paper, the pencil scratched on the paper.

Then she exclaimed in surprise, straightened herself: "Oh, I thought he was there."

"Okay, sure." She replied to whatever they said on the other line.

"Okay, no problem, thank you." Amelia watched Meredith, scribbling something down, waiting for her to end the call and spill what was going on. "Bye, bye." She said before finally ending the call and put it back. "What was?" Amelia asked as soon as Meredith ended the call. "Uh, nothing." But Meredith's voice clearly showed that it was definitely not nothing. "It was just the White House calling. Derek never showed up at his meeting this morning." Meredith answered. "Uhuh." Amelia looked at her.

"I am sure his flight got delayed or something."

Meredith waved it aside, pushing her real feeling aside as well. She wasn't calm, at least not at the inside. She couldn't help but worry.

She then left, smiling at her although her smile was somewhat forced and bizarre. On the place where she worked was a notepad with the name 'Derek' followed by a question mark.

"I haven't heard from him." Meredith added, it was clear that she was worrying - who wouldn't be? Her husband was missing. All they knew was that he had taken a secret shortcut (Bailey and Amelia insisted that there weren't any shortcuts to the airport but who knows right) ...

And nobody has heard from him since he departed for the airport, after reception was lost ...

She turned around, a mixture of disbelief and worry covered her face. But mostly it was disbelief that Meredith saw in the face of her mentor. She didn't speak out the words that they all feared: "He never made it to D.C." Because that's what it's mostly likely meant. That his plane crashed. For a second time. But it wasn't a plane crash, it was a car accident ...

But the universe can't just be that cruel, right? But somehow it tends to be cruel.