He thought a lot about what to do and finally he had a brilliant idea. He would use Laguna Honda to house the homeless mentally ill. He would take over two or three wards as mental-health wards; then he would move the mentally ill patients at the MHRF and in the County Hospital’s psychiatric ward over to Laguna Honda. This would kill three birds with one stone. He could turn the MHRF into a cheaper residential facility; he could clear out the County’s psychiatry ward; and, since Laguna Honda was not an institution for mental disease but a hospital, he would get reimbursed for those patients.
He called up the head of our admitting team, who was Dr. Romero, and explained his new plan to her.
Dr. Romero had been at the hospital for a long time and had come to love it with a passionate, protective love. When she was medical director, she had also studied the city’s health-care system and learned about its politics. Plus she’d become friends with Dr. Kay, who was a righteous man, a man of principle, a man who didn’t mind saying no. Although she herself liked saying yes, with Dr. Kay by her side, Dr. Romero said no to Dr. Stein. She was sorry, but she just couldn’t do it.
Do what? Dr. Stein said.
Admit the mentally ill to Laguna Honda. Use the beds of the only public long-term-care institution in the city for the homeless. Privilege patients who had a place to stay over those who didn’t. Laguna Honda was the almshouse for the city, and she would always first admit the patients who needed it the most. Besides, it would be illegal for her to admit mentally ill patients to Laguna Honda. We were not an institution for mental disease, and it wasn’t safe. Not to mention that the DOJ was keeping a close eye on just such kinds of admissions.
Dr. Stein was not happy with her answer. Many of the mentally ill patients did have medical problems, he pointed out; surely those patients could be admitted. Dr. Romero should come over to the County and the MHRF, and evaluate the patients for herself.
So she did. Every morning she went over to the County and the MHRF. But she was able to take only a few of Dr. Stein’s psychiatric patients because most of them were dangerous, and the few she did take created a lot of problems. They attacked other patients; they brought in serious drugs; and the number of patients emergently transferred back to the County’s psychiatric department tripled.
Things finally came to a head with Larry Charles, a schizophrenic who had previously been in a locked psychiatric facility. One day he began refusing to take his medication, as was his right, and eventually he went into a psychotic rage and tried to strangle his roommate. The facility discharged him to the MHRF; the County got a court order that forced him to take his medication; he reverted back to his unpsychotic, pleasant self; and Dr. Stein asked Dr. Romero to admit him to us.
She refused. Larry Charles had no medical diagnosis, and Laguna Honda was not a locked psychiatric facility. She couldn’t guarantee his safety or the safety of the patients around him.
Dr. Stein was furious. He demanded an immediate meeting with the medical director, nursing director, and executive administrator. They must overrule Dr. Romero, he insisted. Larry Charles was fine. He was taking his medications, he was calm and pleasant, and he wouldn’t be a problem.
But the medical director, nursing director, and executive administrator refused to overrule Dr. Romero, who had concluded that Larry Charles was a risk. After all, according to the hospital’s admissions policy, Dr. Romero, not Dr. Stein, was in charge of Laguna Honda’s admissions.
Dr. Stein saw them out of his office, and the next day we awoke to find that overnight our admissions policy had been hacked. The director of public health, our policy now read, could admit to Laguna Honda whomever he wanted.
Of course, this was quite illegal, and the board of supervisors called an emergency meeting. It was crowded and televised. The supervisors began by asking Dr. Stein to explain his side of the admissions dispute, which he did. Then they asked for the public’s response. Dr. Romero, Dr. Kay, Sister Miriam, Miss Lester, several nurses, and our executive administrator stood up and explained their position, which was that the MHRF was the right place for Mr. Charles. Then the board went into a closed session. When they came out, they ruled that Dr. Romero was correct: Mr. Charles was too dangerous to be admitted to Laguna Honda. Dr. Stein was to change the admissions policy back to its former wording.
