Elevator Love Letter

"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 it really makes us feel. 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 of 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."

- Alex Karev

 is the nineteenth episode of the fifth season and the 97th overall episode of Grey's Anatomy.

Short Summary
The pressure is on for Derek as his first surgery back is part of Izzie's treatment, while Alex and George individually try to cope with their feelings for Izzie, as her boyfriend and her best friend, and her diagnosis. Izzie knits, as is alone for the day because nobody comes to visit her. Owen's PTSD hurts Cristina again, this time more violently to the concern of Callie and Meredith. Mark, Karev and Lexie try to keep a patient alive although her family are fed up of her being "almost dead" every month. Derek and Meredith get a happy ending as Cristina loses her own happy ending.

Full Summary
Alex looks in on Izzie, who is fast asleep in her hospital room.

Callie and Arizona are at Callie's place, “dancing it out.”

In Cristina's bedroom, Cristina and Owen are finally spending nights with each other, and Cristina relaxes the only way she knows how: by watching videos of surgeries. Cristina falls asleep as Owen is still watching, so Owen turns the TV off and shuts off the lights. He lays awake, staring at the ceiling fan. The scene then jumps to Owen choking Cristina violently, and it's not a dream. She struggles but cannot free herself. Callie knocks door to see if everything is okay, and following no response from either of them, she enters and is greeted by the sight of Owen choking Cristina. She intervenes to stop him and Cristina runs into the bathroom and locks the door. Callie calls Meredith and she immediately rushes over.

Cristina assures them that she is fine and that Owen did it by accident in the middle of a nightmare. Owen, sobbing, knocks on the door asks if she is all right. Meredith will not let Cristina see him, but she ignores and walks past her. She hugs him and says that everything is fine and she is fine.

The next morning, Meredith is back at her house. She is making breakfast when Derek comes home. He is still unshaven and unshowered. Without saying a word, he opens the ring box and presents the diamond ring to her. She says, “No, not like this.” She reminds him that it's his first day back and it's all about Izzie. He has to save Izzie.

At work, Cristina is wearing a turtle-neck to cover up the strangle marks. Meredtih does not want Cristina to cover for her boyfriend because neither of them is okay.

George is upset that Izzie didn't tell him about her illness. He refuses to think about it, and asks Callie if he can be on her service today in order to avoid thinking about Izzie, and takes the charts and walks away, barely hearing the surgeries for the day.

Bailey greets the residents before they go into Izzie's room. She tells them all that today Izzie needs them to be friends, not doctors.

During the presentation, Derek comments that he is surprised the cancer was not caught sooner, as the location of the metastases can produce intense hallucinations, and the penny drops for Alex. The oncologist, Rebecca Swender, is overseeing all of Izzie's treatment and she tells them that every surgeon on Izzie's case reports to Swender first. After the "doctors" leave, Izzie knits and reminds her friends that they have other patients and tells them to go save lives.

Derek asks Alex, as Izzie's boyfriend, if he has any questions before her surgery today. Alex doesn't say much, but makes a jibe at Derek, commenting "Just try and keep her frontal lobe inside her skull this time." Derek doesn't respond. Later, Richard awkwardly asks Alex whether he wants to produce a sperm sample because they are harvesting Izzie's eggs prior to her treatment, and the eggs have a better chance of surviving if they are fertilized. Without so much as a thought, Alex immediately agrees.

Mark's patient is an elderly woman unlikely to make it through the day. But her nephews and niece are anxious to catch flights and are not bothered to stick around until she dies.

Dr. Swender wants to tell Izzie that her cancer treatment, specifically her chemotherapy, is going to be as harsh as chemotherapy can get, but Cristina is reluctant to do so, pointing out studies that claims that patient have higher surgical complications on the table if they receive bad news before undergoing surgery.

Meredith and Callie run interference when Owen approaches Cristina, preventing him from getting anywhere near her. Owen looks at Meredith with sorrow, but Meredith is stern and not letting him pass.

