The nurses of E6 and the nurses of L5, the bride’s ward, were in the back, dressed in mothers-of-the-bride-and-groom dresses. They had on pearl earrings; their hair was done; and they were fussing with the reception table, which had on it presents, a cake, and two bowls of punch. Mr. Teal was already there in his wheelchair, nervous, and smiling shyly. The chapel was full.
I looked at my watch. It was 11:02 AM. Where was the bride? There was a bustle and a whisper. 11:05 AM. She was still on her ward, someone said, getting the finishing touches put on her coiffure. 11:10 AM. We heard she was coming, being wheeled off the elevator and down the corridor that leads to the chapel. 11:15 AM.
Here she was. And she was beautiful. “Bright as the sun and beautiful as an army with banners” as the Song of Songs has it. She was a warm mahogany brown, and she was wearing a diaphanous silk dress with light golds, yellows, browns, and reds in an African pattern. The dress was long and flowing; it covered her body and her wheelchair, and made her look, not like the stroke patient she was, but like a queen on a wheeled throne. Her black hair had been straightened and curled and woven with tiny rhinestones. Her earrings were gold; she wore a heavy gold necklace; and she was beaming, smiling so widely that even the paralyzed side of her face was lifted. Everyone turned their heads to see; several went over to her, to touch her and exclaim.
Mr. Teal, sitting in his wheelchair, was also smiling, a kind and grave and gentle smile. The organ began Mendelssohn’s “Wedding March,” and people hurried back to their places as the rest of us stood up, turned around, and looked at the bride and groom in the back.
Dr. Bart, the bride’s doctor, and I looked at each other from our pews. It just didn’t seem the moment to let our patients struggle by themselves down the aisle, rolling their wheelchairs as best they could. So Dr. Bart walked to the back and went over to the bride, and I went to the back and over to Mr. Teal, and we grasped the handles of their wheelchairs. Then Dr. Bart and I, with our charges, paced slowly in time to the music down the aisle, side by side. We left the bride and groom at the altar.
Meanwhile the minister had appeared. He was in front and dressed in black with a clerical collar. The organ music stopped, and there was a minute of silence while he looked at the couple in front of him. He cleared his throat and took a piece of paper from his inside pocket. Then he looked out at us, sitting in our seats, not knowing what to expect.
“Thomas and Jessie came to me several weeks ago,” he began. “They told me they wanted to compose their own wedding vows. They worked very hard on them.” He cleared his throat again, unfolded the sheet of paper, and began to read from it.
“Will you, Thomas Teal, take Jessie to be your wife, to love her as best you can for your whole life that remains to you?”
“I will,” said Mr. Teal, blushing as we looked at him and turning to his bride with an indescribable smile.
“Will you, Jessie, take Thomas as your husband, to love and to hold, to cherish and take care of, as best you can, as long as you shall live?”
“Yes, I will.” She was beaming so brightly when she said this and looking right into Mr. Teal’s eyes, returning his glance as we seldom return a glance.
“Then I declare you husband and wife,” said the minister. “You may kiss the bride.”
We all held our breath. They were sitting next to each other in their wheelchairs, and Mrs. Teal couldn’t move her left side, and Mr. Teal couldn’t walk, but he could turn to her and throw himself slightly out of the wheelchair and grab her in his arms and give her a real, passionate kiss. Which he did.
I never forgot that moment. The wedding of the Teals crystallized something for me that had been hard for me to conceptualize, but it had something to do with miracles and transformations and community. I thought of it as the “Wedding at Cana.”
The Wedding at Cana was where Jesus performed his first miracle—the transformation of water into wine. And Mr. Teal’s survival and transformation had certainly been miraculous. There was the first miracle that the paramedics had bothered to pick him up at all; and the second miracle, that he arrived at the County Hospital just in time for his resuscitation. There was the third miracle of his reconstitution in his bed on E6; and there was the miracle of his transformation—falling in love with Jessie.
But it was not only miracle and transformation that made the wedding of the Teals stand out in my mind as the Wedding at Cana. It was also, and even more—Cana.