Fine, Dr. Stein said. That was fine with him. He would send Mr. Charles to that expensive private psychiatric facility he’d been trying to avoid. But since the money to do so had to come from somewhere, he would take it from Laguna Honda’s medical budget. As he would do in the future with any other patient that Dr. Romero refused to accept.
Two months later, in a budget-cutting move, Dr. Stein eliminated the positions of medical director and nursing director at Laguna Honda, and dismissed the executive administrator. He sent Mr. Charles to that expensive psychiatric facility out of the county, and he did take the money from the medical department.
Mr. Charles is out there still, I believe, with the cost of his psychiatric care still coming from our medical budget. Or perhaps not. But probably. Because Dr. Stein, as it would turn out, had a very long memory.
All these investigations and politics were stressful, not to mention having the director of public health unhappy with our medical department. But at the time I didn’t pay too much attention. I had finished my PhD and was planning to walk the medieval pilgrimage to Santiago de Compostela in Spain. I had decided to do this years before, as a present to myself when I finished my PhD.
But what is a pilgrimage? And why did I want to go on one?
A pilgrimage is a journey for spiritual reasons, but with a material goal—a shrine, a church, a mountain. It comes from the Latin word for pilgrim, peregrinus, from per ager, meaning “through the territory.” A pilgrim, therefore, is someone who leaves home to travel “through a territory” that is, by definition, “not home,” and so has the wider meaning of alien, foreigner, stranger.
But peregrinus (stranger) is different from hostis (stranger), which is the root for the hospes of hospitality. Hostis is the stranger from the host’s point of view—the stranger who knocks at your door. Peregrinus is the stranger from the pilgrim’s point of view—the one who does the knocking. The pilgrim leaves home in order to experience being a stranger—speak a different language, eat different foods, encounter different expectations—to experience otherness as the other.
In the Middle Ages, being a pilgrim was a big deal. It was what we all are, the medievals thought—pilgrims on the pilgrimage of life, leaving our true home at birth and traveling through time until we reach the spiritual goal of death; along the way, feeling “other” to what we see around us. To make a physical pilgrimage was to make that metaphor real.
There were three major medieval pilgrimages: to Rome, to Jerusalem, and to Santiago de Compostela, and the pilgrimage to Compostela was the most exotic. Rome was in the Bible and so was Jerusalem, and the medievals felt they knew something about both. But Compostela was mysterious. It had become a pilgrimage site only in the ninth century, when the body of Saint James, the apostle who had Christianized Spain, was discovered at the northern tip of Spain. It was said that the body had arrived in a stone boat that set sail from Jerusalem after the saint was martyred. A church was built for it, and monasteries were constructed across France and northern Spain as stopping places for pilgrims.
The pilgrimage to Compostela became popular; by the twelfth century, hundreds of thousands of pilgrims were walking to Compostela every year. After the Middle Ages, it fell into disuse, but was revived in the 1980s with the rediscovery of its ancient paths and motivations.
I was intrigued by the idea of experiencing pilgrimage in the medieval fashion. I, too, could make a vow of pilgrimage, and though I would fly to my starting point and apportion the 1,200-mile pilgrimage into four yearly walks—which didn’t seem quite fair—still, I could do it.
I began to look around for a traveling companion.
This wasn’t as easy as I
’d imagined. None of my friends was intrigued by the idea of walking across France and Spain. Until I asked my friend Rosalind. We’d gone to medical school together, and I thought she would make a good companion. She was tough but flexible, adventurous but not wild, methodical but not rigid. She never complained and had a dry wit, especially about herself. She didn’t know anything about pilgrimage, she told me. She was, if anything, antireligious, but she was ready for a long walk, and she was very good at maps.
So Rosalind and I put together our itinerary; we bought the smallest packs and took the fewest things. Then we flew to Paris, took the fast train to Lyon, and the slow train to Le Puy, the traditional starting point for the pilgrimage to Compostela. It was like going back in time, transportation-wise: from jet to high-speed train to the wooden-train technology of the nineteenth century and then stepping out on our own two feet. Le Puy was a big town, but modernity had skipped it, and it was, concentrically, eighteenth century in its outer ring, then seventeenth, sixteenth, and fifteenth century. Right in the center was its eleventh-century cathedral.
