you go to sleep
you wake up
but it is not quite sleep
a drop into blankness
a fall, a swoop
a fogged veil pulled rapidly
you submerge while time wrinkles overhead
and it is not quite waking
though that is closer
many wakings without memory
a slur of lights
the thick dry tongue of reembodiment
voices calling, locating a thaw
you emerge as if from a chrysalis
so it is not quite sleep
and not quite waking
you are different
not so simple.
"Every time an anesthesiologist discusses anesthetic options with a patient, the anesthesiologist strives to balance candor and disclosure of risks with the need to be reassuring and to minimize anxiety. And for most patients, anesthesia is a very safe procedure! Often, sleep is invoked as a metaphor for anesthesia, by the patient or a health care team member. Anesthesiologists use the metaphor as a way to reassure the patient that he or she will wake up at the end — all will be well. After all, the patient wakes up every morning. But, of course, anesthesia is not sleep, and emergence from anesthesia, where frequently the patient is just starting to breathe independent of assistance, is not the same as waking.
This poem is a meditation on the metaphor of ‘anesthesia as sleep.’ And of the journey that the patient undertakes as part of the consent to have an operation and an anesthetic. Ultimately, I hope the poem is a tribute to patients, who trust a complete stranger — the anesthesiologist — with their lives. Surgical patients are extremely vulnerable emotionally — such as when scheduled for cancer surgery — and physically — once under an anesthetic. We like to comment that there may be such as thing as minor surgery, but there is no such thing as minor anesthesia.
As I say in the commentary that accompanies this poem in the Journal of Medical Humanities, the poem had a long gestation. I had been thinking for many years about metaphor and anesthesia, and had written an academic article published in Anesthesiology about the topic. Some people who have read both the article and the poem have commented to me that the poem explains the tension within the ‘anesthesia as sleep’ metaphor better than the detailed article. That’s poetry for you!"
*First published in Journal of Medical Humanities [v. 21, No. 4, pp. 189-98, 2000]. Reproduced with permission of Journal of Medical Humanities and Audrey Shafer. Copyright Journal of Medical Humanities. All rights reserved.
punctured taped painted draped
punctured some more.
You beep through monitors
amidst a hum of directions and requests
he needs more
no, like this.
nurses, physicians, technicians;
the choreography incomplete.
A surgeon asks about the kids
and the urine output;
I ask for a time estimate
and how was last weekend.
But through the banter, complaints and chiding
I focus on your life
cloaked in blue
a gash of yellow, damask rose and inlaid pearl
the rising, now relaxing chest
your name secreted within you
your name’s shadow printed on a plastic bracelet
blood given to surfaces
your arms outspread
your head resting on its small cushion.
I sign the record as covenant to you.
If ever you are not
my teacher and benefactor
then I transform from anesthesiologist to
Moments of terror humble me
but it is in the mundane dailiness
that I understand
over and over
"This poem combines some thoughts about the operating room as theater, where the patient is the star, center stage, the odd mix of conversation that occurs in that theater, and the tensions between the routine and the dramatic.
The operating room is a very familiar place for me. It’s my workplace. Yet it is never a routine place for the patient — and it’s good to remember that. A colleague and I teach a course for sophomore undergraduates, and we bring the students into the operating room as part of the course. It’s truly wonderful for me, to see the OR through their fresh eyes, and to hear their impressions of the experience.
The operating table is narrow; the surgeon needs to stand close to the patient’s body. Frequently the patient’s arms are secured on arm boards, at almost right angles, and the patient’s head in on a little formed pillow called a Shay. Operations are brimful of rituals, like the scrubs we wear, the washing of hands, the cleansing of the body. So there’s also a religious cast to procedure, and I try to bring that into the poem as well.
Finally, there certainly are moments of sheer terror and severe stress for the anesthesiologist. These are rare events, and quite humbling. Anesthesiologists don’t seek these out, they are too easy to cause. We try to prevent them from happening. And it’s that service to the patient — and to the surgeon — to keep the patient safe, alive, and appropriately anesthetized, that forms our role."
*First published in The Lancet [v. 349: p. 1485, 1997]. Reproduced with permission of Elsevier and Audrey Shafer. Copyright Elsevier. All rights reserved. Single copies of the poem can be downloaded and printed only for the reader’s personal research and study.
Don’t Start, Friend
Signs indicating an addicted anesthesiologist:
"1. Addicts sign out ever-increasing quantities of narcotics. . . .
