When Isaac, the hospital lab tech, has an inoperable tumor wrapped around his spine, he turns to Dr. Derek Shepherd to do the impossible, and Derek tests the Chief's authority when Richard objects to moving forward with the risky surgery.
- Derek took over the voiceover duties Thursday on "Grey's Anatomy," talking about why he became a surgeon. He said that after growing up in a house with four sisters, it was the quiet that drew him to surgery. At the hospital, he offered Cristina a chance to work with him, even though he was a "neuro god" and not the cardio god she's been waiting for.
Meanwhile, the chief introduced a new, computerized scheduling system he said would be more efficient. He had Sloan help introduce it, and Derek protested a bit, but the chief told him to embrace the change.
Cristina told Alex that Izzie had a cancer treatment coming up. He figured Izzie would show up.
A tech, Isaac, brought Derek a scan that showed a spinal tumor that Derek figured should have left the patient paralyzed or dead. Derek said, "I'd love to operate on this." Derek explained that he couldn't do it, though, because it would require paralyzing the patient to get to the tumor. Isaac then revealed that the scans were of his own spine, and he asked Derek to try to get the tumor out.
Isaac said he knew Derek would take the chance and saw that Derek was inspired, not afraid, when he saw the scans. Cristina showed up and saw the scan and wanted to operate on it. Other doctors showed up and talked about how crazy Derek would have to be to try to do the surgery. Bailey said Derek could retire on the tumor, but the chief said it was "a malpractice suit waiting to happen." Derek challenged the chief and they got into yet another debate. The chief told him, "You're not operating on an inoperable tumor."
At home that night, Derek told Meredith he scheduled the surgery. "I'm taking out the tumor."
Derek laid out a challenge to the interns and residents on how to handle the microsurgery tools. The goal was to put a pen mark closest to George Washington's nose on a $1 bill, after putting the pen through a small hole in the bottom of a cup. Cristina mocked the rest of the group as they failed, one after another. Dr. Avery landed his mark very close to the nose and Cristina went up after him, oozing with confidence. She didn't even get the pen through the hole in the cup. Dr. Avery would scrub in. Cristina was stunned.
Sloan told Derek that word was getting around that he'd "gone rogue." Derek said the schedule is showing he's doing a craniotomy, so the chief shouldn't find out. Lexie was upset that Derek didn't invite her to the skills labs, but he said she had another job for him -- to take care of him during what was expected to be a long, arduous surgery. Lexie later told Avery that he'd eventually have to take a break to use the restroom and she'd take over for him. Avery told Lexie he knew how to manage his hydration and that she was "playing nurse."
Cristina caught Lexie holding a diaper, and Lexie explained it was for the surgery. Cristina thought it was brilliant, and "hard core." Lexie put it on and walked a little uncomfortably into the operating room. Derek and the crew passed by the chief, who was giving a tour, and Derek hurried Isaac into the O.R. Inside, Derek reminded Isaac of the danger and Isaac told Derek to paralyze him if he ran into trouble getting the tumor. Isaac talked about how much hardship he'd survived -- a war, the loss of his family and country -- so he could survive the loss of his legs if he had to. Isaac left Derek with a parting thought, "Today, if you become frightened, instead become inspired."
Derek got inside and saw that it was more intricate than the MRI showed. He started talking and the doctors around him couldn't make out what he was saying. Then they realized he was talking to himself.
Cristina told Hunt she wanted to be in the O.R. wearing a diaper -- because that would mean she was in a long, intense, meaningful surgery.
After eight hours, Derek still hadn't made a cut toward the tumor. Lexie suggested he take a break, but Avery said he didn't need one. Avery asked Lexie if she was wearing a diaper and they started bickering until Derek shouted at them both to shut up. Bailey came in and told Derek that the chief was going to be doing a surgery across the hall soon, so if Derek was going to do anything he should do it soon.
Alex made a call to confirm Izzie's cancer treatment. Reed offered to cover some rounds for Alex so he could handle his "Izzie stuff," but he became angry and mocked her for the offer. He did the rounds himself.
Sloan told Callie and Arizona that Derek was proving "why you don't go rogue." He said Derek had cracked. Callie walked over to the O.R. window and said, "Ten hours staring at this man, he can't figure out what to do." That's when the chief walked up and asked what she said. The chief walked into the O.R. and asked Derek about what he was doing. He demanded that Derek close Isaac up and relinquish the O.R.
"OK," Derek said. "That's it. Let's close him up."
The chief stopped the surgery clock at 10:22:23. Derek later explained to Isaac there was no way to get the tumor without risking his life and he didn't want to cut the cord. Isaac said he understood, but told Derek, "You will try again tomorrow." Derek said he couldn't. "The tumor is inoperable," he said, adding that he couldn't fix it. Isaac told him to "go home and sleep on it," then come back tomorrow.