Owen and Derek go to the roof of the hospital to receive a motorcyclist with no helmet, sustaining massive head trauma, who was being helicoptered in. The sound of the helicopter makes Owen freeze up for a moment, Derek remarking the patient is DOA, and upon seeing that Hunt still is frozen still, Derek snaps him out of it.

Cristina wants to complain about Dr. Swender to Meredith, but Mer wants to discuss Owen instead. Cristina says that Owen is wounded, and this is no different than if he came home from Iraq without an arm or a leg.

Outside the hospital, Derek reminds Owen that PTSD is a real injury with studies showing altered brain anatomy in patients, but it can also be treated and managed. Owen gets defensive, reminding Derek that he tried to cut out most of a woman's brain and then walked away.

Richard knocks on the door of the room in which Alex is supposed to be "giving his contribution". Alex yells at him to go away, so Meredith takes that opportunity to come in and talk. Alex claims through grief and rage that he should have seen the signs: seeing Denny, what kind of doctor does this make him now, and what about Izzie's future?

Cristina finds Owen in the basement with the secret steam vent. He tells her to stay away from him because he almost killed her. She says gently that she knows her limits and knows how much she can handle.

Bailey comes to check on Izzie. While performing her observations, she quizzes Izzie on her medical knowledge, basing it from one of her surgeries today, so that she won't get rusty. She wants Izzie to be able to do this stuff because Izzie will have to be able to teach how to do it a year from now. Izzie asks her if she really thinks she'll be here a year from now, and Bailey says matter-of-factly, “Yes, I do.”

Stressed out, Derek spends a considerable amount of time in the practice lab going over the surgery he has to perform on Izzie.

Alex deposits his cup on the table right next to where Richard is eating lunch. Richard gets uncomfortable, and reminds him that he needs to actually talk to Izzie about procreating at some point.

The residents eat lunch in the cafeteria, but they all eventually realize that none of them have checked in on Izzie today. Bailey goes in to check on Izzie again and is surprised to see that Izzie has finished the scarf she was knitting. She has had a lot of time to since no friends came to visit.

Callie confesses to Arizona that she wanted Izzie to die while she was with George. Callie feels guilty that she wished death upon someone, but Arizona reminds her that she isn't praying for Izzie's death anymore.

Alex's old patient starts coding again, and her relatives roll their eyes, wondering if this is the time she is actually going to die. Alex throws them out, charges the paddles and revives her again. The patient regains consciousness and hears Alex tell Lexie not to let her heartless nephews and niece in the room again. But the old lady says no, they are impatient, but they are always by her side, every month. They are her people, and having people is better than having no people.

Alex runs to Izzie's room, but she has already been taken to the OR. Before Derek goes to operate on Izzie, Meredith enters the scrub room with Derek's scrub cap with ferry boats. He runs out to tell Meredith that he's not ready to operate because he needs her to say yes. Whatever happens in that operating room today, he needs to know he still has Meredith afterwards. Meredith says no, but that she loves him and he better go back in there and operate because she knows he can do it.

On the table, Izzie tells Bailey that the scarf she was making was for her. Derek remarks it's a beautiful night to save lives, and then begin.

George meanwhile is taking his anger out using a hammer and smashing plaster casts. He tells Callie he doesn't want to talk about it because he is mad that Izzie kept her condition from him and lied about it, and when she needed help she turned to Cristina, of all people. Callie points out that it could also be because she is his best friend, and she might die on him, the more poignant of all reasons. For his own good, Callie takes the hammer and takes George to wait for Izzie, but as George refuses, she reminds him that he slept with her and because of that, she wished Izzie was dead for months. This, he owes her, but she does know George, she loved him once, and she knows that George cares if Izzie lives or dies.

Alex, Meredith and Cristina camp outside the OR, waiting for news of Izzie. They are joined by some interns, but as Meredith tells them to leave, Alex tells them they can stay - some people are better than no people.

