Picking up just after where the last episode left off, Lexie is feverishly trying to stop Nick's bleeding, which eventually she sort of does, at least enough to have him grab the phone and get help. Unfortunately he keeps bleeding on and off again, and after a moment where they think everything is fine, he begins again and has a stroke. Despite the doctors' efforts in surgery, he dies. Ray the paramedic is fortunately luckier, and after some rather kick-ass treatment on Meredith's part, they get him stable enough to get him out of the ambulance and into surgery. The Chief tells her she did an awesome job even though she admits afterward that she was scared, and some pep talking of sorts makes her realize that being scared might mean she really wants to make things work with Derek…it made sense at the time, I promise. She goes and tells Derek, scared but happy, that she doesn't want him seeing other people, only to be met with his not-so-happy face. You see, Rose managed to use her three semesters of computer science to fix the ultra-amazing brain-operating machine, with just a little bit of help at the end from Derek, and after having a moment, they tentatively make out in the scrub room. So once again, Meredith is going to have her happiness and confidence dashed.
Alex gets busted when -- DUH, finally! -- Mark happens to look up to see what Alex is staring at in the gallery and recognizes Ava. As if this weren't bad enough, when Mark has to run out of surgery to help Nick, the patient bursts something and nearly dies. When Alex is at home with Ava later, she wants to talk about how bad his day was (including that he's now suspended for a week for sneaking her in to the gallery), but he gets angry that she's showing up while she's still married. And after yelling at her that he's sleeping with Lexie and that Ava's not there to talk, they get down to the sex. Whatever turns you on, I guess.
In another surgery rife with complications, Bailey has one setback after another with Mr. White Power, making her later and later to meet Tucker. She keeps sending George as a go-between and he has to relay some really awful things from one spouse to another, including Tucker saying that it's all over. But a tiny bit of good comes of all of it when Bailey closes up at the end of surgery and manages to sew the patient up so that one cannot recognize his fetching swastika anymore. While she's recovering afterward, Cristina comes up and tells her how angry she is that Bailey used Cristina for the color of her skin, especially at the expense of her working with Hahn, and Bailey is left to just sigh. Instead, Izzie works with Hahn, who berates her for being too caring a person, leaving Izzie to get reamed by the wife later for not bringing her the promised updates while her husband was in surgery. Hahn, however, later realizes that she might need to be a bit more caring, and after saving her patient so that he can be with his kids, she sucks up her pride and invites Callie and Mark to drinks.
At the very end of the day, Cristina comes across a dejected Lexie and sincerely tells her that she was brave and did a great job with Nick. Lexie is still despondent, though, and finally admits that she has literally no one right now. So Cristina decides to bring her home and after a few uncomfortable moments, Meredith accepts this and the three of them bond with dancing and tequila, eventually joined by George and Izzie so that aw, most of the gang is back together again.
Over some tense guitar music, there's a montage of the ambulance crash and Meredith and Cristina's dancing while Mere revisits the theme she started last week: "At the end of the day, the experience of practicing medicine bears little resemblance to the dream." Alex is down to his tank top, making out with Ava. Because her priorities are clearly out of whack, she keeps stopping their making out to ask him if he's okay, and does not seem to be grasping the "even if I'm not, I don't want to talk about it with you" that he's conveying by brushing her off and kissing her again. Instead she reminds him about how intense and awful the day was, and asks, "How can you be okay after a day like that?" But he doesn't answer, so we're left to wonder just how awful it was as Meredith reminds us, "We go into medicine to save lives."
Cristina and Lexie are in an empty exam room, each wearing scrubs, and Cristina tells Lexie sincerely that she did a good job today. "What you did was not easy, it was brave." But it seems to not be comforting Lexie, who stares silently down at the bed as if she's numb.
Mere's voice continues, "We go into medicine because we want to do good." Mark is sitting silently, somewhat like Lexie, and as the camera pans, we see Callie sitting nearby on the couch, sighing, she takes off her scrub cap. They both illustrate everything but what Meredith mentions: "We go into medicine for the rush. For the high. For the ride." Mark starts rubbing his forehead as Meredith finishes, "But what we remember most days are the losses."
"What we lay awake at night replaying is the pain we caused." Izzie's lying on her bed, looking sad, and George leans over her, resting his chin on her arm, watching her.
"The ills we couldn't cure." And in a miraculous moment four seasons in the making, Meredith walks up to Derek and without a stutter or a flinch tells him, "I don't want you to date other people. It may not be enough for you, but I'm trying here." He turns around and regards her seriously as she lightens up a bit and adds, "I don't want you to date anybody but me!" He gives her a tiny half smile but he seems sad, and oh boy howdy will we see why later.
"The lives we ruined, or failed to save." The Chief is in the bay, looking stricken as the cleanup from the accident finishes up and a tow truck takes one of the mangled ambulances ("ambulance"?) away. "At the end of the day the reality is nothing like we hope. The reality is that the end of the day, more often than not, turned inside out and upside down." As the camera pans around the Chief, the scene changes back to one of disarray, right where we left off with Meredith inside trying to help Ray. She cuts his shirt off while, in his room inside, blood continues to squirt comically out of Nick's neck. The situation itself isn't funny at all, but the squirt-gun-like spurts of blood are just so ludicrous, even if in real life that's what would happen. Fortunately, I don't have any experience in such matters, so I stick by my "funny" opinion.