Jamie woke before his alarm.
A rare thing.
The soft hum of the city outside his penthouse filtered through the curtains, the distant sound of cars slipping through damp streets. He blinked against the early morning light creeping into the room, stretching his arms above his head before exhaling slowly.
A full night's sleep. He almost didn't recognize the sensation.
Swinging his legs over the side of the bed, he let his bare feet press against the cool hardwood floor before rolling his shoulders. The tension that usually settled into his muscles overnight was barely there, his body lighter than it had been in a while.
5:00 AM. Early. But he liked it that way.
"Enough time for a run." Jamie muttered.
--------------------
Jamie tied his running shoes with practiced ease, slipping into a fitted long-sleeve shirt and athletic joggers before stepping out onto the empty streets.
The rhythm of his breathing matched the steady slap of his feet against the pavement, the early morning chill biting at his skin.
Seattle was still waking up, the city not yet burdened with its usual chaos. The air was crisp, cool from the lingering rain overnight, and the skyline stretched before him, softened by the first hints of dawn.
The run was effortless. His body moved on autopilot, muscle memory kicking in from years of discipline. Each inhale sharp, each exhale measured. The repetition soothed him, the pounding of his heart against his ribs a reminder that he was here. That he was alive.
By the time he circled back toward his building, his muscles were loose, his mind clear. The best part of the morning, before the hospital, before the long hours in the OR, before the weight of everything else settled on his shoulders.
The shower was scalding, steam curling around him as the water worked out the last traces of sleep from his system. He let it run down his back, hands braced against the cool tile, head tilted forward as he let himself just breathe.
No rush. No interruptions. Just the luxury of time.
Fifteen minutes later, he stepped out, towel-drying his hair as he moved toward the walk-in closet.
The suit he chose was sharp, tailored—midnight blue, the cut perfect against his frame. Crisp white dress shirt, fitted but effortless. A deep charcoal tie, knotted with the precision.
He fastened the cufflinks and slipped on his Patek Philippe watch with a final glance at the mirror.
Polished. Composed. Every detail intentional.
The world saw what he wanted them to see.
Jamie smirked faintly to himself before grabbing his keys and heading out.
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The coffee stall sat on the corner of an unassuming street, wedged between a bookstore and an old record shop. The kind of place that had been there forever, known only to those who actually paid attention.
Jamie pulled up, stepping out of his car and tucking his hands into his coat pockets as the familiar scent of espresso and fresh bread wrapped around him.
"Morning, Dr. Knight," the barista greeted, already reaching for the order he hadn't placed yet.
"Morning, Ana," Jamie replied smoothly, watching as she slid a large black coffee across the counter along with a fresh croissant, still warm from the oven.
"You're in a good mood today," she noted, arching a brow as she handed him his change.
Jamie exhaled a quiet laugh. "Must be the sleep. Or the coffee."
Ana hummed knowingly. "Or something else?"
Jamie didn't answer immediately. Instead, he took a slow sip of his coffee, letting the warmth settle in his chest as his mind flickered back to last night.
A fleeting moment. A glance across the room.
Lexie. Something about the memory made the corners of his mouth twitch slightly upward.
Mystery. It was rare in his world.
Ana smirked. "See? That's not a 'just coffee' smile."
Jamie shook his head, taking a bite of his croissant as he leaned against the counter. "You analyze all your customers like this?"
"Only the interesting ones."
Jamie chuckled, letting the morning settle around him. The hum of the city was picking up now, cars moving, conversations blending into white noise.
He glanced at his watch.
5:50 AM. Still early. Plenty of time before his first surgery.
For once, there was no rush. No crisis. Just breakfast, the crisp air, and the quiet thought of last night lingering in the back of his mind.
Jamie exhaled, shaking his head as he finished the last bite.
He had a feeling today was going to be a good day.
----------
Jamie stepped into the hospital, his mood still light as he strode through the main entrance. The familiar scent of antiseptic and freshly brewed coffee from the lobby cart filled the air. He was early.He greeted a few nurses as he passed, flashing a rare, easy smile. The halls were still quiet, the usual chaos of the day not yet in full swing. For once, he had time to settle in before diving into the madness of the OR.Jamie walked toward the locker room, still carrying the lightness of the morning with him. As he entered, he spotted Burke changing.
"Morning, Burke," Jamie greeted.
Burke looked up, taking in Jamie's unusually good mood. "You're early. And smiling. That's new."
Jamie just smirked, not elaborating, as he placed his bag in his locker.
After a beat, he turned to Burke. "Have you told Webber yet?"
Burke exhaled, shaking his head. "Not yet."
Jamie frowned. "I thought we talked about this."
Burke pulled on his scrub top and met Jamie's gaze. "I was in surgery for fourteen hours yesterday. No tremors. I haven't had one in a week."
Jamie studied him for a moment, arms crossed. "Are you one hundred percent sure they're gone? That you're in top form?"
Burke hesitated, his silence stretching just a little too long.
Jamie sighed, reaching for his scrub cap. "I'm scrubbing in with you for your next surgery. I want to see for myself."
Burke considered that for a moment before nodding. "Alright."
Jamie's pager vibrated sharply against his hip, pulling him from his thoughts.TRAUMA BAY. IMMEDIATE RESPONSE NEEDED.His expression hardened instantly. Whatever lightness had lingered from the morning was gone. He met Burke's gaze for a fraction of a second before turning on his heel and striding toward the ER.Burke followed without a word, falling into step beside him.
The moment they pushed through the double doors, the chaos of the trauma bay swallowed them whole. Bailey stood in the center, barking orders as medics wheeled in patients, the sharp scent of antiseptic and blood filling the air.
"Driver lost control of his car, plowed through the fish market. We need all hands on deck," Bailey informed them briskly. "Yang, take that stretcher. Karev, with me. Knight, Burke—primary trauma coming in now."
The EMTs rushed in with a gurney, pushing through the frantic movement in the ER. The man on the stretcher was barely conscious, his breathing labored.
