1. Day Shadows

She looked out the window and said to me, “Any time I find myself alone in an elevator with a man I don’t know, I mentally get ready to fight for my life.”

We were sitting together at a small counter in a tiny Mennonite cafe, far east of the mountains, with hazy sunlight streaming through the golden leaves of the aspens outside.  She took a bite of her sandwich, chewed for a minute.

“Have you been attacked in an elevator before?” I asked.

“No,” she said.  “I’ve never been attacked or assaulted or raped.  Never even been punched.”  She paused again for another bite.  “I don’t think I’ve even been slapped.”

I grinned at that.  “No bitch fights in high school?”

“Never,” she said, and smiled.  And then the smiled faded.  “But once I started doing this work, I noticed the elevator thing.  I do it every time.  What do I have in my hands that I can use as a weapon?  What does he have?  Can I try to punch him in the throat?  Choke him with his tie?”  She shrugged.  “And in the end, I hit the button for the next floor, and I get off the elevator.”

“Take the stairs?” I asked, taking a bite of my own sandwich.

She shook her head.  “The only thing worse than being alone in an elevator with a stranger is being alone in a stairwell with a stranger.”

We ate in companionable silence for a few minutes.  And she said, “And the only thing worse than that is knowing that it’s all in my head, and I can’t seem to make it stop.”


We had ducked out to the cafe from our full-day conference for Advanced SANE (Sexual Assault Nurse Examiner) Training.  The day was turning out to be less about training and more about conversations, stories, exchanging ideas, comparing programs, asking for advice.  Just before we left, an APRN and SANE from the south had cut into a small pause in the dialogue.

“How many of us are taking care of ourselves, by the way?  How many of us are acknowledging our secondary trauma?”

There was silence in the room.  We glanced around at each other, all twenty of us, but said nothing.

“How many of our programs have embedded debriefings?  How many of us have accessed EAP, or seen our own therapists?”

We were still silent, but answered regardless.

none of us, none of us, none of our programs, none, not one.


She crumpled up the wrapper of the sandwich, took a bite of pickle.  “I know it’s vicarious trauma.  I know why I do it.  I know I don’t need to do it.  But I can’t help it –”

“I shadowbox in the shower.” I said suddenly, interrupting her.  She tilted her head, but stayed silent, listening.

“I’ve been doing it for years.  It’s such a mindless, repetitive task, showering before work.  So my mind wanders off, and soon I’m arguing with an angry patient, then the patient becomes violent, then he pulls a knife and I have to find something in the room to ward him off, protect myself.  Or I’m in triage and someone walks in and pulls a gun, and takes a nine-year-old girl hostage, and I’m the only one who can keep him calm and start to evacuate the other people in the lobby.  And sometimes he shoots me anyway.”

I picked absently at the label on my bottle of iced tea.  The cafe murmured distantly behind us, unaware of the silent battle raging on at the counter, on our barstools, behind our plaid shirts and down vests.

“And then I snap the water off and I realize I’m shaking and my heart is racing and I’m angry and frightened, and all that’s really happened is that I’ve cleaned my hair and washed my face.”

She said, quietly, “What do you do?”

I smiled, and shrugged.  “What else can I do? I put on my scrubs and drive to work.”


~ ~ ~ ~ ~

We are all shadowboxing.

When we cross the street to avoid the tall man walking alone in the dark, we do it.

When we leave the light on as we fall asleep, so that we can see immediately if someone breaks into our apartment, we do it.

When we sleep with the gun by the bed.

When we get off the elevator three floors early, and wait for the next one.

When we decide that it’s better to simply be alone than to risk that emotional toll yet again.

When we sit at the nurses station and sarcastically denigrate our patients —

What do you expect when druggies take all the beds?
That one in the hall bed just wants a sandwich and a percocet
Did you see the classy mess in room 8 and her baby daddy?
What did she expect?  If she didn’t want to get raped, she shouldn’t have gotten drunk

—we do it.

We shadowbox with the ghosts that plague us, that haunt our thoughts, our dreams, our subconscious.  We fight the spirits that infuriate us, frighten us, make us want to scream with the injustice of it all.

Most insidious of all:  we do it all the time…and yet remain blissfully unaware.

How do we find an antidote for our own poison?

~ ~ ~ ~ ~


2. Night Shadows

Four years ago I backpacked the first 125 miles of The Long Trail, a hiking trail running north-south along the length of Vermont.  Like many of the scenic trails along the east coast, there are a series of shelters built at popular overnight stops along the trail, some just open-faced huts, some enclosed cabins with racks of bunk beds stretching to the rafters.

Just shy of mile marker 100 I spent the night at the top of Killington Peak, a high and dry rocky outcrop on the backside of a ski resort, the lifts now silent and dark above green trees and tall grasses.  A dozen wooden tent platforms, raised three inches off the ground to protect the fragile mountaintop, dotted the hill near an old stone shelter.

I had deliberately chosen to ‘tent’ that night, as opposed to sleeping in the shelter.  A young man, no older than nineteen, was hiking at a pace similar to mine and had stopped at the same campsites for the most of the previous week.  I’d stayed in a shelter with him and a dozen other hikers exactly once that week, and he’d awakened all of us in the middle of the night, screaming in terror, trapped in a nightmare and unable to wake up.

I knew he was staying in the shelter that night.  I had no interest in being startled awake again by someone else’s boogeyman.

I cooked my typical dinner of ramen and hot chocolate, set up my ultralight tent on the platform, chatted with a few other hikers as the sun set beyond the granite hills, and then crawled into my sleeping bag and fell deeply asleep.


The cold woke me up.