Cana was just a little village in Palestine, and the wedding was nothing special. Yet everyone in the village attended—Jesus’ mother and cousins, his aunts, his friends and relations, the rich and poor, the children, the elderly, the beautiful unmarried women, and the men looking for wives.
And at the Teals’ wedding, when I saw the nurses in their mothers-of-the-bride-and-groom outfits; the other patients, dressed up and streaming into the chapel; Dr. Bart; and many others I didn’t even know, what hit me was that the hospital was Cana—a little village and a true community. And that a great part of Mr. Teal’s transformation had to do with this community—with its patients, its staff, its priest and nun, its open breezeways, its groups of smokers and scalawags, its doctors, nurses, and administrators.
After hospitality, I decided, community was the second principle of Laguna Honda.
What do I mean by community?
Community comes from the Latin communio, for which the Oxford Latin Dictionary gives two derivations. Communio as a verb comes from munio—wall—and means “to build a wall around.” So a community is defined by the wall—symbolic or otherwise—around it. Everything inside the wall is the community, and everything outside the wall isn’t.
That was a good definition of the community of Laguna Honda: You were a member of it just by being inside its wall. Because the hospital did have a wall, a real wall of polished rocks, piled up and shellacked by patients long ago. And we were a community simply because we were behind that wall and stuck with one another—doctor, patient, nurse, administrator, and budget. We had to do the best we could with what we had.
But communio as a noun derives from munis—gift; so communio also means “those who share a gift in common.” That was true of the hospital’s community, too, though it was not as obvious as the wall. At the Teals’ wedding, when I saw almost all of Laguna Honda pouring into that church, sitting rapt during their vows, and, yes, even crying, I understood that it wasn’t only me who was interested in the Teals, who made time, who was touched by them. Almost everyone was there; the wedding was a gift we shared in common, and that sharing made us a community.
For all the years I knew him after his wedding, Mr. Teal remained transformed.
He never went back to drinking and, although he was never as clean and handsome as he was on the day of his wedding, he stayed married. By that I mean, when Mrs. Teal had another stroke, he sat by her in his wheelchair and held her hand and worried; and when she recovered, he waited for her to appear in her wheelchair, with his sad and patient face, his bright blue eyes, and his farmer smile.
I saw them often sitting together on the nice days in the breezeway, on the cold days just inside, sharing their smokes and, I believe, even getting into marital tiffs. Possibly about Mrs. Teal’s flirtatiousness and Mr. Teal’s jealousy. Because there were days when Mr. Teal sat alone, and Mrs. Teal was nowhere to be seen. But then a few days later, there they would be again, together; and Mr. Teal would be, well, joyous; there is no other word for it.
Not too long ago, I asked him about his wedding. Wasn’t his anniversary coming up?
He couldn’t remember; I should ask the missus about that; she knew, she would remember.
Now, we had e-mail at the hospital, and I did use it, but when I wanted to meet someone, I didn’t bother with it; it was too inefficient. Instead, I thought about whoever it was, his or her face fluttering across my mental screen, and in spite of our sixty-two acres and 534,000 square feet of building, I would run into him or her within a few hours.
“Well, well, Mrs. Teal! How perfect. We meet again. How are you?”
“Oh, fine! I’m fine, Dr. S.! But I’m going for a smoke. I started smoking again.”
“Oh, well. You’ll stop again, I’m sure …. I’ve got a question for you. When is your anniversary?”
She smiled more broadly. “I can’t quite remember. It’s in the book, though.”
“The book?”
“The book the nurses made me—the wedding book. It’s by my bed. Do you want to see it? It’s got the date in it.”
Of course I did. So we went over together to Mrs. Teal’s ward, to her bedside.
“It’s in the third drawer,” she instructed me. “In a maroon pouch.”
She was right; there it was. I took it out, sat down on her bed; and we turned the pages together. There was Mr. Teal in his gray-green Armani suit and white silk tie; there was Mrs. Teal in her gown; there were Dr. Bart and me in our white coats, giving the bride and groom away. There was the minister, and there was the kiss. On the reception table I saw the wedding cake; and there was Mr. Teal, feeding Mrs. Teal cake.
