Then we strolled back through the hall with its vending machines and patients. We passed a 1950s-era beauty salon with steel-helmet hair dryers and Naugahyde swivel chairs, and we peeked in at the barbershop, which had a miniature barber’s pole inside. We went upstairs to see the operating room, with celadon tile and glass cabinets, and the laboratory, with black benches, a microscope, and a centrifuge. Dr. Major showed me the little store that sold candy, batteries, and shaving cream, and a book-lined library with oak tables and newspapers on wooden racks.
We went down more stairs and came to the theater. Its cement floors were painted and polished; there were red velvet curtains drawn across a stage and carved box seats behind us. In the old days, Dr. Major said, the theater had been used for silent movies, hand-cranked by the superintendent’s son; now it was mainly used for the Christmas show and the Valentine’s Day dance. Next to the theater was the chapel. It was not the neutral “Quiet Room” of a modern hospital. No. The chapel of Laguna Honda was more like a small church. Its stained-glass windows were large and real; its pews were made of polished wood; and the Stations of the Cross lined its walls.
Then Dr. Major took me outside.
Laguna Honda covered sixty-two acres, she told me, and this was because it originally had been as much a farm as a hospital. Patients had been expected to work if they could. They grew most of the hospital’s vegetables; they took care of the dairy; they raised pigs, cows, and sheep; ran the laundry; and sewed, mended, and cooked. If they could do nothing else, they gardened. And, as we walked, I could see the remains of old orchards and flower beds now run wild. There were apple trees and quince, olive trees and fig. Scattered among the trees were medicinal herbs: digitalis, rosemary, nasturtium, lavender, geranium, and valerian. Finally, we came to the end of the tour—the greenhouse, the aviary, and the barnyard.
The greenhouse smelled of humus and plants. On Saturdays, Dr. Major explained, the therapists brought patients out to sit at the wooden benches and pot their own plants. Next to the greenhouse was the aviary, with doves, parakeets, pigeons, chickens, and incubators. Later I would discover that the AIDS ward had even had its own incubator and its own chicken, which had hatched on the ward. It roamed the ward and pecked around the patients’ beds until the state found out and had her taken away to a fate unknown but guessed.
Last we looked in at the barnyard. There were wooden coops for the rabbits on the right, for the chickens on the left, and, free to root in the green lawn in the middle, two miniature black pigs. Behind a short fence at the back was a pond for ducks and geese, and hillocks for a turkey and two goats. On certain holidays, Dr. Major told me, the therapists would put the animals in little carts to visit the bedbound patients. They would dress the animals in appropriate holiday attire—the goats with little Pilgrim hats for Thanksgiving, the turkey in dark glasses and a tie for the Fourth of July.
Then we walked back to her office and sat down. It was a plain office—one large desk, bookcases with reports and manuals, a window that gave out onto a parking lot, where ambulances were coming and going.
Dr. Major offered me the position.
I wasn’t sure. Laguna Honda was like no hospital I’d ever seen or even imagined. But it was the only situation where my criterion of time was satisfied. So I accepted, but only temporarily. Two months, I told her. I could make only a two-month commitment. It was a way of hedging my bets. I didn’t think she would accept; two months wasn’t much for the amount of paperwork my employment would entail.
But Dr. Major knew something I didn’t know: Laguna Honda cast a kind of spell. Most everyone came for just a few months, maybe a year or two, and most everyone stayed for decades—thirty, forty, even fifty years. She herself had come to the hospital for only four weeks of consulting, two and a half years before.
Dr. Major was pretty sure I would fall under that spell.
She was right. I would fall under it.
I would stay at Laguna Honda not for two months but for more than twenty years. I would finish a PhD in Hildegard’s medicine; I would go off on a medieval pilgrimage and come back; and I would be present as the old almshouse was transformed, for better and for worse, into a modern health-care facility. Above all, I would take care of 1,686 of its patients, and what they taught me would change me and how I practiced medicine in ways I would never have imagined.
To my surprise, Dr. Major accepted my offer of two months.
