But Hildegard used viriditas—greening or greenness—in a broader sense, I learned as I wrote my article. She used it to mean the power of plants to put forth leaves, flowers, and fruits; and she also used it for the analogous power of human beings to grow, to give birth, and to heal. I didn’t know how I’d missed it in my thesis. But there it was—greenness—a medical or perhaps spiritual concept that supported the gardening analogy I saw at the basis of premodern medicine. Had Hildegard invented the concept? I wondered. Was there a precedent in older medical texts for a power related to plants that also stood for the body’s ability to heal?
I spent the next year investigating those two questions, and in the meantime I met Terry Becker, who would show me what viriditas really meant.
If Jimmy was my skinniest patient and my patient who gained the most weight, then Terry was my longest and most miraculous patient. I had her for the longest time, she teetered the most on the edge of disaster, and she ended up by surprising me the most.
And the best way to tell you about Terry, about what she meant for me—the first time I admitted her, the second, the third, and now, when I look at her paid obituary in the River City Times—is to start with the photograph attached to that obituary.
You wouldn’t call her pretty, but her face, at least through the medical retrospectoscope, is arresting; it is the face of a robust, barely smiling Native American. Hair thick, dark, and flowing down her back; full face with broad cheekbones, dangling beaded earrings, beaded necklaces, and beaded armbands. Behind the glasses we gave her on the day she left the hospital, her eyes are dark and Indian.
That picture tells it all; it shows just what Laguna Honda could do in its time and with its time. Whether it was efficient or inefficient, I’ll leave you to decide, but I think you’ll agree that only death is truly efficient. Life is very inefficient and not cost-effective at all, from a health-care efficiency point of view.
I met Terry for the first time while taking care of the rehabilitation ward. Its usual doctor was on vacation; Dr. Curtis was elsewhere; and the admitting ward was temporarily closed due to the budget crisis, which occurred annually. No matter whether the economy was good, great, or a disaster, our city’s budget was always in crisis and the hospital’s budget especially so. When it came down to it, why did our city need an almshouse? No other city still had its almshouse. In other cities, patients somehow found elsewhere to go, and though that was more expensive in the long run, in the short run it was way less expensive. So there was always a money crisis and always attempts to cut Laguna Honda’s budget.
Dr. Major took this particular budget crisis as a challenge, however, and she decided to make a point by shutting down the admitting ward. This meant that no new patients could be admitted, except for patients for rehabilitation who could go to the rehabilitation ward and terminal patients who could go to the hospice ward. All the other patients in the city who normally would have come to us, could not; instead they stayed on at the County Hospital and at other hospitals around the city, waiting for someplace to go. Since hospitals did not get paid for patients who no longer needed acute care, this meant that hospitals around the city were losing money and pressure was, therefore, being applied to approve Laguna Honda’s usual budget as soon as possible. In the meantime, Dr. Fintner and I were taking care of the patients on the rehabilitation ward.
That was how I met Terry Becker the first time. She was transferred from the County Hospital for rehabilitation, and I admitted her.
She was a street person, I read in her records, a heroin addict, and a prostitute; she had a boyfriend; and they lived on the streets. She’d been fine—at any rate, in her usual health—until twelve days before, when she woke up to find that she could no longer move her arms or her legs. So her boyfriend took her over to the emergency room and there the diagnosis was made: she had transverse myelitis, which is an inflammation of the spinal cord that, in just a few hours, can cause a section of the spinal cord to swell against the inner bony sides of the spinal column. This swelling is devastating to the body’s ability to move because the spinal cord is made up of nerves that act like wires, transmitting messages and impulses between the brain and the rest of the body. When the spinal cord swells, the nerves stop working, and everything past the swelling can’t function. Terry’s swelling was in her neck. So she couldn’t move anything past her neck—not her arms or legs, bowel or bladder. Transverse myelitis is a rare disease, one in a hundred thousand, but Laguna Honda being what it was, Terry was my third case.