The wind was screaming over the pass where we were camped, freezing air that rushed up the treeless alleys of the ski resort, up under the wooden raised platform, up through the mesh footing of my flimsy tent, and rattled my bones until my teeth were chattering uncontrollably.

If I don’t get out of this tent, I will be hypothermic within hours.

Unimaginably cold, I grabbed my sleeping bag, my ThermaRest, my boots and a headlamp, and wrestled my way out of the tent.  I zipped it closed, clicked on the light, and trotted quickly down the hill to the shelter.

The ancient metal door creaked horribly as I pushed it open.  sorry sorry sorry sorry I whispered under my breath, hoping the sleeping hikers inside were as exhausted as I was.  oh lordy please let there be an empty bunk.

There was.

I climbed quickly to the top bunk, dove into my mummy bag, and pulled the drawstring around my face until only my mouth and nose were exposed to air.

I was instantly warm.

There was no wind, no rattling tent walls, no creaking trees.  I was asleep in seconds.


The screaming woke me up.


The last shriek was drawn out, eerie and childlike, and I was awake and fighting the drawstring of my bag before I knew what I was doing.  My heart was racing in my chest, and my hands were shaking violently.  His screaming had torn me from a deep, midnight sleep, and I was working on adrenaline more than conscious thought.

I pawed blindly around the top of my bunk for my headlamp, found it, and snapped it on.

And there he was.  Skinny and gangly in the way of teenage males who haven’t grown into their bone structure.  Dark shaggy hair, pale skin made paler in the harsh light of the headlamp by the sheen of sweat covering his face.  He had thrown himself out of his own sleeping bag and was sitting at the edge of his bunk, his hands white-knuckled on the edge of the platform.  He was gasping for breath.

“Jesus fucking christ, dude.”  I said.  His terror had frightened me, and the adrenaline letdown had left me angry.  “What the fuck.  Are you OK?

He was silent for a second, his skinny chest heaving as he struggled to fully cast off the shadows of his night terrors, to fully emerge back into the real world, an old stone shelter on an ancient hillside with the wind humming quietly outside the wood-shuttered windows.  Finally, the only shadow left was the one made by the light I held in my hand, shining on him from across the room.

“Yeah,” he said quietly, his voice raw and broken.  “Yeah.  I’m ok.”

~ ~

~ ~ ~ ~ ~

I don’t have a good answer for this one.  I don’t know what the antidote is.

Awareness has helped.  I catch myself shadowboxing more frequently than I used to.  And when I catch myself in the act, the self-imposed rule is that I need to describe, out loud, in detail, whatever object I happen to be blindly staring at at the time.

I have, in the past few months, among many other things, described two shampoo bottles, a box of Kleenex, the kitchen sink, the plastic frog that sits on my car’s dashboard, my sneakers, my mom’s dining room table, an empty cardboard box, and my boyfriend’s cat (he is white and grey and kind of an asshole, if you’re wondering.  The cat, not the boy).

It’s a trick that I learned to help patients who are trapped in an anxiety attack.  It’s a grounding exercise, and it helps.

I continue to use the perspective I gained in West Africa to help manage my emotional reaction to difficult patients: pain and suffering is always relative.

I can tell my smack-addled, verbally-abusive, meth-pocked hallway patient that I held small children in my arms as they died three years ago.  It doesn’t make a difference.  My perspective doesn’t make their pain any less, their fear any smaller, their sickness any better.  The only thing I can do is accept their suffering for what it is to THEM, not to ME.

It’s hard sometimes, but it’s helped a surprising amount.


The antidote is different for everyone.

And knowing that, one of the most difficult things I encounter these days is the patient who is carrying a shadow so big, so painful, so all-consuming that I can do nothing but watch from the sidelines as they are slowly, inexorably, and terribly devoured.

~ ~ ~ ~ ~

~ ~

3. Silent Shadows

We were about halfway through her head-to-toe exam.

She had walked into my ED two hours ago, three days after being raped on the bathroom floor at a drunken college party.  She’d finally broken down in tears and told her roommate, who promptly got an Uber and brought her to the hospital.

She was lying on the cot, dressed in a gown and covered in blankets.  Her roommate chatted quietly with the local on-call Victim Advocate.  Taught by one of the best SANEs I’ve ever known, I moved through my exam methodically, following the same steps each and every time, ensuring I wouldn’t skip or miss anything important.

“I need to take a listen and look at your belly.  I’m going to keep you covered from the waist down with the blankets, but I’m going to pull your gown up just a little, ok?”

She nodded at me, and, instinctively protecting her privacy, I moved around the bed and stood between her and her roommate and the advocate, blocking their view.

I gently pulled her gown up to just below her ribs, and came to a complete stop.

There, feathered out on either side of her bellybutton, were fine silvery stretch marks, the battle scars of a past pregnancy carried to term.

My mind reeled backwards, running rapidly through everything I had done so far.  We had discussed her medical history – no mention of pregnancy.  We had talked about her parents in a different state – no mention of a child.  We had talked about her birth control pills, her last period, whether or not we needed to consider emergency contraception – no mention, no flinch, no sideways glance, nothing to even hint that maybe, at one point in the past, she’d had this discussion before – to a very different end.

I flicked my eyes up to hers, and found her staring at me.  She knew exactly what I had seen, and knew that I knew what it meant.

She was eighteen, a college freshman far from home, and the baby that she had carried for nine months at some point in her life was nothing more now than the deepest of secrets and a set of scars.

I carefully pulled her gown back down over her belly, tucked it back beneath the blankets.

I took my gloves off, and placed my hands carefully on her stomach, pressed gently, continuing the exam and honoring the shadows beneath them.

“Does it hurt here?” I asked, desperately wanting to cry.

And told me the truth as she lied and said, “No.”