I would be assigned to the admitting ward, she told me, where I would be replacing Dr. Judd, who was moving to a different ward. I would start in three weeks. On my first day, I should stop off in personnel to sign the papers, then pick up a white coat in the laundry and meet Dr. Judd on the admitting ward. He would show me around and turn his patients over to me.
One
FIRST YEARS
IT WAS EARLY MORNING ON MY FIRST DAY, and Dr. Judd was waiting for me.
As Dr. Major had instructed, I stopped first at personnel and then at the laundry, where I picked up a white coat—highly starched, neatly pressed, slightly frayed. Then I went up the stairs, down the hallway, through the double doors of the admitting ward, and into the doctors’ office. The doctors’ office was small and narrow, no larger than a single patient’s room. But it was familiar, with the same bareness, plainness, down-to-earthness that I was used to in the kind of medicine I practiced—businesslike, if your business was taking care of the sick poor.
I was taking over the patients of Dr. Judd, who was transferring to another ward. Somber, even a little withdrawn, he handed me his index cards. These were the cards on which he, like all of us at the time, wrote down the basic information about his patients: name and medical number, date of admission, list of diagnoses and medications.
He was anxious to be on his way. Nevertheless, we left the doctors’ office together to go on rounds, so that he could introduce his patients to me and summarize their medical problems. There’s an art to it—in a few sentences to tell the essence of a patient, past, present, and future—and Dr. Judd was good at it.
First on our rounds was Mr. Tarn, who had Parkinson’s disease. He had consequently fallen and broken his hip, and needed daily manipulation of his many medications. Mr. Benturi had been hit by a car and was recovering from head trauma and multiple orthopedic injuries. Mr. Davis also had a fracture and the additional problems of alcoholism and diabetes. There was Fred S., disabled from a brain tumor and on dialysis; Mrs. Lorenz with Alzheimer’s; and Mrs. Roche, rehabilitating after a stroke. We were treating Betty Wilson for fractures of both arms, both legs, and pelvis, and Ms. Devlin for the rare and inexorable disease of spinocerebellar degeneration. Mr. Demmings was at Laguna Honda with terminal alcoholic cirrhosis—bleeding, confusion, and jaundice—although he was improving.
Dr. Judd’s patients were familiar to me, not specifically but in general; they were just like the patients I’d managed throughout my medical training. Complex, fragile, and unstable, in need of close monitoring of medications and laboratory tests. The only thing surprising about my new patients was that they were at Laguna Honda and not in an acute hospital. Although, as we walked around the ward and I thought about the last few years in medicine, having the patients at Laguna Honda and not at an acute hospital did make sense, in a way. What with the changes in medical financing of health maintenance organizations (HMOs) and diagnosis-related groups (DRGs), doctors and hospitals were now paid for “maintaining health,” not for treating disease. Often, to encourage health-care efficiency, doctors simply received a fixed amount per patient per month, and hospitals a fixed amount per disease, regardless of how sick a patient was. Doctors, therefore, tried to retain only their healthy patients, and hospitals tried to ensure the shortest possible stays and the speediest possible workups. But patients like Mr. Tarn, Ms. Devlin, and Mr. Demmings had no health to maintain. They were very ill, and the only way for the acute hospital to be efficient and not lose money taking care of them was to discharge them as soon as possible. Which they
did, if they could find a chronic hospital willing to admit such patients. In San Francisco that hospital was Laguna Honda. So while I was surprised by how sick my new patients were for a chronic care hospital, I wasn’t astonished.
Until we came to Mr. Hickman.
Mr. Hickman was thirty-nine years old, Dr. Judd told me, and he was odd. He lived, no one knew quite how, on the streets. He rarely spoke. He’d been sent to Laguna Honda because he’d failed the usual treatment for his disease, which was tuberculosis. He hadn’t taken the four daily medications necessary to kill the tuberculous bacteria, which, consequently, had multiplied in his lungs, forming pockets of pus that were inaccessible to medication. He’d been taken to surgery, therefore, and his infected lung was removed, along with much of his chest wall—ribs, sternum, and skin—so that he could heal from the inside out. It was an old-fashioned treatment, Dr. Judd explained to me, an “Eloesser flap,” developed before there’d been medications for tuberculosis. Our job was to dress the open wound twice a day, and make sure Mr. Hickman took his medicines.