The County Hospital admitted her, and its doctors made sure that there was no other cause for her paralysis, such as AIDS, syphilis, or multiple sclerosis. Then they waited to see if she would get better, which is often the case. She did get better, but not enough better to go back on the streets, and so they sent her over to us for rehabilitation. The nurses assigned her to one of the double-bedded semiprivate rooms at the entrance to the rehabilitation ward, and after I’d reviewed her records, I went over to her room to see her. When I got to her room, I stopped in the doorway and looked in.
She was sitting in her wheelchair with her back to me, staring out the window; an uncovered urine bag was hanging from her chair. No one else was in the room—no friends or family—and nothing of her was in the room either—not even the usual plastic bag of clothes, framed photos, and cigarette packs left in a lump by the Russian ambulance drivers. Then I knocked on the open door, walked in, and went around the wheelchair to take a closer look.
She was worn, like so many of the drug users and street people, and looked to be in her fifties, though I knew from her records that she was only thirty-seven. She was very thin. Her long, colorless hair was stringy and unwashed; her face was tired and drawn, and there were dark circles under her dark eyes. Her teeth were decayed; her nails dirty, untrimmed, and stained with nicotine; and she was positioned uncomfortably in the chair, with her neck awry. Her eyes, when she looked up at me, were slightly out of focus.
“Can I sit on the bed?” I asked.
“Can I have a cigarette?” she replied.
I sat down. “After I talk to you for a bit and examine you; how about that?”
She sized me up. I wasn’t very big, but I was determined, and she couldn’t move.
“Okay.”
I commenced my exam. On the whole, the news was good. She was able to move her right shoulder and her right foot, a bit. Also she was able to feel her limbs, somewhat. Even though there is no treatment for transverse myelitis, most patients do get some recovery, and this improvement meant that Ms. Becker was likely to regain a considerable amount of her movement and her independence.
“Do you have anybody to take care of you when you leave?” I asked.
“My boyfriend. Mike. He’ll be here soon.”
After my examination and her cigarette, the nurses took Ms. Becker away to bathe her, shampoo her, and cut her nails. Then she started our program of rehabilitation.
Soon after her admission, though, the first of the month rolled around. Now, in our city this is “payday” for the homeless, because anyone who shows up at City Hall on the first of the month receives $360, no questions asked, as part of General Assistance. And right on schedule—that is, on the first of the month—Mike the boyfriend did show up. He was blond, cute, and in his twenties; and he wore tight and not-entirely-clean Levi’s and a denim jacket. He was not unkempt, and he was polite, but he was not kempt, either.
He wanted to take her out, he told me, just for a few hours, down to South of Market, where she could sign her check over to him.
I watched as he wheeled her off in the wheelchair with the bag of urine, now covered, at her side. She was somewhat better than when she arrived. Her hair was washed and brushed; her clothes were clean; and she could move both shoulders. Mike put a cigarette in her mouth and off they went.
She didn’t come back as promised, though. At least not right away. What I learned through the doctor grapevine was that a few days afte
r she left, she’d been found alone on the streets in her (actually our) wheelchair, with a blocked urine catheter, a swollen bladder, and, consequently, a rip-roaring kidney infection that had infected her blood. So she was admitted to the County Hospital, stabilized, and then sent back to rehabilitation.
By this time I was back on the reopened admitting ward, but I kept track of her progress anyway, which was good and bad. Good because she continued to improve: her arms strengthened, and she was able to stand. Bad because Mike, her cute blond boyfriend, continued to roll her out and bring her back intoxicated and high. After three such misadventures, Dr. Major gave up and discharged Terry, in her wheelchair, to the Baxter Hotel and into the care of her boyfriend.
