"We've all heard the buzz words: streamline, optimise, integrate, adapt. Every day, someone comes up with a new strategy or tool or technology to increase our efficiency. The idea is to make our lives easier, but the question is, does it? To really be efficient, you have to eliminate what doesn't work. You have to figure out what's important and hold on tight to the things that matter most"

"but nothing ever stays the same, it's fighting you at every turn"

Meredith, Cristina and Lucy were in the CCU, watching a newly installed camera. "They've installed cameras", Meredith stated. "They're all over the CCU", Cristina replied. "Next they'll be in the ORs, the hallways, the on-call rooms. We're being spied on. Who knows what evil lurks behind that electronic eye?" "Morning, Dr Yang", a voice said from the camera.

"Big Brother knows my name"

"Big Brother can see your name tag", Lucy pointed out.

"Excuse me". She covered her name tag with her hand.

"The cameras are not here to spy on you", Cahill explained to the attendings in an OR. "They are here to supplement you. On the other side of the camera is a remote physician, an extra set of eyes to reduce mistakes, improve patient care, and maximise physician hours... And of course, ultimately reduce costly litigation. So does that answer your questions?" "With disturbing clarity", Cristina said.

"Alright. Let's move on then. As you can see, this OR has been arranged with maximum efficiency, specifically for OR turnover. Now, what are the main causes for bottleneck? The layout of OR supplies, equipment, and instruments. So what we have done here...". Callie and Arizona slipped in late. "What did we miss?" Callie whispered. "ORs are sloppy", Richard replied. "There are doctors in the ceiling", Bailey added. "What? What do... What does that even mean?" Arizona asked. "We'd know if you'd just put her stupid tights on her", Callie remarked.

"I was talking her into it, okay? She was getting on board"

"She's two. At a certain point, she doesn't have to get on board. She has to be in daycare. So you pick her up and you yank her tights on her"

"That's what you do. And then she cries"

"Yeah, because you wasted all that time cajoling her, so now I have to be the bad cop. If you just made it clear in the first place that she has no choice"

"Because when every second counts, you need the most efficient approach", Cahill concluded.

"Mm. What she said"

"Your average time between surgeries is 37 minutes. With these new OR procedures, I'd like to see that cut in half. Thank you, everyone"

"Closing the ER should cut down on time", Lucy commented as they left the OR. "We won't have any patients". "How's Hunt feel about that?" Jackson said. "I heard he's not gonna do anything about it until it actually happens", Cristina said.

"It's happening"

"And he can't be a trauma surgeon without an ER", Alex pointed out. "Do you think he's gonna leave town?" "The ER is not going to close. Derek has a plan", Meredith reassured them. "Where is Derek?" Lucy questioned.

"He spent the night with Aurora"

"It's gonna work, right?" Aurora said to Derek in the conference room.

"Of course. See, 'cause if derm cuts a fellow, and then cardio skips the TED conference, plastics/ortho shares lab facilities, we'll get a little bit here, a little bit there, and we'll have enough saved to keep the ER alive"

"They're gonna be mad about the TED conference"

"They're gonna be pissed about everything, but that's okay. It's gonna work. Do we have a reply yet?"

"No, not yet"

"That was the subject line?"

"What, is that bad?"

"Well, would you open an email that said "proposed budget cuts"?"

"Oh, no. Did I just kill our proposal?"

"No. We're just gonna have to pitch it in person. Go door to door, which is better anyway. It's hard to say no to someone's face"

She flinched away from his face. "No offence, Derek. You have a good face, I'll give you that, but..."

"I have to brush my teeth"

"Mm-hmm"

"I know. You do, too"

Outside a patient's room in peds, Callie and Lucy came over to Arizona and Alex. "Has she moved yet?" Lucy asked them. "What do you think?" Alex replied. "Is her mom here? 'Cause she's nicer when her mom's here", Arizona said. "No, she had to leave for work", Lucy said. "You sure the kid didn't eat her?" Alex asked.

"Stop. She's angry. She's 13 and she had a double hip replacement. You'd be angry, too"

"She's mean", Arizona said. "Like a badger", Alex added. "She's three days post-op now. Okay?" Callie said. "If she doesn't move her hips, we're looking at clots, contractures, poor recovery. We just have to make her do it for her own good. Oh, look who I'm talking to. Can't even put a toddler in tights". "Well, then you just... You show me how a bad cop does it", Arizona said.

"Karev, get in there"

"Why me?" Alex questioned.