"Male, mid-50s, no ID," one of the medics rattled off. "Blunt force trauma. He was hit by the car that lost control. BP is 80 over 50, pulse 130. Possible rib fractures, signs of internal bleeding—his abdomen is rigid. Suspected splenic rupture, possible aortic involvement."
Jamie immediately took control. "Alright, let's get him to trauma one. I want a chest X-ray, FAST ultrasound, and cross-match for four units of O-negative blood on standby."
Burke moved alongside him, assessing the patient. "Breath sounds are diminished on the left side. Could be a hemothorax. We need a chest tube ready."
As they moved the patient, Jamie caught sight of the monitor—the heart rate was climbing, oxygen saturation plummeting.
"He's decompensating," Jamie said sharply. "We need to intubate before he arrests. Grey, get the RSI meds. 20 of etomidate, 100 of sux."
Meredith nodded, moving swiftly. She glanced at Jamie as she prepped the RSI meds, curiosity in her expression. "Dr. Knight, if there's aortic involvement, what exactly are we looking for?"
Jamie continued positioning the laryngoscope but explained as he worked. "The biggest concern is aortic rupture or dissection. A partial tear like this can become catastrophic in minutes if we don't reinforce it. We're watching for signs of a widened mediastinum on imaging, rapid blood loss, and loss of distal pulses. That's why we're moving now—if this tears completely, he won't make it to CT, let alone surgery." Jamie positioned himself at the head of the bed. "Burke, check for femoral pulses. If we've got aortic involvement, we're going to need to move fast."
Burke palpated quickly. "Weak, thready pulse. We need to move now."
"Agreed. Tube's going in now." Jamie guided the endotracheal tube into place, securing it as the ventilator was attached. The patient's oxygen saturation steadied, but the abdominal swelling was worsening.
Bailey appeared at the doorway. "CT's backed up."
Jamie didn't hesitate. "Then we need to open him up now. Burke, scrub in—this guy doesn't have time to wait."
Burke nodded, already moving to prep. Jamie locked eyes with Bailey. "Tell the OR we're coming in now."
The monitors blared another alarm, but Jamie was already moving. Time was against them, but he wasn't going to let this man die today.
The patient was rushed into the OR, a flurry of movement as the surgical team prepped. Jamie and Burke scrubbed in quickly, their focus sharp as they stepped up to the table.
"Anesthesia?" Jamie asked as he positioned himself.
"Patient is stable but critical. BP 85 over 60, holding on with transfusions," the anesthesiologist confirmed.
Jamie nodded, pulling down his surgical loupe. "Alright, we go in fast and control the bleeding first. Scalpel."
The scrub nurse handed Jamie the instrument, and he made a swift midline incision, carefully slicing through the skin and subcutaneous tissue. "Metzenbaum scissors," he requested, using them to separate the layers of fat and fascia with delicate precision.
Once he reached the linea alba, the fibrous structure that holds the abdominal muscles together, he switched tools. "Bovie." The electrocautery device sparked as he used it to incise the structure and gain access to the peritoneal cavity.
As soon as the abdominal wall was open, dark arterial blood pooled into the cavity.
"Confirmed hemoperitoneum," Burke observed, stepping in. "Bleeding is significant."
Jamie worked quickly. "Lap pads—five. Suction!" The nurse handed him the pads, and he placed them deep inside the cavity, carefully applying pressure to slow the bleeding while suction cleared his view.
"Meredith, watch closely. This is a classic case of splenic rupture," Jamie said as he navigated through the blood-filled cavity. "The spleen is highly vascularized, which means it can bleed out quickly if we don't control it. That's why trauma cases like this are time-sensitive."
Jamie located the spleen in the upper left quadrant, already darkened and swollen. He carefully mobilized the splenorenal ligament, the tissue that connects the spleen to the kidney.
"I'm clamping the splenic artery first. If we remove the spleen without clamping it, he'll bleed out before we can stop it," Jamie explained as he carefully placed a vascular clamp on the artery.
Burke assisted, holding the tissue back while Jamie moved to the short gastric arteries, which were still pumping blood.
"We have to tie off the short gastrics individually, or else we risk back-bleeding from the stomach. Hemostat," Jamie instructed, using the clamp to grasp each artery before securing it with 2-0 silk ties.
Once the arteries were secured, Jamie gently lifted the damaged spleen.
"Suction now. I'm dissecting the last part of the splenocolic ligament, which is what connects the spleen to the colon. Once I free it, we can remove the spleen."
Burke assisted with the retraction as Jamie carefully cut through the ligament, fully freeing the spleen from the abdominal cavity.
"Spleen is out," Jamie announced, placing it in a basin held by the scrub nurse.
"Now, we inspect for collateral damage. The biggest risks here are injury to the pancreas or bowel." Jamie used a fresh lap pad to wipe away residual blood before running his gloved fingers along the pancreatic tail. No damage.
He then examined the bowel loops, searching for perforations.
"Bowel is intact. No secondary injuries," Jamie confirmed.
"Bleeding control looks good," Burke added, scanning the cavity. "But we still have the aortic tear to deal with."
Jamie took a deep breath. "Alright, we need to place a graft. Burke, we're handling this ourselves. Meredith, I want you observing closely."
He turned to her. "This is a partial thickness tear in the aortic wall. If we don't reinforce it, the pressure from the heart will cause it to rupture completely. That would be fatal."
Burke nodded. "We'll need a Dacron graft. Sutures—5-0 Prolene."
The scrub nurse handed Jamie the materials. Burke positioned two vascular clamps above and below the damaged area to temporarily block blood flow, preventing further hemorrhaging.
"Now, we cut away the weakened section of the aorta. Scissors."
Jamie made precise incisions along the damaged arterial wall, removing the weakened portion.
"Next, we position the graft. The key here is making sure the anastomosis is perfectly aligned so we don't create turbulent blood flow, which can lead to clotting."