Over the next several months, Terry was admitted to the County Hospital many times—mostly for kidney infections and once after Mike beat her up and robbed her. Finally, in the middle of winter, she was found sitting in her wheelchair on the streets, cold, unarousable, and without a heartbeat. Someone called the paramedics. Even though she was clinically dead, they began resuscitation efforts and also warmed her body. It took them a while, but once she warmed up, her heart resumed its steady beat; her pulse returned; and she began to breathe. After two hours, she woke up.
The paramedics took her to the County Hospital, and a few days later, she came back to us.
This was the second time I’d seen her. She’d lost quite a bit of function. She could still move her arms, but not her legs, and she couldn’t stand anymore. The rehabilitation staff went to work. After a few months, she was back to her baseline; she could stand again. And again, after a time, Mike appeared with alcohol and drugs, and Terry left the hospital.
But not for long.
Mike did not do a good job of taking care of his patient, and Terry did not do a good job of taking care of herself. They drank; they smoked; they took cocaine; sometimes she stayed for days in her wheelchair. Eventually she developed an open wound on her sit bones from sitting so long—a bedsore—and it became infected. So she was admitted back to the County Hospital, where the plastic surgeons spent many hours covering the open wound with a graft of skin from her thighs—an expensive operation needing weeks of careful nursing to heal properly. But after the surgery, the first of the month rolled around, and Mike turned up.
The County Hospital taught him how to take care of Terry’s graft, dressings, and bladder catheter. Although, since they were homeless, he never was able to change the dressings, not even once. It must have been frustrating for Mike, who was a kind of mystery man, anyway. What tied him to Terry? Money? Love? At any rate, a week after that particular discharge, he took a two-by-four to her, fracturing her skull and breaking her left leg.
When she showed up in the emergency room for this, the twenty-eighth time, even the ER doctors were dismayed. The expensive surgical flap that covered her wound had deteriorated; it was no more than a mass of rotten flesh; and there were two new open sores on either side of her sit bones. They called in the surgeons to take a look.
The surgeons were appalled at the damage to their handiwork. The beautiful piece of skin that they had, over so many operating hours, detached, rotated, and then affixed with meticulous sutures to the open wound on her back had turned gangrenous. It had to be removed—picked out of her open, infected wound in tiny pieces.
Would the surgeons consider, the ER doctors asked, trying again?
They declined. Perhaps in several months, if Terry complied with their orders. In the meantime she should have the old-fashioned treatment of thrice-daily dressing changes laid in the wound and removed when dry. This would clean the infected wound, and it could be done at Laguna Honda.
And so I admitted Terry for the third and last time, four and a half months after her second flight from us.
Those four and a half months had not been good to her, I saw when she rolled into the admitting ward. She was thinner and more wan than she’d been at the beginning of the year. There was an IV going; there was a cast on her left leg; and the circles under her eyes were darker. She looked even older than she had the first time I admitted her. But—and this was a change—when she saw me, she smiled.
We knew each other pretty well by this time, so I waited for her to have her smoke and for the nurses to bathe and shampoo her, and change her clothes. Then I went over to examine her. This time the nurses had placed her at the far end of the ward, next to the wall and nearest the bathroom, which was good, but far from the smoking room, which was bad. Best of all, she was under the care of Connie, the nursing assistant whose patients, I’d noticed, always improved.
Terry’s physical exam was much as I’d expected from her records and not much different from the last time I’d seen her, except more so. Although this time she seemed played out, her spirit tired, given up. Her flesh—the tone of her skin, the absence of muscle—told the same story; it, too, lacked that vital force, that vis vitalis that is the essence of health and the substance of life.
I looked at the soiled cast on her left leg, and from the rest of the exam it was clear that whatever gains she’d made on her previous admission had been lost.
Then Connie turned Terry on her left side, and I saw the open wound on her back. The description from the County Hospital had not done it justice.
Terry’s bedsore was the worst I’d ever seen. It was huge, enormous, and deep. It went from the middle of her back all the way down to her tailbone, and it spanned both of her sit bones. The skin was completely gone, of course, but so were the fat and the muscles that cover the spine. In their place was an unidentifiable mass of decayed and decaying and infected tissue from the failed skin graft, and at the bottom of this wide, deep hole I could see bone—Terry’s spine.