Swender crashes Izzie's surgery, second-guessing Derek's every move, leading Bailey to defend his actions.

Lexie is all by herself with her patient crashes again and is unable to resuscitate her. She tells the impatient relatives that their aunt has died and she has done everything she can, until the monitor shows she has a pulse again. Lexie listens to her heart and tells them that it is the pacemaker, and she is actually gone. Since she is only an intern, she cannot call time of death and goes to find her superior.

Alex, Meredith and Cristina are camped outside the OR, joined by Callie and George and more interns. Meredith and Cristina fight over what has happened with Owen.

Dr. Sloan confirms Lexie's decision and deactivates the pacemaker. Now the patient is dead, they family decide to stay a bit longer to pay their respects.

The Chief walks into the hallway to find a small army of his own staff, wondering what they are doing. Alex tells him they are waiting for Izzie, and Richard replies that they are all scared. And so is he.

In surgery, Derek is still doubting himself and Swender keeps questioning his actions. He finally gets his confidence back and tells Swender that he knows what he's doing.

Bailey comes out to tell them good news and bad news. The good news is that Derek was able to take out all of the tumor from her brain and she will be in the PACU, but she is fine. The bad news is that they were all terrible friends to Izzie today.

After surgery, Derek whines to Richard that Meredith turned down his proposal twice. Richard tells Derek that it was Meredith's idea to have Izzie's eggs harvested because she was confident Derek would save her, and he finally shaves.

Alex looks on at Izzie in the PACU and tells her he is here. Bailey walks by, wearing the scarf, and walks on as he sees Alex there.

Cristina approaches Owen in an on-call room to tell him that Izzie's surgery went well. Owen asks to hold Cristina. They consummate their relationship just when they realize that they can't be together.

Meredith tries to walk into an empty elevator, but Richard stands in front of the door, blocking her way for some reason. Meredith presses the button again, and the other one opens.

Derek is in the elevator. He has plastered the walls of the elevator with MRI scans of all of the successful surgeries they have had together. He tells her that she doesn't freeze. She's seen the worst and been through the worst, but that is how she has the strength to help everyone. Her dark and twistiness is a virtue, not a flaw. He doesn't get down on one knee. He doesn't ask the question. He simply says that he loves her and wants to spend the rest of his life with her, and she says the same.

Cristina lies Owen's arms, Cristina whispers she is afraid to fall asleep. She cannot have a relationship with someone she is afraid of in this way.

Hunt is in a CT scanner, apologizing to Derek as he finally gets help.

Cristina stares up at the ceiling fan, in her apartment in tears. Meredith walks in and reveals she is engaged. There is no real celebration of their engagement. Meredith goes over to Cristina where she learns that she broke up with Owen. She climbs into bed with Cristina and they both lay there quietly with each other.

Alex climbs into Izzie's hospital bed and holds her hand.

Main Cast

 * Ellen Pompeo as Dr. Meredith Grey
 * Sandra Oh as Dr. Cristina Yang
 * Katherine Heigl as Dr. Izzie Stevens
 * Justin Chambers as Dr. Alex Karev
 * T.R. Knight as Dr. George O'Malley
 * Chandra Wilson as Dr. Miranda Bailey
 * James Pickens, Jr. as Dr. Richard Webber
 * Sara Ramírez as Dr. Callie Torres
 * Eric Dane as Dr. Mark Sloan
 * Chyler Leigh as Dr. Lexie Grey
 * Kevin McKidd as Dr. Owen Hunt
 * Patrick Dempsey as Dr. Derek Shepherd

Guest Stars

 * Kimberly Elise as Dr. Rebecca Swender
 * Jessica Capshaw as Dr. Arizona Robbins
 * Molly Hagan as Jackie
 * Todd Waring as Tobin
 * Brandon Scott as Dr. Ryan Spalding