He carefully positioned the Dacron graft, ensuring it sat flush against the healthy artery.
"Starting proximal end first," Jamie said, threading the 5-0 Prolene suture through the graft and native aorta, securing it with fine, interrupted stitches. He repeated the process on the distal end, ensuring an airtight seal.
Burke carefully released the proximal clamp first, allowing blood to slowly re-enter the repaired section.
"No leaks," Jamie confirmed. "Removing distal clamp now."
As blood flow resumed, the graft pulsed with restored circulation.
Meredith leaned in slightly, watching the repair hold. "That was incredible," she murmured.
Jamie smirked. "Welcome to trauma surgery."
Just as they finished closing the abdominal wall, a sudden alarm blared from the monitors.
"He's desatting!" Meredith called. "Lung sounds are absent on the left!"
Jamie's eyes flicked to the chest X-ray on the monitor.
"Damn it—his fractured ribs must have punctured the lung. We've got a pneumothorax."
Burke grabbed the chest tube kit. "We need to relieve the pressure now."
Jamie quickly palpated the fifth intercostal space, midaxillary line—the ideal location for a chest tube.
"Scalpel," Jamie ordered. He made a 2 cm incision over the rib, then used a curved Kelly clamp to bluntly dissect down to the pleural cavity.
A sudden rush of air escaped.
"Tension pneumothorax confirmed," Jamie said.
Burke handed him the 28 French chest tube. Jamie inserted it posteriorly toward the lung apex, ensuring proper placement.
"Connecting to water-seal drainage," Burke said as he secured the tube.
Within moments, the patient's oxygen saturation improved, and his breathing stabilized.
"Breath sounds returning bilaterally," Meredith confirmed, relief in her tone.
Jamie exhaled. "Crisis averted. Now let's close."
They worked efficiently, suturing the abdominal layers with Vicryl while ensuring no tension on the vascular repair.
Jamie checked the vitals. Stable.
Burke let out a slow breath. "That was solid work."
Jamie smirked slightly. "Not bad yourself."
As they stepped back from the table, Jamie turned to Meredith. "Remember what I told you—timing, precision, and knowing when to make the right call. That's what saves lives in trauma surgery."
Meredith nodded, absorbing every word.
------------------------------
Trauma Bay
Derek stood at the head of the stretcher, scanning the trauma team as Christina Yang rattled off the report.
"Larry Shane Dickerson. 68. GCS 8. BP of 100 over palp. Pulse in the 120s," Christina said quickly, assessing the patient.
Callie had already begun evaluating the man's lower extremities, her hands pressing gently along the obvious deformity of the tibia and fibula. She frowned. "Obvious tib-fib fracture. Get X-rays and let me know if it's surgical. But he's got a lot worse problems than a broken leg."
Dickerson groaned weakly, his eyes fluttering open before rolling back again.
His wife gripped his hand tightly, leaning close. "Honey, let me hear your voice. Oh, that car… that car… just about killed him."
Derek's brow furrowed as he looked between them. "The car hit him?"
Callie shook her head. "No, he was driving."
Christina glanced at the monitor, then pulled back the trauma gown, noting the bruising along his chest. "Hit his head on the windshield. Chest hit the steering column. Old car. No airbags."
Derek's focus sharpened. "So, he was driving the car that crashed into the fish market?"
Dickerson's wife quickly shook her head, her voice rising in urgency. "He wasn't driving it. That's what I'm telling you. It was driving him. He didn't do all this. It was the car. He couldn't stop it."
Derek exchanged a glance with Christina, his concern deepening. "Alright, left pupil is sluggish. We could be looking at a subdural hematoma."
Christina immediately reached for the portable ultrasound probe, conducting a quick FAST exam for any signs of internal bleeding. "We need a head CT and full trauma workup," she confirmed.
"Mrs. Dickerson," Bailey said as she approached, her voice firm but patient, "I have two police officers waiting to take your statement about the accident."
The woman turned toward her, her expression desperate. "It was the car. He went to drop me off, just like he always does. He's a good driver. Please, I just want to be with my husband."
Bailey sighed, softening slightly. "Yes, Mrs. Dickerson. But just give the statement. We need to understand exactly what happened."
"Not now! Please."
Bailey hesitated, then gave a short nod. "Okay, um... right. I'll ask them to come back later. Let's go."
She gestured to Christina, who immediately began preparing to transfer Dickerson to radiology for further imaging.
-----------------------------
The ER doors hissed open, and for a moment, everything else blurred.
Standing just inside the entrance, a woman covered in blood stood motionless, her face pale beneath the crimson streaks. The automatic doors slid open and closed behind her, but she didn't move.
Addison had been heading toward the nurses' station when she spotted the woman.
"Ma'am? Ma'am?" Addison called, taking a cautious step forward.
The woman's lips parted slightly, her eyes unfocused. She took a slow, dazed step into the room—then collapsed.
"I need a stretcher over here!" Addison shouted as she rushed forward, catching the woman before she hit the ground.
----------
Alex Karev was already at her side, assessing the scene. "Awesome cuts."
The woman, now being carefully placed onto a gurney, blinked up at him, her pupils sluggishly reactive.
"I flew through a window," she murmured, her voice distant. "I flew."
Addison pressed lightly on her radial pulse. It was thready, barely there. "Karev, let's get her stabilized. Can you tell me your name?"
The woman inhaled sharply as she winced in pain. "Janelle Duko."
Addison's focus sharpened. "Janelle, what do you do for a living?"
"I sell vegetables at the fish market."
From across the trauma bay, a familiar voice cut through the noise.
"Janelle, honey, can I get you anything? Some food maybe?"
Mrs. Dickerson stood near the edge of the trauma bay, watching anxiously.
Janelle's eyes widened slightly. "Mrs. Dickerson? Is that you?"
Mrs. Dickerson nodded tearfully, clutching her hands in front of her chest. "Larry's a good driver. The car went crazy. Janelle, if you need anything, I'll be right over here."