Now, before I came to Laguna Honda, and even for a while after, I didn’t understand the importance of a bedsore. It doesn’t sound that bad—a sore from lying in bed. In fact, though, bedsores are a disaster both in what they mean and in what they signify. They mean that someone has not been paying attention to the difficult problem of a patient like Terry, who no longer feels the lower part of her body and so does not make the unconscious, fidgety movements the rest of us make to relieve pressure on the parts of our body pressed against shoes, chair, bedclothes.
What bedsores signify is even worse. They signify that the body has lost its integrity. Normally the body is covered with skin, which is impermeable to fluids and to germs. Slather healthy skin with any amount of germs, and nothing will happen—no infection—unless there’s a break in the skin. As extra protection there is the fat under the skin, which cushions the muscles, and the muscles under the fat, which protect the bones, and the bones, which protect the spinal cord.
So Terry’s bedsore was scary. She had no protection. Everything delicate and crucial in her body—bones, kidneys, spinal cord—was exposed and vulnerable to an environment full of danger, full of germs—to bacteria of all sorts and from every source, even the bacteria that live on and within our bodies. Giving antibiotics to try to prevent infection wouldn’t protect her, I knew, because germs would rapidly become resistant to them. And the bedsore was too big to graft, even if the surgeons agreed. It would have to heal on its own, and that would take years. In the meantime, what chance did Terry have of not getting an overwhelming infection that would kill her?I walked back to our little doctors’ office and sat down at my rickety desk. I stared for quite a while at the wooden shelf on which was Mrs. McCoy’s robust plant, now grown all over the wall. This bedsore was a catastrophe, and possibly the end of Ms. Terry Becker.
For the second time with a patient, I thought about Hildegard, and I asked myself: What would Hildegard do? How would she treat Terry Becker’s huge and open wound? And as I did so, I stared into Mrs. McCoy’s green plant.
What she would do, I suddenly saw, was remove obstructions to Terry’s viriditas, to Terry’s natural ability to heal. Because if nothing was in its way, then viriditas would heal her wound as surely as a plant will grow green.
> What was in its way? I asked myself.
The mass of dead tissue was in its way, and every bit of it had to be removed.
Any pressure on Terry’s body, from wrinkled bedclothes to hard mattresses, was also in its way and had to be removed. Anything that interfered with the circulation of her blood—nicotine, for instance—was in the way of viriditas. Dirt, unkemptness, stale clothes. Unnecessary medications. Fear, depression, hopelessness. All were in its way.
My first job, therefore, as gardener-doctor, was not to make a brilliant diagnosis or give any magical medication, but to remove obstructions to Terry’s own viriditas.
What else?
To see what else was needed, I had to start with a vision of Terry whole, complete, and healthy, in a future when all that was missing from her complete health was a pair of glasses. And walk my way back from that. Which I did. I walked past the repair of her teeth, the strengthening of her body, the strengthening of her will, the resolution of her depression, and the healing of her bedsore. I walked all the way back from the perfect future to the imperfect now, and then I organized my strategy forward.
What my strategy would be, I understood from Hildegard, was that, in addition to removing obstructions to viriditas, I would fortify Terry’s viriditas with Earth, Water, Air, and Fire. That is, with good nutrition—tasty food, vitamins, liquids—deep sleep, fresh air, and sunlight.
After that? Peace. Rest. Safety.
Not much else. It might be just that simple. Oh, and time. As much time as Terry needed.
It was quite amazing how fast Hildegard’s prescription worked.
Within a few weeks I began to see signs of healing deep within Terry’s wound. There was no infection, and deep down, at the base of the wound—was it my imagination?—there was a smooth and pink glistening, which was starting to cover and protect her spine.
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 10