"We're attendings. You're a fellow. That's an order"

"Start with Russell. You want to do the opener or me?" Derek said to Aurora as they walked down the hall.

"Well, the numbers are so compelling. I think I'd start with how much his department cut's will save the hospital. And then I would..."

"I'll do the opener"

"Good idea. Okay, so you do the talking, and I'll hold up the chart when you give me the signal?"

"Perfect. Damn it. Hunt needs me in the OR. You're gonna have to start without me"

"No, no, no, no. I can't. You know it better. I'm just supposed to hold up the chart"

"Talk from your heart, not about the charts or the numbers. You can do this"

In the CCU, Leah and Beck approached Cristina. "Dr Yang, about the IV heparin you ordered for room three", Leah said. "Is there a problem?" Cristina asked. "No, it's just Dr Richardson insists we give sub-q enoxaparin", Beck explained.

"Who the hell is Dr Richardson?"

"Big Brother"

"Yeah. Ignore it"

"Tried that. He keeps insisting, and it's really upsetting the patient"

Cristina sighed and got up, walking into an empty room to talk to the camera.

Aurora approached Dr Russell. "Dr Russell, hi. I'm Dr Sloan, I'm a resident here", she greeted him. He stayed silent.

"So, we're trying to save the trauma department, I was wondering if I could talk to you about some ideas"

"Got your email. "Proposed budget cuts". Nice try"

"Well, I think that you'll see that a 2%... Okay, numbers don't really matter. I..."

"Ever been to a TED conference?"

"I haven't, no"

"Inspiring. Finest minds of our generation under one roof, sharing stories of mind-bending innovation"

"That sounds great but..."

"Innovation is what's gonna save this hospital..."

"Okay"

"Not this penny saved, penny earned crap"

"Okay, but..."

"Good to meet you, Dr Slane"

"Sloan"

Paramedic Nicole came into the ER with a cardiac trauma. "What do you got?" Cristina asked her.

"Skateboarder versus car. Late teens. Didn't have ID. The kid was slaloming hills with a buddy. Was nonresponsive in the field. His last systolic was 70. Heart rate tacking along in the 130s. EKG shows some changes, so I suspect cardiac trauma"

"Okay, I need a portable X-ray up here, stat. I need a 12-lead, and let's get a TEE bedside. Murphy, set up the TEE. Type and cross for six units. Hang two units of O-neg as soon as possible"

"Hey, what's your buddy's name?" Beck asked the boy that had come in with them. "Rich. Rich Campion", the boy replied.

"Does he have any allergies that you know of? Is he on any medications?"

"I don't know. Look, is he going to be okay?"

"We're doing everything we can"

"No breath sounds on the right. Someone set up a chest tube", Cristina said.

"It looks a mediastinal hematoma"

"Could be an aortic transection. We need to move fast, people"

"BP's still dropping"

"Scissors. Yeah, he's crashing. Where is that blood?"

"Right here, doctor", a nurse said, coming over with the blood. Beck noticed a silver chain fall to the ground. "He has a medical ID. It must have broken off", she said, bending down to pick it up. "Okay. What's it say? What's he allergic to?" Cristina said.

"Oh, my God"

"What is he allergic to?"

She showed her the silver tag that said: Jehovah's Witness.

"Okay, stop. He's a Jehovah's Witness. We can't give him blood"

"They're prepping the OR for a bloodless surgery so we'll need to recirculate his blood", Cristina explained as they got in the elevator. "So we'll put him on a cell saver machine, and then continue the hypertonic saline, colloids, and factor VII to pump up his intravascular volume". "We're seriously repairing an aortic transection without blood?" Leah asked. "Does it look like we have a choice?" Beck replied.

"We could use blood"

"You're not very bright, are you? We could be arrested for assault and battery"

"Very funny"

"I'm not joking"

"There are protocols in place for people who won't or can't accept supplemental blood", Cristina said. "We do bloodless surgeries here all the time". "Have you ever done this, a bloodless aortic transection?" Leah said.

"No"

Callie, Lucy and Arizona approached Alex at the nurses station. "Alex... You don't have her walking yet?" Callie said. "There's no talking to that girl", he replied. "It's dark in there. Really dark".

"Karev..."

"I'm serious. That girl turned me into a suicide risk"

"I'm gonna move her myself then"

"Excessive force, bad cop's go-to move", Arizona said.

