Tonight’s episode of Grey’s Anatomy, entitled “Walking on a Dream” had both literal and figurative meanings for the staff of Seattle Grace-Mercy West — which now includes newcomer physician advisor, Dr. Cahill (Constance Zimmer). While Derek (Patrick Dempsey), Meredith (Ellen Pompeo), Cristina (Sandra Oh), and Arizona (Jessica Capshaw) count their loot (to the tune of $15 million dollars), the hospital’s financial situation proves to be far more tenuous. In an effort to keep operating costs low following the multi-million dollar payout, Owen Hunt has been forced to call in fiscal backup in the form of the hard-as-nails Dr. Cahill.

After missing the morning meeting to stake-out (and berate) the hospital’s emergency room staff, Dr. Cahill quickly makes her presence known by insisting that she will observe all surgeries the following day, much to chagrin of Derek and Arizona, who have some particularly high-profile projects on the books.

While her husband meets a terminally ill tumor patient and debates a risky surgical procedure, emotional-as-they-come Meredith is taking the hospital by storm. Literally. Turns out being preggers isn’t the “dream” she thought it’d be. Between pulling Derek into the on-call room for a quickie and bursting into hysterical tears in front of her interns, it’s only a matter of time before someone mentions that they know she’s pregnant — and Dr. Ross does, in one truly awkward ambulance ride with his attending.

Poor Shane. He really does find himself in some messy situations this episode. After butchering the chart of Mer’s pregnant-and-needing-a-liver patient Brie — thereby causing her to go into cardiac arrest — he also manages to ruin the liver that UNOS found for her. Aw, rookie mistakes. In the midst of it all, he spills to Mer that he knows she’s pregnant and makes hella awkward conversation about symptoms and stages of pregnancy before ultimately redeeming himself by supporting her as she faces her biggest fear.

When the pregnant Brie and her unnamed wife — played by Navi Rawat, also known as Chino-dwelling homewrecker Theresa Diaz on The OC — have all but given up hope, UNOS calls with another liver with moments to spare. The catch? It’s in Portland. Faced with the prospect of flying, Mer initially gives all responsibility to Dr. Ross, before surprising everyone by showing up on the tarmac and joining her intern on the plane to help save the day.

Meanwhile, April [Sarah Drew] is forced to hold down the fort in The Pit, alongside her new least favorite person ever (aka Avery’s new hook-up buddy), Dr. Stephanie Edwards. After a day filled with a particularly stressful patient and a paramedic who just keeps hanging around, April comes to respect Stephanie for all of her hard work. Although, it doesn’t hurt that the super-cute paramedic Matthew (played by Justin Bruening) finally admits that he’s only been creeping around the ER because he’s totally crushing on Kepner. Get it, girl.

And while the on-call room was busy being occupied by both Derek and Meredith, and Jackson and his new lady love, Jo and Alex Karev were actually not shacking up this episode — but that might’ve only been because Karev had even bigger things on his mind, like keeping his African orphan pro-bono surgery program running despite threats of cutting all unnecessary spending. 

Karev’s young patient requires a particularly difficult heart surgery, much to the excitement of Cristina. Can’t say the same for Arizona though, who finds that using her prosthetic is much more of a challenge than she initially anticipated, and begins to suffer from severe phantom limb pain. (She’s walking on a dream, like, as in her imaginative or “dream-like” leg pain. Like I said, literal meanings.) Unwilling to ask Callie, Arizona turns to Owen (Kevin McKidd for help. Cue a strange sequence of Dr. Hunt’s innovative treatment plans to help Arizona deal — including looking at the reflection of her leg in the mirror and a meditative practice that involves “calming the waves.”

Ultimately, Arizona’s pain gets the best of her and she freezes and falls in the operating room. As her patient starts to crash, she demands that Karev stab a knife into her plastic limb. The sight of a sharp object sticking out of her sneaker seems to help, and Arizona is able to re-focus to finish. But — dun, dun dun — the omnipresent Dr. Cahill is there to witness her surgical struggle and now Alex is more worried than ever that his beloved program will definitely be shuttered.

Derek and Jo, already annoyed with Dr. Cahill, lie about the time of Derek’s brain surgery in hopes of ducking her. Of course, she shows up during a particularly difficult moment, and Derek is forced to take control and kick her out. In true superstar surgeon form, he finishes the operation and the next morning the patient wakes up good as new, impressing interns and physician advisors alike. Yep, he’s back, y’all. Doc Shepherd 1, New Girl 0.

So, where is (former) Chief Weber in all this you may ask? Noticeably absent, as Dr. Cahill is quick to point out when she hands down her ultimate sentence — er, recommendation — to the staff. 

The result of all of her observations? It’s time to close the ER. It’s not making the money, most patients who come in aren’t emergent anyway, and it’s a waste of the surgeons’ time and energy. Most of the staff protests, but Bailey (shockingly) supports the new doc’s decision. “Not all of us have millions to fall back on,” she snaps, while pointing out that if the hospital goes under, none of them will have any jobs to do. Me-ow, Dr. B.

As Dr. Cahill heads off into the night, she closes by warning Dr. Weber, who we’ve come to find out is also her former teacher, that big changes are to come. Medicine is constantly changing, she tells him, implying that such an idea might be hard for “someone who’s spent the least amount of time in the OR so far this year” to grasp. Looks like Weber’s doctor “dreams” may also be in jeopardy.

And now it’s time to look to next week, where we’ll learn more about the already much-hated Dr. Cahill and (perhaps) find out the fate of our favorite former Chief!

Catch the next new episode of Grey’s Anatomy on Thursday, January 31, 2013, at 9 p.m. ET/PT on ABC.