“They call us Mr. and Mrs. Laguna Honda,” Jessie told me, “’cause we were the first to get married in the church. I’ll never forget the day we met.”
“How did you meet?”
“Didn’t I ever tell you? We were in the smoking area. I asked Thomas for a smoke and he smiled and gave me one. He was so nice! Then I thought to myself, I’ve never kissed a white man before! And we kissed! It was so nice! That’s how we met, and we’ve been together ever since.”
And they did stay together. Mr. Teal’s pyromaniac reputation continued to prevent him from being discharged, although his social worker did keep trying. He wouldn’t have gone anyway without his missus, he told me, who could not be discharged because she was just too disabled to live outside the hospital.
I worried a little that once the new hospital was built, there might be efforts to move Mr. and Mrs. Teal together into one of the semiprivate rooms. That, I thought, would be a mistake. Because theirs was not a modern marriage, privileging intimacy over privacy; theirs was an old-fashioned, a Victorian marriage, where you sleep in separate bedrooms, keep your separate friends, and live your separate lives, meeting coifed and shaved at dinner.
The Teals’ future—and the future of my other patients—was on my mind especially at this time because the city had just received a second letter from the Department of Justice. This one accused the city of discriminating against the disabled by keeping them at Laguna Honda, and it demanded immediate remedial measures. The DOJ’s first letter had accomplished its main goal; a modern hospital was in the works. Despite, or perhaps because of, this success, the DOJ continued to investigate us, arriving several times a year, though never stating its objectives.
Finally, its second letter arrived, long and detailed, and summarized the investigation so far. Its main complaint, now, was that the city was violating the 1999 Olmstead decision, which ruled that disabled persons had a right to live in the community. Since our city did not provide alternatives to Laguna Honda for all its disabled citizens to live in the community, it was violating this civil right. So the letter stated.
The DOJ this time demanded that the city remedy the situation immediately, and the letter provided thirty-two minimal remedial measures for that purpose. Most of them had to do with discharging as many patients as possible and preventing any new admissions.
For instance, Laguna Honda was ordered to revise its admission assessments and utilization review procedures; institute new policies regarding admission and discharge; and create a complete database of its patients. Most important, it was to reassess, once again, all 1,178 patients and discharge the eight hundred patients that the DOJ believed did not have to be in the hospital.
It was a tough letter, and administration threw itself into the DOJ’s demands with a flurry, nay, a snowstorm of activity. It was impressive.
To prevent future admissions, a team of doctors and nurses was put together to screen any potential Laguna Honda patient. The team would review the potential patient’s chart and sometimes even go over to the acute hospital and examine the patient there. Did the patient need our care? Was there a community alternative? It was a thankless task, and I was glad it wasn’t mine, because trying to figure out how sick a patient really was when an entire acute hospital was determined to stack the deck in favor of Laguna Honda must have been stressful.
For the patient database, administration installed the minimum data set (MDS) on our computers. This was a form to be filled out for each patient. It was twenty pages long and had hundreds of questions, the idea being to have a computerized measure of how sick every patient was. On a scale of one to four, how demented was the patient? On a scale of one to ten, how dependent? In how much pain? The MDS form was so complicated that a full-time MDS coordinator had to be hired for each ward in order to fill them out. Ellen Mary found the best nurse on each ward, had her trained, and then installed her in one of the few private rooms on the ward, where she henceforth spent all day entering data into the MDS.
To accelerate discharges from the hospital, administration decreed that every patient was to be reevaluated quarterly as to his or her potential for discharge, even if he or she had been comatose for years.
Last, a second team of doctors, nurses, and social workers reviewed every patient for discharge. Once again, this took weeks. The team did find eight patients to discharge, which wasn’t the eight hundred patients the DOJ estimated could be discharged, but it was something.