Janelle sighed weakly, her body trembling slightly as the shock set in. "She's my best customer."
Addison exhaled, then turned toward Mark Sloan, who had just entered. "She collapsed in my arms. I just want to make sure she's okay."
Mark smirked slightly. "They don't call me doctor for nothing."
Janelle shifted slightly on the gurney, her breath hitching in discomfort.
"Mr. Dickerson is such a nice man," she mumbled. "I hope he didn't kill my baby."
Addison's head snapped up.
"Addison! She's pregnant," Mark said, already reaching for an ultrasound probe.
Addison turned back to Janelle, her mind shifting gears. "How far along are you?"
Janelle swallowed, her throat tight with discomfort. "Ten weeks."
Then, suddenly, she flinched in pain.
"OW!"
Alex, carefully removing glass from her forearm, looked up apologetically. "Sorry. You've got deep lacerations, and there's still embedded glass."
Mark raised an eyebrow at Karev. "Try a lighter touch."
Janelle blinked sluggishly, her expression vaguely amused. "The doctors… hot men. They're all really hot. It's not just 'cause I'm wearing a plate-glass window?"
Addison smirked. "Nope. They're man-candy."
Janelle smiled faintly. "Good."
Then—she started coughing violently.
A thick, red mist of blood splattered across the front of her gown.
Janelle looked down at it, wide-eyed. "Okay. That is nasty."
Addison's expression hardened in an instant. "Her SATs are in the 80s. We need oxygen. And I need a portable chest X-ray, STAT!"
Mark, suddenly serious, grabbed the oxygen mask, securing it over Janelle's mouth. "Breathe deep, Janelle. We've got you."
Alex adjusted the IV fluids, watching as the heart monitor flickered irregularly.
"There's something else going on," Addison murmured. "That's not just glass injuries. We might have a pulmonary contusion or a pneumothorax."
"I love you bossing," Mark muttered. "Boss more."
But Addison barely heard him.
The portable chest X-ray was on the way, but something told her they didn't have time to wait.
-------------------------------
The OR doors swung open, and Jamie stepped out first, peeling off his gloves before disposing of them in the bin. The surgery had been a success—the trauma patient was stable, the aortic graft was holding, and the chest tube had resolved the pneumothorax.
Burke followed closely behind, rolling his shoulders. "Good work in there."
Jamie smirked faintly, running a hand through his damp hair. "Not bad yourself. But we should keep a close eye on him overnight. Any sign of clotting or ischemia and we'll have to go back in."
"Looks like your hand is fine Dr. Burke. I can't make out any tremors" Jamie said quietly.
Burke smiled, but stayed silent.
-------------------------------
Addison turned to Meredith as she prepped the chest tube kit, her expression focused.
"Did Dr. Bailey see the chest X-ray?"
Meredith shook her head, adjusting the surgical tray. "No, but with the low pulse ox and decreased breath sounds, she suspects Janelle will need a chest tube."
Across the trauma bay, Alex sighed dramatically as he worked to remove embedded glass from Janelle's arm.
"I'm dabbing out freaking glass splinters, and she gets to do a chest tube?"
Mark smirked. "You signed on for this."
Janelle groaned from the gurney. "This is not a good day for me. This is not a good day for me at all."
Addison kept her voice even. "The baby looks good, Janelle. The heartbeat is strong. Do you want to call the father?"
Janelle let out a breath that was almost a laugh, but not quite. "You could, but that would require me speaking to him, which I no longer do. Hearing he's a daddy from some random doctor might not go over so well."
Addison arched an eyebrow. "So the father doesn't know?"
Janelle shook her head weakly. "No, and he's never going to."
------------------------------
Meredith adjusted the chest tube tray, rolling her shoulders as she prepared for the procedure. It had been hours since she and Jamie had walked into the OR together, and now she was in the ER, shifting gears.
Janelle's breathing had worsened, her oxygen saturation dipping lower despite the non-rebreather mask over her face. She was getting tired, her body struggling against the blunt force trauma from the accident.
Alex, still working to remove embedded glass, groaned as he threw a piece into the basin. "This woman is basically a human windshield."
Janelle let out a half-hearted chuckle, though her voice was thin. "This is still not a good day for me."
Meredith pulled on sterile gloves and glanced at Addison. "Bailey still wants me to place the chest tube?"
Before Addison could answer, Bailey herself stepped in, her face unreadable.
"We're not doing a chest tube, Grey."
Meredith froze. "What? But her lung is collapsing—"
Bailey's voice was sharp but calm. "Because the X-ray showed something else." She turned to Janelle, her gaze firm. "Ms. Duko… you have a shard of glass going into your heart."
The room went silent.
Alex's hands stilled, the forceps hovering over another embedded splinter.
Mark muttered under his breath. "Well, that complicates things."
Janelle's eyes widened, panic settling into her expression. Her heart monitor began to spike, the erratic beeping filling the trauma bay.
Addison leaned in quickly, soothing but firm. "Janelle, stay calm. We're going to take care of you."
"Glass… in my heart?" Janelle rasped.
Bailey nodded. "It's millimeters from perforating the myocardium. If it moves, we could lose you. That's why we need to take you into surgery right now."
Janelle tried to nod, but her chest rose and fell too quickly, hyperventilating.
Mark's voice was softer than usual. "We'll fix this, Janelle. You just have to trust us."
Meredith pulled off her gloves, pushing the chest tube kit aside as she met Bailey's gaze. "Let's get her to the OR."
----------------------------
The OR was silent, save for the steady beep of the heart monitor and the muffled hum of the ventilator. Janelle lay motionless, her chest open, her heart exposed beneath the surgical lights. Every beat was a reminder of how fragile the situation was.
Jamie stood at the head of the table, surgical loupe in place, his eyes locked on the shard-induced injury to the heart.
Meredith stood across from him, sterile and ready, waiting for instructions.
"Alright," Jamie began, voice even, professional. "We need to move carefully. The glass punctured the right ventricle and went through the septum. If we don't reinforce the defect, she'll go into heart failure."