"You know what makes a bad cop bad? When the good cop's namby-pamby approach gets us nowhere. Then bad cop has to set a limit and ends looking like a big meanie"

"A good cop's approach takes time and patience. Bad cop is a notorious hothead"

"If she's going to insist on wearing dresses, she has to wear tights"

"This clearly isn't about the patient anymore", Lucy stated. "I'm gonna go lie down", Alex said.

"His vitals are worse. How's the cell saver coming?" Cristina said as they walked into the OR. "Almost ready", a scrub nurse replied.

"Do we have surgical glue?"

"Yes"

"Avitene?"

"Yes"

"Okay, I want two bovies set up. Joy, get my headlamp ready. Wait a minute. Wait a minute. Where is my gel foam and thrombin? We're trying to keep blood loss to a minimum. We need a whole bunch more. Okay, hypertonic saline? Factor VII?"

"Check. Check", Leah said.

"Cell saver ready?"

"Check"

"Okay, let's go before he bleeds out. I can't cut. He'll lose too much blood"

"What do we do?"

"We'll go in percutaneously. Get the OR ready for an endovascular repair. Let's move"

In the CCU, Cristina, Beck and Leah were treating their patient post-op. "Let's add a CPK to his next blood draw. What was his last haemoglobin?" Cristina said. "Four", Beck said. "The guy's on fumes", Leah stated. "Try and stimulate blood production by giving EPO", Cristina replied.

"Or we could give him blood and cut out the middle man"

"We can also give IV iron-dextran", Dr Richardson suggested. "Thanks, Bob", Cristina said flatly. "We can give him iron? How is that logical?" Leah vented. "We can give him the components of blood, just not blood?"

"We have to respect his wishes"

"What wishes? He can't tell us anything. His friend didn't even know that he was a Jehovah's witness"

"Yeah, I doubt it's not the kind of thing you talk about at the skate park", Beck commented.

"I'm just saying, he's 19. How can he even know what he believes? When I was 19, I was a completely different person than I am now. I wanted to be a radiologist"

"Wow. I feel like I'm seeing a whole new you"

"Start his EPO and keep a close eye on his crit", Cristina instructed a nurse. "So you're fine with this?" Leah said. "Even though he could die, you're fine with just...".

"It doesn't matter what I think. He had an alert. It was very clear, no blood. I don't get to have an opinion about it, and neither do you"

"So there's nothing we can do?"

"Yeah, there is. We can talk to the family"

"Good luck", Dr Richardson said as they left the room.

Cristina, Beck and Leah were talking to the family of their patient. "He's lost a lot of blood. I'd say more than half his volume", Beck informed them. "He'll make new blood", his mother replied.

"It takes about four days to make new blood cells. He may not have that much time. What would really help is a blood transfusion"

"No. No blood", his father said. "If you're worried about disease transmission, I can assure you that all of our blood is meticulously screened", Leah tried to reassure them. "It's not that we don't trust your blood. We just...", his mother tried to explain. "We believe that life is a gift from God and we don't try to sustain it by taking in blood", his father interjected. "Let me be perfectly clear, your son's condition is critical", Cristina said. "Without blood, his organs will start shutting down. And once he starts that spiral, there is nothing we can do". "Oh, dear God", his mother gasped.

"We are juggling all kinds of substitute measures, but nothing is as good as blood. As his surgeon, I urge you to let us give him the best chance we can. Let us give him blood"

"We have seen amazing miracles through prayer. If it's God's will..."

"So you won't allow blood, even if it's gonna save his life?" Leah questioned. "'Cause prayer...". "Murphy", Cristina warned. "We appreciate all you're doing for our boy", his father said. "But your blood wouldn't save his life. It would condemn him. Living with it would be so much worse for him than dying without it".

"We understand. We will do everything in our power to keep your son alive"

"Thank you", his mother said.

"Colvin said I was insulting him and everyone in his field", Aurora informed Derek. "Beck said she doesn't talk to fund-raisers. And... And Springfield basically had me agreeing to give him money. And then Russell...".

"You talked about the numbers?"

"No"

"Aurora"

"I didn't. I mean, just a... Like barely at all"

"We don't have a lot of time, but I'll see what I can do"

"There's Redmond"

"Hey, hey, Tim. I saw your little Howie today when I was dropping Zola off at day care. Man, he's cute"

"Thanks. Yeah, he's a kick", Redmond replied.

"Yeah, Zola's at that age where she's just putting everything in her mouth"

"Yeah, we're not quite there yet"

"Just you wait. It's like, Legos, magnets"

"Really?"

"Anything that is a choking hazard, they find it"

"Jeez"

"Yeah, well, lucky for us, the ER is right downstairs from the day care"

"Yeah, that's for sure. Wait, isn't that closing?"