We bought our walking sticks in a little store, and the next morning we went to the special mass for pilgrims. After mass, the bishop presented each of us with a cockleshell, the thousand-year-old sign of the pilgrim, for us to put on our packs, and a “pilgrim’s passport” for us to sign. The passport averred that having decided to leave our home to take ourselves to Saint James in Compostela, we would respect the spirit of pilgrimage, the other pilgrims, our hosts, and the nature we would walk through. In return, the bishop confided us to the care of all we met and asked them for the love of God, to receive us with charity, pray for us, and help us in our needs.
We were to have our passports stamped every night, the bishop explained. When we reached Santiago, we would give them to the Bishop of Compostela, who would present us with our Compostela, the Latin document that confirmed we’d completed our vow of pilgrimage and forgave us our sins.
The Way was always an adventure, he added, always a proving. Many were the reasons that put a pilgrim on the path: They were inscribed in the depths of each one’s heart. But no matter what the interior quest, the Way was a way of life, and what he wished for us was that, with the sound of our footsteps, whatever we were seeking would fill us to overflowing.
Rosalind and I looked at each other. This was way deeper than we’d expected. We signed our passports anyway, attached the cockleshells to our packs, picked up our sticks, and walked out the west door of the cathedral. And I think I can say for both of us that the bishop’s good wishes for us came true, and to the very sound of our footsteps.
The thing about a pilgrimage is that there is no way to experience it except to do it. In that way it is very much like life. No armchair reading, no movies, no virtual photo albums can substitute.
Pilgriming isn’t like backpacking. We didn’t carry backpacks; instead, we reserved rooms in no-star hotels, in hostels, and once in a monastery, where nuns still practiced the virtue of pilgrim hospitality. So at the end of each day’s fifteen miles, we did not put up a tent and cook Ramen. We had hot showers, good wine, and French meals. But pilgriming isn’t like day hiking either, because we were walking not just through nature but through history. So nothing went by us too quickly; we were not tourists but actors in a landscape made to the measure of our footsteps. The scenery changed at the pace of walking, and just when we were ready for a village, there a village was, or a river, or a tree with plums.
There were many stunning moments on that first section of the pilgrimage, but the one I carried back to the hospital was the day it was pouring rain. We were a long way from that evening’s shelter, and we would be walking in the rain for a long time. It was cold; I was soaking wet; and Rosalind and I were singing to keep warm. There were mud, fields, and rain; and I was chilled to the bone. Yet I didn’t want to be anywhere else than in that muddy field, or doing anything else than walking in the rain, or be anything else except chilled. I didn’t want to have arrived at our warm and comfortable destination. I didn’t want the rain to stop or the fields to stop being muddy. I didn’t want to be dry or warm, or to be one step farther along or one step farther back. I wanted to be just where I was because only by being where I was could I experience what I was experiencing. Which was pilgriming.
As I walked through the field, I thought about how much of my life I had spent trying to make sure I would never be in that place—out in the cold, homeless, and without shelter. I thought about my patients who lived on stoops, slept in doorways, and drank vodka while I was working. Once I’d asked a patient who was eager to get discharged and back to her stoop what the attraction of her life was. From what she told me, I’d thought it was freedom—from work, duties, responsibilities. But in the rain that day I wondered if, homeless, cold, and sheltered only by her stoop, she meant the feeling I had that day. I was happy and knew I was happy, the happiest I’d ever been. Not blissful, joyous, angels-coming-out-of-the-clouds happy, but happy as in “a feeling of great pleasure or contentment of mind, arising from satisfaction with one’s circumstances.” Happy from hap, as in what happens—things as they turn out to be.