Meredith's eyes flicked to the monitors, noting the slight irregularity in rhythm.
"What's the approach?" she asked.
Jamie motioned for the scrub nurse. "First, we expose the field further. We need better visualization before we attempt repair. Scalpel."
The nurse placed the blade in Jamie's palm, and he made a precise incision, extending the opening in the pericardium, the thin sac surrounding the heart.
As he carefully peeled back the pericardium, revealing the torn cardiac muscle, Jamie continued his explanation.
"The right ventricle is the most vulnerable chamber in penetrating trauma cases. It's thinner than the left ventricle, meaning it can tear further under stress. We need to support the defect without constricting normal heart function."
Meredith nodded, already following his line of thinking. "Pericardial patch?"
Jamie gave a slight nod. "Exactly. We reinforce the septum and ventricular wall with a pericardial graft to maintain structural integrity while allowing the heart to beat naturally."
He glanced at the scrub nurse. "We'll need a bovine pericardial patch, pre-soaked. 5-0 Prolene for primary closure."
The nurse retrieved the patch, handing it to Meredith, who carefully laid it on the sterile field.
Jamie used fine forceps to position the graft over the defect. The torn tissue quivered slightly with each contraction, a stark reminder of how precise they had to be.
"Meredith, take the distal edge. We'll suture together—interrupted stitches. If we make the suture line too tight, we'll restrict blood flow through the right ventricle."
Meredith picked up her needle driver, mirroring Jamie's technique as they worked in tandem, placing evenly spaced interrupted sutures along the perimeter of the patch.
The room remained silent, all eyes on the delicate repair.
Jamie's voice remained calm but firm. "Each stitch has to be deep enough to hold but not so deep that we compromise the myocardial tissue. If we take too much muscle, we risk arrhythmias."
Meredith tied off her last suture and sat back slightly. "Bleeding is minimal. Looks like the patch is holding."
Jamie nodded, inspecting the repair. "Good. Let's reinforce with an over-and-over layer. 6-0 Prolene."
As he worked, he continued explaining. "We're doing this secondary layer to prevent dehiscence—meaning, we don't want this patch tearing loose under pressure. If that happens, we're back to square one, and she'll code on the table."
They completed the secondary closure quickly.
Jamie sat back slightly, rolling his shoulders. "Alright. Let's rewarm. We'll take her off bypass in ten."
Meredith turned to adjust the bypass machine, gradually allowing the patient's core temperature to rise.
Jamie double-checked the suture line, ensuring there was no residual bleeding.
"Alright, Meredith. You see any issues?"
She carefully scanned the field. "No leaks, no tension along the suture line. Heart rhythm is stable."
Jamie gave a short nod. "Good. Let's take her off bypass."
He motioned to anesthesia. "Slowly reintroduce circulation."
The anesthesiologist adjusted the machine, allowing blood flow to resume through the repaired heart.
Everyone watched the monitors, waiting.
A second passed. Then another.
The heart continued beating smoothly, rhythm strong.
Jamie let out a breath. "It's holding."
Meredith glanced at the fetal monitor. "The baby's okay, too. Strong heartbeat."
Jamie gave a rare, small smile. "Two lives saved today."
The tension in the room eased, the collective relief palpable.
He turned back to Meredith. "Alright, let's close."
Meredith began suturing the pericardium closed, securing the heart within its protective sac.
Jamie worked beside her, bringing the sternum back together with stainless steel wires, tightening them carefully.
By the time they finished suturing the final skin layers, Jamie glanced up at the clock.
The entire procedure had lasted over three hours.
-----------------------------------
Derek Shepherd stood in Radiology, scanning through Larry Dickerson's images while Cristina Yang stood beside him, arms crossed as she studied the scans.
"Larry Dickerson. The guy who crashed into the fish market," Derek muttered, clicking through the CT slices. His brows furrowed as he zoomed in on the spinal column. "Subdural hematoma, air in the mediastinum. But look at this—his spine."
Cristina leaned in, her gaze narrowing. "Spinal stenosis."
Derek nodded. "Yeah. Advanced. So advanced that I doubt he could even feel his feet."
Cristina exhaled, realization dawning. "Which means he shouldn't have been driving."
Derek's frown deepened. "Exactly."
A moment later, the door swung open, and Preston Burke stepped inside, still in scrubs from his previous surgery.
"You paged me?" Burke asked, glancing between them before shifting his gaze to the scans.
Derek nodded and turned the monitor toward him. "Yeah. Take a look at this."
Burke stepped closer, his eyes moving between the different CT slices.
"Subdural hematoma, which is Shepherd's territory. Air in the mediastinum, which explains his respiratory distress. And… spinal stenosis," he said, voice even.
Cristina crossed her arms. "So advanced he probably hasn't felt his legs in years."
Burke's expression remained neutral, but his voice carried a note of disapproval. "This man should never have been behind the wheel of a car."
Derek sighed. "Well, he was. And now we have to fix him."
Burke continued scanning the images, his fingers drumming lightly against the monitor. "The mediastinal air suggests tracheal or esophageal injury. Possibly secondary to impact from the steering column. We'll need to assess intra-op, but if the trachea is involved, that's going to be delicate work."
Cristina nodded. "Agreed. And that's not even the worst part."
Derek tapped the screen, pointing at a subtle abnormality near the aorta. "Look at this. There's a thinning along the aortic wall. If this is an evolving aneurysm…"
Burke's posture stiffened slightly. "Then we could be dealing with a rupture waiting to happen."
Derek glanced at him. "You're taking point on the chest. I'll handle the subdural. Cristina's with you."
Burke gave a sharp nod. "Alright. Let's move. We don't have much time before this turns into a disaster."
Without another word, they all headed for the OR, where Larry Dickerson's life was already hanging in the balance.
----------------------------
The monitors beeped steadily, the scent of antiseptic and cautery thick in the air. Burke was at the operating table, hands steady as he worked on the tracheal repair, ensuring the airway was stabilized before moving deeper into the mediastinum.