Derek told Meredith that night that he stood in the O.R. for 10 hours and did nothing. He started talking to Meredith about the tumor, then he took a page out of Dr. Gregory House's book and started drawing on the wall with a Sharpie. First it was a simple diagram, which was enough to shock Meredith. A little time-lapse action then showed a full scale color mockup of Isaac's spinal cord and the tumor.
Derek explained to the chief that Isaac understood the risk of cutting the spinal cord, and the chief granted Derek permission to do the surgery, but only gave him a couple of hours in the O.R. to do it because Hunt had a surgery afterward. When the chief left the room, Derek told Avery and Lexie that they were not, in fact, going to cut the cord. Instead, he was going to pick a spot and cut the tumor out. He said Isaac wanted them "to take the risk." When Derek left, Avery mocked Lexie again for wearing a diaper, but Lexie told him her diaper was "hard core" and said she'd wear it with pride.
Hunt told Cristina about a 12- to 15-hour surgery and told her to "gear up." She ran to put on her diaper when Derek came to Hunt and asked him to give up the O.R. Hunt did, leaving Cristina disappointed.
Sloan came into Derek's O.R. offering "support," and Lexie told Derek that he needed experienced surgeons to talk to, "and you can't say no because I'm in charge and this is what I'm prescribing."
Reed told Alex that he was too distracted to keep working and told him to go to the third floor to be with Izzie during her treatment. She insisted that he was making the choice to leave Izzie alone if he didn't go. He went.
Back in the O.R., Derek had a major scare after making a cut that he thought paralyzed Isaac. There was a lot of bleeding and things got tense. Cristina, watching in the gallery, was relaying the events to Meredith by phone. After a few moments passed, Derek was in the clear -- at least in terms of his patient. He told Lexie to take off his mask. When she did, he puked.
Derek sat on a stool like a boxer between rounds in a heavyweight fight, with Sloan on one side telling him to get back in there and Lexie forcing him to drink water. On the third floor, Alex waited for Izzie to show, but there was no sign of her. Back on the operating floor, the chief ran into Hunt and asked why he wasn't in O.R. 1. He claimed Callie was doing an emergency surgery, but she walked up behind the chief and asked, "What am I doing?"
The chief was angry and was about to storm into the operating room, but Arizona stood in front of the door and told him he was not allowed to go in and be a bully while Derek was operating on the inside of a man's spinal cord -- and that man just happened to be a friend she wanted to see come out of surgery alive and well. The chief walked away.
The clock continued to count past 13 hours when Derek came upon two vessels -- one that could be feeding the cord and the other could be feeding the tumor. He had to make a blind cut, risking stroking Isaac out.
The clock read 21 hours when Avery's hand started cramping. Lexie tried to massage it a bit, but Derek knew Avery was dehydrated because he stopped taking fluids so that Lexie wouldn't be able to jump in on the surgery. Avery apologized and Derek asked Lexie to take over. She stepped in.
The clock read 26 hours. Derek asked, "A or B?" Everything was out, except for the blind cut. He asked Lexie, who stalled. Avery said he didn't like to gamble. Sloan said he didn't want Derek to blame it on him for the rest of his life. All the doctors were watching and watching to see what Derek would do. He started playing "eeny, meeny, miny, moe."
Voiceover Derek repeated his earlier observation, that surgeons would usually say it was the high and the rush that got them into the surgery. "For me, it was the quiet," he said.
He made the cut.
All the doctors waited to find out if he made the right cut -- including Meredith, who was still on the phone.
Isaac woke up in his recovery room, muttering, "Oh, no. No, no. no." He was upset because he could move his toes, figuring Derek was unable to do the surgery. Derek told him he got the tumor without cutting his spinal cord. Isaac was incredibly relieved and told Derek he was "a good man."
Reed went to Alex and gave him the update on Derek and said she did all the rounds. Alex told Reed that Izzie didn't show up. "She can't be this stupid," Alex said. He cried, worried that Izzie wasn't getting the proper care.
Cristina practiced using the microsurgery tools and Hunt saw her, telling her she was standing too close. He came up behind her and showed her where she should be.
The chief, settling back into old routines, was writing the surgery schedule on the dry-erase board. Derek told the chief he was tired of fighting him. "Let's try and put this behind us and move on. I can if you can," he said.
"You're fired," the chief told Derek. "Immediately. Get the hell out of my hospital."
Derek told the chief to "go home, sleep on it. We'll talk more tomorrow."
Derek brought a bottle of champagne home, but before he could start telling Meredith about the surgery, he fell asleep.