Derek begins this episode by talking about appreciating surgery and finding appreciation in it. A Seattle Grace employee, Isaac, asks Derek about a complicated spinal tumor. It turns out to be about Isaac, and the surgery is very risky. Everyone vies to scrub in. The Chief refuses to do this risky surgery because it is too risky, Isaac may end up paralyzed. Isaac is willing to take the chance. Derek goes against the Chief's orders and decides to do the surgery. He chooses Lexie to scrub in.
Back at home, Derek explains the dilemma to Meredith. He draws the spinal cord out on their bedroom wall. Derek decides to perform the surgery and lies to the Chief. He cuts into Isaac's back then pauses to throw up. Derek saves Isaac's life.
The Chief decides to implement a new computerized scheduling system. It makes him more unaware of what is going on in the hospital. Derek approaches the Chief and apologizes for going behind his back. The Chief fires Derek. Alex is very upset with Izzie avoiding her treatment. Reed confronts him. Hunt teaches Cristina some skills to help her in the future. Cristina gives Meredith a play by play of Derek's surgery.