Cristina Yang stood opposite him, holding the retractor, her eyes locked onto the surgical field.
At the head of the table, Derek Shepherd was still focused on the subdural hematoma, working with precision as he relieved intracranial pressure.
"Vitals are holding for now," the anesthesiologist reported, but the concern in his tone was clear.
Cristina glanced at the monitors, reading the BP trends.
"Burke, he's still dropping. Systolic is down to 85 and falling."
Burke didn't look up, his hands working with precision. "I need better visualization. Suction."
Cristina adjusted the suction tip, clearing the pooled blood.
That's when she saw it.
Her stomach clenched slightly.
"Burke—" she started, voice tight.
Burke's jaw clenched the second he saw what she was looking at.
The aneurysm was expanding. Fast.
-----------------------------
Derek looked up briefly, sensing the tension. "Talk to me."
Burke's voice was controlled but urgent. "Aortic aneurysm. It's growing. If it ruptures, he'll bleed out in seconds."
Cristina kept her hands steady. "Can we stent it?"
Burke shook his head. "Not an option. We need an open graft repair, and I need another set of hands."
Cristina grabbed the suction tip tighter, keeping the view clear.
"Page Dr. Knight. Now" Burke said urgently.
"Dr. Knight is still in surgery." a nurse added quickly.
"Then call for Dr. Hahn. She is here for a Consult. Someone go and get her." Burke added after thinking for a moment.
Within minutes, the OR doors swung open.
Hahn stepped into the OR, her eyes immediately locking onto the surgical field.
She took one look at the aneurysm and exhaled sharply. "Well, damn. You weren't kidding."
Burke, hands steady, gave a quick nod. "We don't have time to waste. It's expanding fast. We need to resect and replace the weakened section before we lose him."
Cristina adjusted the suction, keeping the area clear. "We've already clamped proximally and distally, but the pressure is dropping."
Hahn positioned herself across from Burke, already reaching for instruments. "Let's get the graft ready. Prep the Dacron."
The scrub nurse moved swiftly, handing over the pre-soaked Dacron tube graft, which Hahn laid out carefully beside the exposed aorta.
Burke glanced at the monitors. "We'll work quickly. We cut the aneurysmal section, secure the graft, and restore circulation before ischemia sets in."
Cristina handed him the Metzenbaum scissors, and Burke carefully began excising the weakened arterial wall, cutting along the pre-measured section to ensure a clean anastomosis site.
Hahn followed his pace, suctioning excess blood as they moved. "You're going to need a reinforced suture line. I'd double-layer it to prevent post-op leaks."
Burke nodded. "Agreed. 5-0 Prolene."
The scrub nurse handed over the sutures, and Burke began placing carefully spaced interrupted stitches, working methodically to ensure an airtight seal.
Cristina kept her eyes locked on the field, watching as Hahn assisted in securing the distal end of the graft.
Burke's hands were steady, his focus unwavering.
Then—the monitors let out a sharp alarm.
------------------------------
Across the hospital, Jamie had just stepped out of an OR, stripping off his gloves and tossing them into the bin.
The surgery had gone smoothly, but the momentary relief was short-lived.
His pager buzzed aggressively against his hip.
TRAUMA OR 1 – AORTIC ANEURYSM. IMMEDIATE RESPONSE NEEDED.
His heart rate kicked up, instincts already shifting back into trauma mode.
A nurse rushed toward him, confirming what he already knew. "Dr. Knight, they need you in Trauma OR 1. Burke and Hahn are in, but they're calling for backup."
Jamie didn't hesitate, already moving. "Page anesthesia and have extra blood on standby. If they need me, it means this guy is crashing."
-----------------------------
The second Jamie stepped in, he assessed the room immediately.
Burke was working fast, but the bleeding had intensified.
Hahn had her hand deep in the field, pressing down on the proximal clamp to slow the hemorrhage.
Cristina, at the suction, was doing everything she could to keep up with the blood loss.
Jamie moved in fast. "What happened?"
Burke's voice was tight. "The aneurysm ruptured mid-repair. We're losing volume fast."
Jamie glanced at the monitors—BP was dropping rapidly, heart rate skyrocketing.
He grabbed the surgical forceps, eyes locked on the field. "Cristina, more suction. Hahn, what's the status on the graft?"
Hahn kept pressure on the clamp. "Distal anastomosis is holding, but the proximal end blew before we could secure it."
Jamie nodded, already strategizing. "Alright. We need a reinforced anastomosis—suture it to the native vessel wall. Double layer it to prevent dehiscence."
Burke adjusted his grip on the forceps, his eyes scanning the site for any weak points. "Knight, you take proximal. I'll reinforce distal."
Jamie nodded once. "Alright. 5-0 Prolene. Let's move."
The scrub nurse swiftly handed him the needle driver, and Jamie immediately began securing the proximal end of the graft, threading precise interrupted stitches through the aortic wall. Each stitch had to be deep enough to hold but not so tight that it risked causing stenosis—a complication that could lead to future thrombosis or graft failure.
Burke mirrored his work at the distal anastomosis, using fine vascular forceps to ensure even tension along the suture line.
Cristina kept the suction steady, clearing residual blood from the field as the two senior surgeons worked.
The seconds ticked by, every movement calculated.
Burke glanced up briefly. "Make sure your suture line is uniform. We don't want turbulence at the graft site."
Jamie didn't miss a beat. "Already on it. Last two sutures going in."
He placed the final interrupted stitch, ensuring the graft was seamlessly integrated with the native aorta. He took a beat to inspect it, double-checking the tension and vascular integrity.
Burke finished his last reinforcement stitch and gave a firm nod. "Looks solid. No tension points."
Hahn inspected the site. "No active leaks."
Jamie glanced at the monitors—BP was still low but holding steady. They had no more time to waste before ischemia became a real issue.
"Let's release the clamp," Jamie said, voice steady.