20. Undetected addicts are found dead."
American Society of Anesthesiologists
The bared thigh of enticement — come
to the misty land of escape
it’s just what you need
locked drawer far
it’s easy friend, so easy
back and forth on the same path
until the grass is pulverized
the trail turned to beaten dirt
you eye a new blade struggling in the rut
crush it with your next footfall
at the end of the path
a field of poppies —
you fall on one knee
then the other
crawl till your arms give.
So you slither, leaving
a trail of crushed flowers
you turn face up to a muted sky
and half close your eyes
lapping, lifting rivulets
flood the field and you float
spent and hapless as a fallen leaf
warm as blood
warm as tears
warm as a womb
you don’t care
about the abyss at the far edge
you smile at the fruit trees
bearing full globes of red and yellow.
In your first bite
you don’t even taste the worms.
"You’d be hard pressed to find an anesthesiologist who doesn’t know of a colleague who was either caught with drugs, or caught too late and found dead of an overdose. Despite all kinds of efforts to prevent addiction and to detect problems early, anesthesiologists die of drug overdose. We have extraordinarily easy access to drugs with high addictive potential.
We administer these drugs in titrated amounts to our patients, so we feel comfortable using them and think we can control their use. We do research involving these drugs and their effects. We think we understand the drugs. And because doing our jobs well ensures continued access to these drugs, an addicted anesthesiologist will perform very well in the operating room until extremely late in his or her addiction pattern. Hence it can be hard to tell that an anesthesiologist is addicted. In our program, if someone is suspected of a drug problem, an intervention is made by a prearranged group, including the chair of the department, and that anesthesiologist is escorted to a well known inpatient drug treatment program.
I wrote this poem after, once again, we had failed to detect an addict among us. He was found dead in a hospital bathroom when he did not return several pages while on call. People liked him. He worked hard. He had been in our home on numerous occasions for social events. He was dead. I was angry, furious with him, for doing this to himself, his family, his colleagues and friends. I was angry that his death made each of us feel guilty that we didn’t suspect his addiction. So I wrote this poem as a way to channel that guilt, anger and sense of loss."
*Published in Sleep Talker [Xlibris, U.S.A., 2001] Reproduced with permission of Audrey Shafer. Copyright Audrey Shafer. All rights reserved.
Morning frost cocoons my car.
I drive anyway
peeping through the hole widened,
by hot air and the slash of wipers.
excises, exenterates, exhorts
a vertical parasite on the supinated.
Yet, even so,
A patient will gently
push aside the doctor’s probing fingers,
Reach in, and produce his own
Soul, which he holds out on his palm
a gleaming light
a sudden clarification
Before he collects himself and pockets it back inside.
Today is a day of gurney tears
glistening in canthi or lingering in the hollow between cheek and tragus.
I see fluorescent lights mirrored on the liquid
taste salt on my mind’s tongue.
The mother of three
Embarrassed, cries before her sterilization.
Tears dampen her black hair.
She smiles, apologizes.
How difficult the letting
The quiet flow continues till she drifts into anesthesia.
The internist, whose coronary artery grafts
Forces his tears inward
like rain dropping into hollow pots.
—They were supposed to last ten years
He mutters over and over
and is drenched in raw, uncontrollable sweat.
And finally — the veteran who had survived
War, operations, pain
today is defeated by the dry suck of cigarettes
The first leg will be amputated.
He shakes the gurney with sobs
before his piecemeal death.
Only forty-five, he is already white whiskered —
they look soft
I want to touch them.
Instead I touch his hand, then inject into his intravenous line.
I am swollen. I need time
It’s getting cold.
Perhaps it will snow tonight
and I can sleep
under the white, white covers.
"As I recall, what spurred me to write this poem was a young boy who does not appear in the final poem. Because I came to feel that he deserved his own poem, but then I was not able to write it. Maybe you will. This boy was on a gurney, teary-eyed, waiting to have some rather minor surgery, PE tubes, I believe. He wasn’t my patient, but as I walked by, his mother, who stood by his gurney, mocked him by saying, "Don’t worry, they’re only going to cut off your ears." This did not do much for the boy’s equanimity. I was appalled that a mother would say this to her child, and I was angry. At any rate, that was the seed, that little glimpse into someone else’s life. As William Carlos Williams commented, physicians are truly privileged to peek into such private
areas of people’s lives. "[M]y ‘medicine'" Williams wrote in his autobiography, "was the thing which gained me entrance to these secret gardens of the self."