With this, Dr. Judd introduced me to Mr. Hickman, who was skinny and taciturn, and lying in bed, staring up at the ceiling. He did not shake my hand or turn his head to look at me. I went over to the left side of the bed and Dr. Judd went over to the right, and he turned back the covers. Mr. Hickman’s chest was heavily bandaged. One by one, carefully, Dr. Judd removed the bandages and dressings and placed them on the nearby table. Then I looked into Mr. Hickman’s open wound and saw that, exposed and vulnerable, nestled in the hollow that the surgeons had created, was Mr. Hickman’s beating heart.
It was extraordinary.
I could see the fine, delicate film of the pericardial sac glisten as it pulsed and caught the light. Woven through it—I could just make out—were tiny veins and arteries. It was so alive, that beating heart! It was as alive as Mr. Baker’s body at my first autopsy had been dead. For a minute or so Dr. Judd and I stood there and watched the heart beat, pink and oblivious to us, while Mr. Hickman stared up at the ceiling. Then Dr. Judd repacked the lung cavity with fresh, white four-by-fours. He covered up the heart with a new dressing, taped the chest closed, and pulled the sheet back around Mr. Hickman’s neck. We walked back together to the doctors’ office at the front of the ward, and he left me with my index cards and my patients.
It was Dr. Rachman who showed me the ropes, which were refreshingly few.
Dr. Rachman was Italian from New York, and she was quick, funny, warm, and talkative. I was to have the rickety wooden desk in the corner next to the window. It looked out onto the green hill across the parking lot, and, hence, onto all the comings and goings of patients, staff, and ambulances. Crammed into the room were also a computer, Dr. Rachman’s desk, Dr. Romero’s desk, a hat rack, and extra chairs for family and visiting doctors.
Dr. Romero and Dr. Fintner were the other two doctors on the admitting ward, Dr. Rachman explained, and they were job-sharing; that is, they shared a desk and shared their patients. I would get to know them both very well. Dr. Romero was from Cuba but grew up in Florida; and she’d been the first in her family to go to college. She’d gone to Ivy League schools, trained in the best medical program in the country, and married well. She was ambitious and incisive, Dr. Rachman said, but her two upbringings—first as younger Cuban daughter and then as brilliant American student—were not perfectly melded together. So she was a little like those plastic figures whose left and right sides do not quite match up. Outside our tiny office, Dr. Romero was sweet and patient; inside it, she was sardonic and witty, and did not tolerate fools gladly.
Dr. Fintner, on the other hand, was melded together perfectly well. The daughter of a doctor, she was gentle and kind, both inside and outside the office; and, though she laughed at jokes, she did not make them. Dr. Fintner knew almost everything there was to know about medicine, Dr. Rachman went on, but she was modest and I would have to ask, because she never volunteered. It was a good thing that Dr. Fintner knew everything, since she could never find anything in the desk she shared with Dr. Romero. Everything that came into her mailbox, Dr. Fintner saved, piling it in a corner of the desk, not wanting to hurt anyone’s—not even mass-marketers’—feelings.
The four of us were responsible for the daily admissions to the hospital, which were limited to three or four. So I could expect a new patient every morning. There was a waiting list of more than two hundred patients, and patients were admitted based on their needs and the hospital’s capabilities. They came from hospitals throughout the city, from their homes if they had them, or from the streets. The doctors took the admissions one after another in an ongoing queue that was strictly followed—a queue of destiny, as I would learn.
After rounds, I would spend the rest of the morning on my new admission. It took that long, Dr. Rachman said, to perform a full examination; contact family, friends, and former physicians; review the records and medications; and formulate a plan. She showed me a sample of her previous day’s admission. Handwritten, with every T precisely crossed and every I precisely dotted, her five-page workup was inspiring. She’d combined the knowledge we’d accumulated in medical school, the arduous experience of our residencies, and added her own common sense to produce a thing of beauty and of art. As she flipped through the sections of the chart with me, went over the forms for each test and X-ray, showed me the computer and the dictating system, she also continued to chat about the doctors and nurses I’d soon be meeting.