Burke gave a sharp nod. "Slowly."
Cristina reached over, easing off the proximal clamp millimeter by millimeter, allowing blood to gradually flow into the repaired aorta.
For a moment, the room held its breath.
The graft pulsed as blood surged through it.
The repair held.
The monitors beeped steadily, and the anesthesiologist called out:
"BP stabilizing. 100 over 65 and climbing."
Burke let out a slow breath. "No hemorrhage. Graft integrity looks good."
Jamie scanned the site one last time, checking for any micro-leaks or signs of seepage.
Nothing.
He exhaled, the tension finally bleeding out of his shoulders. "We're good."
Burke and Jamie wasted no time securing the repair, placing reinforced pledgeted sutures at the graft edges to ensure long-term stability.
Jamie carefully laid a Telfa patch over the anastomosis site—a protective barrier that would help reduce post-op adhesion formation.
Cristina assisted in suturing the pericardium closed, while Burke reapproximated the sternal edges using heavy-gauge stainless steel wires—necessary to keep the chest stable as it healed.
Once the sternum was secured, Cristina moved on to closing the muscle and skin layers, using a subcuticular stitch technique to minimize scarring.
Jamie stripped off his gloves, his pulse still slightly elevated from the high-stakes case.
Burke glanced at him as he peeled off his gown. "Nice work."
Jamie smirked slightly, rolling out the tension from his shoulders. "Right back at you."
Hahn wiped down her instruments before turning to Cristina. "You were solid in there."
Cristina just nodded, trying to act unaffected, but the hint of a smirk betrayed her.
Derek, who had been finishing up the neurosurgical portion, finally looked up.
"So… is my patient still alive?"
Burke smirked. "For now."
---------------------------------------
The soft beeping of the monitors filled the dimly lit recovery room, the steady rhythm a sign that Janelle Duko had made it through the surgery.
Addison Montgomery stood near the foot of the bed, arms crossed as she watched the slow rise and fall of Janelle's chest beneath the hospital gown.
Alex Karev entered quietly, his usual bravado toned down, though his gaze flicked immediately to the monitors before settling on Addison.
"Dr. Montgomery."
Addison glanced at him before exhaling, her voice calm but relieved. "Karev."
Alex stepped closer, scanning Janelle's pale but stable form. "How's she doing?"
Addison tilted her head slightly. "She made it through the surgery. So did the baby. So… well, like I said, kid's a fighter."
Alex nodded slowly, his eyes still on Janelle. "You think she'll call the guy? The dad?"
Addison sighed, arms still crossed. "No. It takes more than a well-meaning speech to get a girl to make a commitment like that." She paused for a beat, then added, "I appreciate it though. Your take… it was surprising."
Alex's brow furrowed slightly. "Surprising?"
Addison gave him a small, knowing smirk. "Well… for a Mark Sloan protégé."
Alex let out a quiet scoff. "Lackey. I dabbed blood all day."
Addison chuckled under her breath, then turned fully toward him. "You're a decent guy, Alex. I'd hate to see Sloan beat that out of you."
Before Alex could respond, the door swung open, and Jamie Knight stepped inside, fresh from the vascular trauma case. His scrubs were still clean, but there was an edge of exhaustion in his stance, his surgical cap in one hand.
His eyes flicked from Janelle to Addison. "How's she holding up?"
Addison turned toward him, offering a nod of greeting before gesturing toward the bed. "She's stable. The repair held, and the fetal monitoring looks good. No signs of distress."
Jamie exhaled slightly, rolling his shoulders as he took a step closer. "Good. That was a hell of a case."
Alex crossed his arms, glancing between them. "You're telling me. She had half a windshield in her chest and somehow made it out in one piece."
Jamie smirked faintly, then studied the monitors. "We'll keep an eye on her overnight. She's still high risk for complications—pericardial effusion, arrhythmias, or post-op sepsis."
Addison nodded, her expression serious but measured. "We'll watch for any signs of fetal distress too. She's not out of the woods yet."
Jamie's gaze lingered on Janelle for a moment before turning back to Addison. "You staying on her case?"
Addison arched an eyebrow. "You think I'd leave my patient right after you put her heart back together?"
Jamie chuckled lightly, shaking his head. "Fair point."
Alex, standing by the bedside, glanced at Janelle's still form, then back at Addison. "You think she's gonna be okay? Long-term?"
Addison was quiet for a moment before she spoke. "Physically, she's got a good shot. She's young, healthy. But the rest… that's on her."
Jamie gave a small nod. "Yeah. That's always the hardest part."
The three doctors stood in silence for a beat, the weight of the long day and the fragile patient in front of them settling in the air.
Finally, Addison straightened. "I need to check on another patient. You two good here?"
Jamie and Alex both nodded, and Addison walked out, leaving them with Janelle and the steady beeping of the monitors.
Alex glanced sideways at Jamie. "Long day?"
Jamie huffed a small laugh. "You have no idea."
Alex smirked slightly. "Yeah, I think I do."
------------------------------
Jamie hadn't eaten since morning.
It wasn't intentional—just the way the day had played out. One surgery led to another, followed by an emergency consult, and now it was past 6 PM before his body finally forced him to acknowledge his hunger.
He headed toward the hospital cafeteria, exhaustion creeping in as he loosened his scrub top at the collar. He hadn't even stepped inside before he heard footsteps behind him.
"You look like hell," Alex Karev muttered as he caught up to him.
Jamie smirked faintly but didn't bother arguing. "Long day."
"Yeah, no kidding. You skipped lunch, didn't you?" Karev asked as they walked through the cafeteria doors.
Jamie grabbed a tray. "Skipped breakfast too."
Karev whistled low. "Damn. That's almost impressive. Almost."
Jamie let out a tired chuckle. "Yeah, well, I was busy saving lives, remember?"
Karev rolled his eyes. "Oh please, don't get all heroic about it. I was there, too."
Jamie just shook his head, grabbing a plate of whatever looked remotely edible before heading toward the seating area.