The poem is also about disconnection and connection between physician and patient. The physician hovers vertically over the horizontal patient. When a patient cries on a gurney, the tears don’t roll down the cheeks, they pool in the corners, or they spill over sideways towards the ears or hair. As an anesthesiologist, I feel both connected to and separate from the patient. I really only get a glimpse of that person’s life. And mostly, the person wants to move forward and get going with the procedure. The waiting can be agony. So I try to be mindful of the patient, but also mindful of the reason why the patient is lying before
me. And also mindful of the responsibility that even a simple act, like injecting a drug into an intravenous line, entails — it means I’m connected to that patient’s brain. Sometimes it can feel overwhelming to be a physician — the pressures of the day mount up. All those glimpses of the stories of people’s lives, many tragic, can be difficult. And so the physician needs time for renewal. However, even the desired blanket of snow is white like hospital sheets."
*First published in Journal of Medical Humanities [v, 16, No.4, pp. 277-278, 1995]. Reproduced with permission of Journal of Medical Humanities and Audrey Shafer. Copyright Journal of Medical Humanities. All rights reserved.
October light slices through louvered blinds.
to pain-writ poems
A litany of misdiagnoses
inexorable debility —
Finally, a disease label
patched on the illness
Names the horror.
A new stanza begins.
I squeeze between the slats
and listen to a lone vermilion maple
sing to me
of leaves too broad and useless
to last a winter’s chill.
Coughs, the rustle of papers
Cue me to join the applause.
I am about to glide outside again
When I am grabbed by words:
a child draws
hunched over her paper, crayon gripped
oh so careful not to cross the lines
careful, lest mommy’s cancer return.
Tender and quiet, the scene is painted
auburn and henna in my mind.
But I take care to hide my care —
glance surreptitiously about
and hunker down.
The earth’s long bow to summer sun is done —
Another year perhaps I’ll share
Such plaintive notes
with tears allowed to fall.
"I was sitting in a lecture hall at a conference listening to a poetry reading and my mind wandered, as it is wont to do. Perhaps yours does the same. Anyway, I had flitted through the louvered blinds and was playing with a brilliantly colored fall maple tree when one of the poems reeled me right back into the room. I was very moved by the poem, and felt like crying. But no one else seemed to be responding this way, and I didn’t either.
In this way, the poem is a metaphor for the doctor’s efforts to hide his or her emotional response from a patient. And I think more and more, the teaching is that such suppression is not entirely healthy — for the doctor or the patient.
Lastly, I’d like to comment on one of the lines: "The earth’s long bow to summer sun is done" This line refers to the tilt of the earth, so that the hemisphere with the tilt towards the sun has the summer season. I’ve always been amazed that, for the northern hemisphere, the earth is further away from the sun during the summer months, but it’s the tilt that makes it warmer. Although it’s not explicit in the poem, for me that is also a metaphor for interpersonal interaction, such as the doctor-patient relationship. That it doesn’t matter if you are far away, as long as you are tipped towards that person, receptive to the rays, so to speak, you’ll benefit from that person’s warmth."
*First published in The Pharos [v. 59, No.2, p. 33, 1996]. Reproduced with permission of The Pharos and Audrey Shafer. Copyright The Pharos. All rights reserved.
"Even falling rises
In praise of light" Wendell Berry Sabbaths: 1979 II
She fell twenty feet
off a balcony like a most unlucky Juliet
landing in the lap of grace
fractured jaw shattered knee, she was
collected home, unto wings of parents
despairing over those few seconds
the swish of the pendulum
now a scythe
now a swing
Stripped of metal
I sit in the scanner room
watch my son’s head disappear
into the white torus
The machine jackhammers
off on off on
beats the air between us
His legs, too short for the bolster
remind me of a bus bench, a church pew
that precious space between
children’s feet and the floor.
At work, life is not so fortunate.
Cancer eroding through vessels
a hip infected and foul.
Daffodils trumpet spring one day
pollarded by snails overnight.
We rise, praise god
the lengthening day
and the day to come.
"This poem, about luck and fate, was prompted by a congruence of happenings one spring a number of years ago. A friend, also a
poet-anesthesiologist, had written to me about a terrible mishap to his daughter. While away on a senior class trip, she had fallen from a third story balcony of the hotel. She was lucky — she recovered completely. My friend and his family were lucky, but the memory of how closely disaster breathed on them remained.