Then she took me upstairs to the X-ray department and the laboratory. I would read my own X-rays, Dr. Rachman told me. True, we had radiologists from the County Hospital who came in the morning, but any X-rays taken after that I’d have to look at myself.
Like the doctors’ office, the two rooms of the X-ray department were old-fashioned and plain. In the first room sat the X-ray machine, and in a corner, the film developer and darkroom. This meant that we did not have to be satisfied with standard X-ray views, Dr. Rachman pointed out, as we had to be at modern hospitals, where the X-ray machines were off-limits to everyone but registered technicians. Instead, we could participate in our patients’ X-rays, and even suggest the positions and views we wanted to see.
The second room was where I would read my X-rays. Its windows were covered by blackout shades from the 1940s, and its bookshelves held dusty, ancient, but, of course, still-relevant examples of the X-rays I’d be reading. On one wall were the light boxes. On the opposite wall were the files of X-rays for all 1,178 of the hospital’s patients. Once I’d learned the filing system, I would have access to all of the patients’ X-rays—no filing clerk or computer system to go through.
Also, Dr. Rachman said, I could examine my patient’s blood, urine, sputum, or skin in the laboratory across from the X-ray department. She opened its door, and I saw the three rooms of the laboratory, lined with black-topped counters. There was a Bunsen burner, a centrifuge, and, best of all, a microscope, with boxes of slides and delicate slide covers, lens papers, and little bottles of chemicals. Then she closed the doors of the laboratory and the X-ray department, and we walked back together to the doctors’ office.
I marveled, and I was thankful. Laguna Honda was off the radar screen. Tucked away in that tiny office, over the hill and far away from HMOs and insurance companies, I was going to be able to practice medicine the way I’d been taught, the way I’d learned, and the way I wanted.
Quickly my habits were set.
In the early morning I’d make rounds on my patients on the ward; in the late morning I’d receive my new patient; in the afternoon I’d review lab tests, talk to families, and do procedures. In the late afternoon, doctors from the rest of the hospital would visit us on the admitting ward to talk over puzzling cases. We’d look at X-rays together, examine patients, and discuss diagnoses. Before going home, I’d round again on my patients. This was the time, as the sun got low in the sky, that I’d sit on their beds and listen to their stories.
For my first years, until I started work
ing on my PhD, I was at the hospital full time, eight to five, five days a week; only after hours did I pursue my scholarly investigation of premodern medicine. The patients were always very sick, but on Mondays and Fridays they were even sicker. Mondays, because over the weekend they didn’t have the concentrated doctor time they had during the week and were seen only for emergencies by the house physician. Fridays, because the sickest patients arrived on Friday afternoons—rejects from acute hospitals all over the city, who were clearing their decks for their weekends.
But the patients were very sick during the week, too. Since there were three of us (Drs. Romero and Fintner counting as one), we divided the thirty-six patients of the admitting ward into thirds. So I usually had about twelve patients, the same number I’d had as an intern in the acute hospital. And most were about as sick as the patients I’d had as an intern, as I’d learned from Dr. Judd on my first day.
So the admitting ward was comfortable, and it was also collegial and satisfying. It was comfortable because it was so familiar physically—the small office, the wooden desks, the open window, and the books. And mentally—the number of patients, the morning excitement, the resolution of that excitement during the afternoon, and the peaceful, social ending of the day.
It was collegial in the Latin sense of the word. The admitting ward had collected together a group of experienced doctors in a small space; we got along well and helped one another out. Put together, the four of us had more than sixty years of medical experience, and it was a very rare disease that one of us didn’t recognize. But the patients did have very rare diseases. Instead of the usual medical adage that “common things occur commonly,” at Laguna Honda the adage was “uncommon things occur commonly.”
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 2