When I got back home that year, I put away my things—my stick, my pilgrim’s passport and shell, my pilgrim clothes. I wouldn’t take them out again for a year. And yet I didn’t stop feeling like a pilgrim. Now and then, as I was walking down the wide corridor between wards, the click of my footsteps would remind me, and I would be pilgriming across that muddy field, happy with things just as they were.
Perhaps for that reason, my relationships with my patients began to deepen. When you think about it, doctoring has everything to do with not accepting things as they are, and while I didn’t stop doctoring my patients, there was some new way in which I was appreciating them just for who they were.
Which was a good thing for the patients on my other ward, E4.
E4 was two floors below E6 and looked just like it, with a narrow entrance, linen room, nursing station, and big, open ward.
But E4 was not a “dementia ward.” It was a “medically complex” ward, which meant that it had patients with serious illnesses who, for other reasons, were unable to take care of themselves. The patients on E4 were paralyzed from strokes or car accidents, had multiple sclerosis, Parkinson’s disease, head trauma, spinal cord injury, and cerebral palsy. In addition to their main problem, each patient—and this is what made them “medically complex”—had other problems: diabetes, seizures, chronic pain, lung disease, heart disease, kidney disease. Almost every patient also had a psychiatric diagnosis—schizophrenia, manic depression—and often a personality disorder, too—borderline, schizoid, histrionic, or obsessive-compulsive disorder. Quite a few had been affected by the closure of the state mental institutions; with no place to go, they had done the best they could on the streets. Many had treated their psychiatric illnesses with cocaine and heroin, and then treated the side effects of cocaine and heroin with alcohol, and so had the complications of their drug and alcohol abuse as well.
Not only were they medically complex, but the patients on E4 were complicated nursing problems. Almost every patient had tubes the nurses had to manage—shunts in their brains, PIC lines in their veins, PEG tubes in their stomachs, nephrostomy tubes in their kidneys, catheters in their bladders. Several patients had open wounds from a chronic infection or bedsore, and the nurses cared for those, too, changing dressings three times a day.
Although the men of E4 were complicated and sick, they were not withdrawn or depressed but open-faced, flirtatious, and handsome. There was a reason for their good looks: No ugly person would have survived what they had survived. Even in orphanages, on the streets, and in prison, handsome people get special treatment. And the men of E4 knew that they were handsome, which is why they were flirtatious. They rarely complained either, at least not about the hand God dealt them. They complained about the food and the paucity of cigarettes, sometimes about the nurses, and occasionally about pain;
but mostly they were stoic and funny.
Like its patients, E4 was a shabby and unregenerate ward. What with the new Laguna Honda a-building, administration was loath to put money into the old hospital, although every now and then some lucky ward would get new paint, new curtains, and, when the pressure from the investigating magistrates became too heavy, new dressers. But E4’s ticket had not yet come up; its paint was peeling; its curtains faded; its dressers cracked.
Nor did it have much decoration. Most of the patients had only the tops of their dressers on which to put the photos that had survived the shipwrecks of their lives. Bill Luckly had a picture from his navy days, wearing the handlebar mustache he still wore, with husky shoulders and a white grin. Steve Milton had a pink-and-orange psychedelic poster of his rock band, and Sammy, our Down’s patient, had his photo from St. Patrick’s Day; with a green shamrock pinned to his green vest and a shiny green top hat, he looked like an aging elf. Occasionally a student from the Art Institute would sketch our handsome men, and a beautiful charcoal drawing would appear above a bed. But, on the whole, there wasn’t much decoration on E4.
There was even less after the fire on D3.
A patient set the fire. He’d waited until the day before his discharge, which happened to be the first of the month. He left the hospital and went first to City Hall, where he picked up his $360 of welfare cash that the mayor hadn’t yet stopped. Then he went to a gas station and bought two cans of gasoline and a quart of vodka, and came back. D3 was closed for its renovation, but he snuck inside, and as he looked around for towels, he started to drink. Then he dowsed the towels in gasoline, shoved them under the doors, lit them, and fell asleep.
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 22