At about the same time, my eleven-year-old son began having terrible headaches. We thought it was the onset of migraine, as that was consistent with the family history. But the headaches were so unremitting that his pediatrician felt an MRI scan was warranted. MRI scanners are extremely loud, and of course it was unnerving waiting to find out if there was any tumor. I felt like the pendulum swing between good fate/bad fate was as staccato as the MRI noise. We were lucky — the scan was normal. His childhood would not be truncated.
On the other hand, as an anesthesiologist at a Veterans Hospital, I often witness poor fates. Advanced cancer, terrible infections,
debilitating chronic diseases.
Yet spring is traditionally the time of renewal, new growth rising to the light, and hope for the future. Sometimes it’s quite difficult to reconcile feelings of gratitude with sorrow and the potential for sorrow. To grapple with the disturbing sense that, at least this time, I had been spared the scythe-like stroke of the pendulum."
*First published in Journal of the American Medical Association [v. 281, No.2, p.113, 1999]. Reproduced with permission of Audrey Shafer. Copyright Audrey Shafer. All rights reserved.
Just a brief archeological note
A glossy photograph of fossil bones
Prior to excavation.
The baby dwarf, eleven hundred years old, lies
Nestled in his mother’s arms.
His thickened cranium rests on her zygoma.
Why did they die
Tears will not fossilize.
An eternal embrace - till science
Rooting and poking
Labeled the remains.
The stillborn is perfectly formed.
Her father sobs. He rocks her as she
The mother lies stirrupped, numb.
Why was the cord so unforgiving.
A brief movement and a rest.
These tiled walls have held much sorrow.
And I am left, to offer kleenex.
The room is not great. It is not green.
It is an ordinary bedtime, and I sing
The usual songs, and kiss his hair,
Still damp from the bath.
The eight o’clock local dopplers past.
Leaving the quiet pings of spring rain, my thin voice,
And the throaty breaths of his slumber.
Cum by yah.
"This was my very first published poem. I had sent it in to Annals of Internal Medicine, and to my surprise and delight, the editors published it. So I’d like to thank the editors of medical journals who do find space to print creative writing alongside scientific articles — I believe it’s a noble and wise decision to incorporate both.
Each stanza in the poem centers on a different mother. The first stanza was prompted by a brief article I had read. The caption to the photograph of the archaeological find — the bones of the dwarf infant embraced by his mother’s skeletal remains, speculated on why they had died together. Did she sacrifice herself because her baby would not survive the migration of the tribe? So the photo made me wonder about maternal sacrifices and the complex relationship between mother and baby.
The second stanza reflects an incident from work. At that time, I was an anesthesiologist at Stanford, and I had provided anesthesia care — an epidural anesthetic — for a woman who had a known dead, full term fetus. The baby had died in utero from cord strangulation. Very tragic for the mother and for the father, who was in the delivery room to comfort his wife. He had asked to hold the stillborn. One naturally associates death with cold, and he was understandably shocked to find his baby so warm,
having just been delivered. And, although the epidural ‘worked’ and the mother was pain free, clearly she suffered a great deal. Grief counseling had already been arranged, and Stanford was quite good about facilitating, as much as possible, this family’s time in the hospital. For instance, this mother would not go to the maternity ward to recover, but rather to a regular ward bed. Nonetheless, I felt helpless. I think you have to acknowledge and not ignore that sense of helplessness as a doctor.
Ironically enough, I had given birth to my son in that same delivery room. So, in numerous ways, I knew the tension and the joy that particular room held. And that leads, in the poem, to the last stanza and some of the simple, yet extraordinary pleasures that I feel as a mother. The first line of the last stanza is, of course, a reference to the wonderful children’s book and poem, Goodnight Moon by Margaret Wise Brown. "In the great green room/ there was a telephone/ and a red balloon. . ." And this last stanza takes place, not in a burial excavation, nor in a delivery room, but in a very ordinary child’s bedroom. The train whistles by. Childhood is transient, brief. Nonetheless, I think there are connections between mothers through time and across the world that transcend barriers and facilitate communal understanding."
*First published in Annals of Internal Medicine [ v. 112:, p.237, 1990]. Reproduced with permission of the American College of Physicians and Audrey Shafer. Copyright The American College of Physicians. All rights reserved.