In addition to the DOJ investigation, the city was facing a lawsuit, called the Davis lawsuit, put together by disability-rights lawyers in order to stop the city from building a new Laguna Honda. These were the same lawyers who, in the 1970s and 1980s, constituted the “Mental Health Bar,” which had successfully closed the state mental hospitals. Now they had set their sights on closing the country’s long-term-care institutions, and Laguna Honda was one of their test cases.
Initially they had opposed the bond for the rebuild on the grounds that it would be cheaper, as well as more just, for the city to close Laguna Honda and care for patients in the community. When the bond passed anyway, the lawyers strolled around the wards and finally found Mr. Davis and seven other patients willing to join him in alleging that by keeping patients at Laguna Honda, the city was denying them their civil rights. This was Davis.
Davis had many demands, but its main one was that the city fund a new program to assess—yet again—each Laguna Honda patient for discharge and every potential new admission. This multimillion-dollar program, Targeted Case Management (TCM), would have its own director, nurses, and social workers (though not its own doctors) and would be independent of Laguna Honda, since the disability-rights lawyers did not trust Laguna Honda’s own staff to evaluate its own patients. Davis also demanded that the city decrease the size of the new hospital by one-third.
The city did not fight Davis but settled. It refused to reconsider the size of the new Laguna Honda but it did fund TCM, whose staff began appearing on the wards soon after. I was surprised that they never examined or even met the patients they took on, and that they never talked to the patients’ doctors. They read the charts we wrote and studied the MDS forms. And almost invariably they picked the patients for discharge who were the least likely to be discharged—the comatose, the terminally demented, the severely developmentally disabled. It was a little strange.
During TCM’s first year it discharged two patients from Laguna Honda. After three years, it had discharged 139, many of whom were scheduled for discharge anyway. Since the program cost $2.5 million per year, that worked out to about $46,000 per discharge. Which wouldn’t be expensive if the patients that TCM discharged stayed discharged. But it was impossible to f
ind out what happened to them, and I always wondered how it worked out, efficiency-wise.
Because TCM did not discharge our patients to sweet little houses in the suburbs. Our patients went back to the single rooms in skid-row hotels from whence they’d come. And I wondered: What happened to them after they hobbled or wheeled themselves back into the life that got them to us in the first place?
I did find out what happened to four of the eight patients named in Davis, and perhaps they are exemplary. Two were so sick that they died before Davis was settled. The third patient failed his discharge in less than a month and came right back to us. And the fourth was thrilled with his life outside the hospital and never returned. I knew many patients who, after their TCM discharge, ended up right back in the hospital, and I knew a few who, while they didn’t blossom, didn’t wilt either. But I could never tell how it worked out in the end, either financially, medically, or morally.
In any case, Laguna Honda was starting to be an expensive proposition for Dr. Stein.
It used to be that we brought in revenue for the city. But now, what with the DOJ letter and the new building, the Davis settlement and TCM, Laguna Honda was requiring an ever larger share of Dr. Stein’s budget. And his budget wasn’t great to start with. There was the recession; there were all the other demands on his budget—immigrants, AIDS, the uninsured, the elderly—and last but not least, the mentally ill homeless. They were even more of a drain because the newly elected mayor had campaigned on the slogan of “Care, not cash.” If elected, he promised, the homeless would no longer get their $360 a month at City Hall but the equivalent in care, in particular, a place to stay. He did win the election, and he had charged Dr. Stein with the job of housing the mentally ill homeless.
Now Dr. Stein should have had an easy time doing this, because he had the city’s Mental Health Rehabilitation Facility (MHRF, pronounced MERF) built to fill the niche left by the closing of the state mental hospitals. The MHRF was supposed to provide a place where the city’s mentally ill could be rehabilitated: the idea being that they would live at the MHRF, receive psychiatric medications and learn to recognize their symptoms and get help before they became severely ill. The MHRF was successful, but it took a big part of Dr. Stein’s budget because the state only paid for the first two weeks of a patient’s stay at an institution for mental disease. The MHRF’s patients, however, stayed for months, and this created a big hole in Dr. Stein’s budget.
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 21