At a nearby round table, Meredith Grey, Izzie Stevens, and Cristina Yang sat together, deep in conversation.
"I'm just saying," Meredith was saying, "it was insane. The level of difficulty in that surgery, and he still took the time to explain every single step like it was some kind of masterclass."
Cristina, chewing on a fry, shrugged slightly. "It was impressive, I'll admit. But it's Knight, so not exactly surprising."
Izzie raised an eyebrow. "Since when do you admit other people are good at surgery?"
Cristina smirked slightly. "Since it was actually good."
Meredith rolled her eyes, but her expression was still full of admiration. "Seriously. He was dealing with a ruptured aneurysm, had to handle a graft placement in a high-risk trauma, and still—still—walked me through every single move like it was just another day in the OR. Most surgeons in that position wouldn't even let an attending breathe near them, let alone take the time to teach."
Izzie smiled. "Sounds like someone has a favorite attending."
Meredith shot her a look, but before she could respond, Jamie and Karev walked up and sat down.
Jamie dropped his tray onto the table with a quiet thud, grabbing his fork like a man who had been deprived of food for an entire week.
Karev slid into the seat beside him, grabbing a soda. "Alright, let's hear it. What are you guys gossiping about now?"
Meredith, caught mid-sentence, hesitated for half a second before Jamie raised an eyebrow at her.
Cristina didn't hesitate. "Grey was just singing your praises, Knight. Apparently, you're a 'masterclass in trauma surgery' and a 'gifted teacher.'"
Jamie paused mid-bite, glancing up at Meredith with a smirk playing at the corner of his lips. "Oh? Is that so?"
Meredith cleared her throat, suddenly regretting every word she had just said. "It's not like that. I was just saying—it was a complex case, and you explained everything. That's all."
Izzie grinned, eyes flicking between them. "Sounds like a crush."
Jamie chuckled, shaking his head. "Grey, I'll take the compliment. But I wasn't doing anything special—I just think if you're in an OR, you should know what's going on."
Cristina arched a brow. "Yeah, but you also weren't condescending about it, which is rare for an attending."
Jamie smirked, taking a bite of his food. "Well, I guess that just makes me better than most attendings, doesn't it?"
Karev snorted. "Great. Now his ego's gonna be unbearable."
Meredith rolled her eyes, but there was still a hint of a smile on her face.
Jamie glanced at her, still amused. "Seriously, though. You did good work today. I wasn't just talking to talk—I knew you could handle what I was showing you."
Meredith met his gaze for a beat, then gave a small nod. "Thanks."
Cristina, unimpressed with the sentimentality, picked up another fry. "Alright, enough of this. Can we get back to complaining about the terrible food? Because Knight is actually eating it, and that's just sad."
Jamie, still chewing, raised an eyebrow. "This is better than half the things I've eaten in surgical residency. You learn to lower your standards."
Izzie shook her head. "That's depressing."
The conversation shifted to lighter topics, but there was an undeniable ease in the air. It was rare to find a moment like this—where the weight of the day hadn't completely suffocated them yet.
Jamie leaned back slightly, finally feeling the exhaustion settle in, but at least for now, he had food, good company, and a well-earned break.
--------------------------
Jamie stretched his shoulders, the exhaustion of the day finally catching up to him as he headed toward the locker room. His shift was over—finally. He had been on his feet for over fourteen hours, running between traumas, surgeries, and consults.
And now, he could go home.
At least, that was the plan.
Until he spotted Chief Webber standing by the OR board, his arms crossed, his face pulled into a deep, contemplative frown.
Something was wrong.
Jamie sighed, rubbing the bridge of his nose before changing course. He walked up next to Webber, following his gaze as it scanned the names, cases, and surgical assignments still up on the board.
"Something on your mind, Chief?" Jamie asked, his tone casual but perceptive.
Webber exhaled, his hands resting on his hips, but he didn't turn immediately. "I was told something today. Something I should have known long before now."
Jamie's brows furrowed slightly. "And what's that?"
Webber finally turned, meeting his gaze. "That my head of cardiothoracic surgery had a tremor. And that he operated."
Jamie's expression flickered, but he kept his voice even. "Burke told you?"
Webber's lips pressed into a thin line. He shook his head.
"No. Yang told me."
Jamie's eyes widened slightly, caught off guard. His mind immediately flashed back to the cafeteria earlier. Cristina had been defending Burke, acting as if nothing was wrong.
And now—she was the one who told Webber?
What the hell had changed in the last few hours?
Jamie's thoughts raced, but he kept his expression unreadable, nodding once before shifting the conversation.
He had something to say anyway.
"Chief, there's something I wanted to talk about."**
Webber arched a brow, waiting.
Jamie took a breath, standing a little straighter. "Today, we had fourteen trauma patients. And one of them died."
Webber's face remained neutral, but Jamie could see the flicker of understanding in his eyes.
Jamie continued. "Only that one patient died because I was here. And everyone else was on deck. We barely had enough hands. And I keep thinking—what if I hadn't been here today?"
Webber sighed heavily, glancing back at the OR board. "It's not the first time I've wondered that myself."
Jamie nodded, his tone serious but firm. "This hospital doesn't have a Level 1 trauma certification. Hell, it doesn't even have a dedicated trauma department. You've never had the choice before—you didn't have the resources, the specialists, the setup. But now you do. You hired me, and I want to change that."
Webber was quiet for a long moment, his gaze locked onto the OR board as if he was weighing every possible outcome.
Jamie knew he had to push.
"I won't always be here, Chief. We got lucky today. But next time? Next time, we might not be. And that means more people die."
Webber exhaled slowly.
Jamie let the words hang in the air for a beat before stepping back slightly, giving the Chief his space.
"Think about it, Chief," Jamie said simply.
Then, after a beat, he offered a small nod.
"Good night."
Without waiting for a response, Jamie turned and walked toward the exit, pushing through the hospital doors and stepping into the cool night air.