Co-Starring

 * Tim Maculan as Luke
 * Mark Saul as Intern Steve
 * Joseph Williamson as Intern Pierce
 * Candice Afia as Intern Laura
 * Winston Story as Intern Leo
 * Zibby Allen as Nurse
 * Gloria Garayua as Intern Graciella
 * Amrapali Ambegaokar as Intern Dani
 * Tymberlee Chanel as Intern Claire
 * Molly Kidder as Intern Megan
 * Janeline Hayes as Medic

Uncredited

 * Frances Bay as Aunt Joyce

Notes and Trivia
thumb|300px|right
 * This episode's title originated from the song Elevator Love Letter, originally sung by the Canadian band, Stars.
 * This episode scored 16.10 million episodes.
 * When Meredith is leaning on the OR Board while Izzie's in surgery you can see Izzie's birthday as 06/23/81. So, that would make Izzie almost 28 years old
 * While the Chief is eating, Alex hands him a cup of his sperm. After Alex leaves, a disgusted Chief moves the cup away from him with his fork. This is illogical as he uses the same fork to eat.
 * There's a deleted scene of this episode in which Alex, Meredith, George, Cristina, Callie and Lexie are waiting in Izzie's room for her to wake up. While they are waiting, Bailey walks by, wearing the scarf that Izzie made her.

Quotes

 * Richard: (knocking) Karev? Just checking in. Seeing how you're coming–ah, just seeing how you're doing.
 * Alex: I'd be doing a lot better if you weren't on the other side of the door listening.
 * Richard: Right, right. Sorry.
 * Meredith: (knocking)
 * Alex: I said go away.
 * Meredith: (entering anyways) You left the door unlocked. That's bold.


 * Alex: You think talking will help? You think a dixie cup of my swimmers will make everything okay? It's crap. This is crap! You just cant go messing with peoples heads like that! Even if she freezes the embryos you think, you think we'll get a chance to use them?! You think she'll still be here? You think she'll survive all this?! You think...I think..she told me, she told me she was seeing a ghost, okay? and I'm so used to all the crazy chicks in my life that I didn't even...I'm a doctor. A doctor! and I didn't even think to..and now she's..this is wrong. This isn't how it's supposed to happen.
 * Meredith: I know.
 * Alex: It's crap.
 * Meredith: I know.
 * Alex: I hate this.
 * Meredith: I know.
 * Alex: This isn't...this isn't how we were...this isn't how I want to do this. This isn't how Izzie and I were supposed to make a baby.


 * Richard: Wait. Um. Wait. No. You can’t take that one.
 * Meredith: Why not?
 * Richard: I said don't take it.
 * Meredith: I will take the elevator I want to take.
 * (The Chief blocks the elevator doors. They close and Meredith presses the button for a new elevator. The other elevator doors open.)
 * Richard: Well go on.
 * Derek: Hey! Come on in. This is a CT of Katie Bryce. 15 year old female severed aneurysm.
 * Meredith: From a fall during rhythmic gymnastics, I remember.
 * Derek: It was the first surgery we ever scrubbed in together on right? Our first save. Right here is a cerebral cyst. Tough save, but we did it. I kissed you in the stairwell after the surgery. And this right here is where Dr. Bailey kicked you out of the surgery because she caught us in your driveway in my car. And right here, this was a 7 hour craniotomy and you held the clamp the entire time, never flinched. That’s when I knew you were going to be an incredible surgeon. Beth Monroe, made our clinical trial a success by surviving. You talked me into putting her under. That’s when I knew I needed you. And this is today. The post op head CT of Izzie Stevens. See that, right there? Tumor free. Because of you. You got me into the OR. If there’s a crisis you don’t freeze. You move forward. You get the rest of us to move forward. Because you’ve seen worse. You’ve survived worse. And you know we’ll survive too. You say you’re dark and twisty. It’s not a flaw. It’s a strength. It makes you who you are. I’m not going to get down on one knee. I’m not going to ask a question. I love you Meredith Grey. And I want to spend the rest of my life with you.
 * Meredith: And I want to spend the rest of my life with you.