"Yeah, that's what I wanted to talk to you about. Dermatology has two fellows. Now if we could just cut one of them, maybe we could possibly..."

Meredith came into the CCU with Lucy to see Cristina. "I hate her", Cristina stated, watching Leah at the nurses station. "Join the club", Beck added. "Who?" Meredith asked. "My intern", Cristina replied.

"Why?"

"Look at her, all mopey-faced just 'cause she didn't get her way. We were never mopey-faced. We just sucked it up. Why aren't you in your skills lab?"

"Oh, because the baby kicked. Wouldn't stop kicking, actually"

"Jerk"

"No, it's good. It's great. Kicking is a good thing"

"Maybe we should kick the intern", Beck suggested.

"Maybe my baby's kicking because it wants a granola bar"

"That's very possible", Lucy said. "Mia used to kick because she wanted me to eat a whole box of powdered doughnuts". They walked off to find a granola bar. As they walked off, Beck looked back over to the nurses station to see that Leah was no longer there. She groaned and walked over to the patient's room where the curtain had been drawn. She opened the door, slightly pulled back the curtain to see Leah replacing his fluids with blood. "Oh, you are so much dumber than I thought you were", Beck stated, causing Leah to freeze.

"You tried to give blood instead of fluids?" Cristina said. "Rich is circling the drain, and he doesn't have to be", Leah tried to reason.

"We are giving him everything we have, just like the family requested"

"Yeah, I know. And they're praying. Awesome"

"Your arrogance is astounding", Beck commented. "You never administer anything to a patient without my orders", Cristina said. "You think that because you've been here all of, what, six months, you know everything? You know nothing. On the timeline of doctoring, you are an amoeba". "I thought that he deserved a chance", Leah said.

"You have passion. I get it. You still have to do what I say. I am your boss and I am trying to save this patient's life. Now get out of here. You're off my service"

"I just..."

"Now"

"I'm sorry"

She left the room. Cristina looked at the camera. "What are you gonna do, get her fired?" she asked him. "She didn't do anything", Dr Richardson answered. "There's nothing to tell".

"She's right, you know? He's circling the drain"

"Yeah, I know", Beck said.

In the CCU, Cristina and Beck were doing everything they could to resuscitate the patient, with Leah watching them. "Still in v-fib", Beck said. "How long has it been?" Cristina asked.

"26 minutes"

"Push another epi and charge again to 200"

"Charging"

"Clear"

"Still nothing"

"Damn it. Charge to 200 again. Clear. Okay, I'm calling it. Time of death, 6:42"

"He didn't have to die", Leah stated. "All they had to do was let us give him blood". "And he still could've died", Beck said. "The CCU is full of people we pump full of blood, and they still die. People die. You know, you're not God, right? What you did was wrong in about a hundred different ways". "We can go over all that later", Cristina interjected. "We have to talk to the family right now. Hey, show's over, Bob. You can change the channel".

Arizona met Callie, Lucy and Alex in front of Simmi's room. "Hey", she greeted them. "How'd it go? Oh, for God sakes. I mean... Okay, see, Officer Hard-Ass? Your approach doesn't always work either". She entered the room and started speaking to Simmi. They watched Arizona talk to her calmly for a few minutes but when that didn't work, they watched her lower the bed and practically forced her to stand. They rushed in to help her take her first steps.

Derek and Aurora approached Alana and Owen. "We figured it out. We can save the ER", Aurora said. "We get each department to make some cuts, and I'm gonna have to park in Tacoma, but it is going to work", Derek said. "I'm sorry. You misunderstood", Alana said. "No amount of budget cutting or shuffling is gonna save your ER. Or your hospital, for that matter".

"You're getting us ready to sell"

"What?" Owen said. "A buyer is going to save your hospital", Alana explained. "I just need to make it presentable". "I'm sorry. What? It's...", Aurora stammered. "You're staging it, like a house", Owen stated. "Exactly", Alana agreed. "And the ER is like the shag carpet. It's gotta go. Sorry. I had a wonderful time today".

Aurora was sitting outside on a bench in the ambulance bay when Owen came out of the ER. "What are you gonna do?" she asked him.

"You mean right now or..."

"Or both. Whichever"

"Right now I am going to drink a lot. That's all I know"

"Can I buy the first one?"

"Yeah"

He grabbed her hand, pulling her up and they put their arms around each other. 

hope you enjoyed! comment your opinions! song is bad blood by black rebel motorcycle club