Instead of the typical voiceovers by Meredith, Alex provides the voiceovers for this episode.

Alex: (opening voiceover) Surgeons are all messed up. We're butchers. Messed up knife happy butchers. We cut people up. We move on. Patients die on our watch. We move on. We cause trauma, we suffer trauma. We don't have time to worry about all the blood and death and crap really makes us feel.

Callie: I wished Izzie Stevens would die. I wished her dead every day of every week for I don't even know how long. I woke up every morning wishing Izzie Stevens would die. And now ... What kind of person wishes someone would die, knowing how things happen. What kind of doctor wishes --
Arizona: Are you in here, right now, praying for Izzie to die?
Callie: No, I'm praying for her to live.

Alex: (closing voiceover) It doesn't matter how tough we are. Trauma always leaves a scar. It follows us home, it changes our lives. Trauma messes everybody up. But maybe that's the point. All the pain and the fear and the crap. Maybe going through all that is what keeps us moving forward. It's what pushes us. Maybe we have to get a little messed up before we can step up.

When Cristina and Owen are in the boiler room, the positions of her hands change from being on her face to having her arms crossed.

Episode Title: Elevator Love Letter

"Elevator Love Letter" is the title of a song by Stars.