As for other ways of preventing patients from such activities—restraints, tranquilizers, and locked wards—they were no longer allowed either. The only thing that was allowed was a “sitter”—a staff member to sit with a patient all day. But sitters were expensive. They threw the budget off, and Mr. Conley had decreed that there would be no more sitters.
So the only way to prevent sex, drugs, and violence was not to admit the patient in the first place. Or if he was in your hospital, to discharge him as soon as you could. Which was why Dr. Stein and the County Hospital had their Flow Project, and why Sister Miriam and Miss Lester founded their citizens’ group. Because in one way, at least, Laguna Honda was just like the almshouse of yore—it was the last resort. Once a patient was admitted, there was no place else to send him.
With all this going on—a new director of nursing, a new executive administrator, the BioPsychoSocialSpiritual program, a ballot measure brewing, and the new kind of patients from the County wreaking occasional havoc—the hospital was ever more chaotic. I was happy that I had my pilgrimage to go back to.
Rosalind and I began to organize the second section. We would walk for two hundred miles through the south of France, and we would begin in our footsteps of the year before. We flew to Paris, took the fast and slow trains to our starting point, and spent the night in the hotel we’d left the year before. Then we put on last year’s clothes, fastened our shells to our packs, lifted up our walking sticks, and took the next step.
As soon as I heard the click of my stick on the cobblestones, I was right back in that space of pilgrimage, right back where I’d been a year before, as if only a night had passed. The swing of my legs, the slide of my stick through my hand, the click as it landed, had a cadence as rhythmic as a heartbeat.
The second section of the pilgrimage starts in the area of France known for its white limestone, the causse. The causse makes beautiful churches and castles, but hard stone paths that heat the pilgrim’s feet and reflect white hot light into the pilgrim’s face. It is also a depopulated part of France. Its villages are nearly empty, each one with a World War I monument that explains the emptiness: entire families of sons wiped out at the Battle of the Marne, the Battle of the Somme. Rosalind and I could walk for hours without seeing anyone, although the countryside was still cultivated somehow, with green farms and truffled oak forests.
The experience that most stayed with me that year was our longest and hardest day. It was twelve miles to our lunch stop and eight miles to our evening shelter, which was a monastery that still offered pilgrim hospitality. It was the middle of a heat wave and hard going, and we didn’t get to our lunch stop until two PM. We lunched on the bread and cheese we’d carried, drank some water, and then hurried along. Because the rules of the monastery were strict: Supper was at seven PM. If you weren’t there by seven PM, our guidebook warned, well, there was always breakfast.
We struggled through the heat, but around six o’clock we realized that we would never make it in time. We would have no supper. And as we stumbled along, although I can’t say I felt sorry for myself, I did keep imagining a Styrofoam ice chest with cold beer that the nuns kept, perhaps, for late-arriving pilgrims. That wouldn’t be so bad, I thought. With an ice-cold beer, the bread and orange I had left would be fine. Then, click, click … my imagination would present a different scenario—a sink of lukewarm water, a dormitory with rows of iron cots. I would be hungry. There would be no privacy. It would be a tough night.
Those eight miles took a long time. It was way past seven PM when we arrived. As we walked through the monastery’s gates, flushed and thirsty, out of the main door came a tiny, very old nun in a dark blue habit and white wimple. She, too, was flushed and sweating. But she was smiling. Her eyes behind her glasses twinkled. She said in French, “You made it! We were so worried! Come in.”
We followed her inside. With its stone floor, stone walls, and stone ceiling, the monastery was cool.
“Put your things here,” she said, showing us the stone washroom. “Wash up … and hurry. We’ve delayed dinner for you.”
We washed up while Sister Monique waited, and then she led us to the dining room. There were other pilgrims seated at a long table, which was set with carafes of red wine and cold water. We sat down, and then we were served one of our best meals ever. Soup, potato-and-caper salad, French lentils, cheese, and for dessert, fresh-cooked plums from the nuns’ own trees. It turned into a party, and the pilgrims we met that night interwove themselves with us for the rest of the walk to Compostela.
After dinner Sister Monique showed us to our rooms. There was no dormitory. I had my own room, whitewashed and plastered, with a sleigh bed of walnut and a rope mattress. In the night, there was a thunderstorm; in the morning, there were the monastery bells; and out of my window I could see the nuns’ medicinal herb garden down below. The longest and hardest day turned out to be the opposite of what I’d expected. And over and over again, for the rest of that second section, that’s how things would turn out. That was the main lesson I took from the pilgrimage that year.
During that second section of walking I began to see that a pilgrimage had a rhythm, a dailiness, just like at home. Every day I awoke, ate breakfast, started walking, and things happened. People showed up; I had adventures. Some I liked, some I didn’t. Some I expected to like and did not like; others I expected not to like and did like. I began to see that the unexpected—the inattendu, the unwaited-for, as the French have it—was the only thing I could expect. One was presented with an experience, a person, whose value one did not know in advance. What seemed to be good might be bad; what seemed to be bad, good. One didn’t know; one had to wait.
That waiting to see how it would turn out was what made pilgriming different from ordinary life, I began to see. And that year I learned I didn’t have to leave it with my last footstep. If I wanted, I could take that kind of waiting home and have my daily life become a kind of pilgrimage.
With that open expecting, I discovered that a day at the hospital was even more interesting. One never knew. All one knew was that there would be a beginning and a middle and an end to the day, just like on a pilgrimage. And just like on a pilgrimage, characters would appear—patients, nurses, deliverymen, doctors—with spiritual and moral messages, if I chose to decipher them. Sometimes in words, sometimes in actions, sometimes in silence.
That year there was Paul, especially.
After Christmas, Paul reached a kind of equilibrium. His wounds had healed; his social worker was looking for a place; he was selling DVDs, smoking and reading outside, and making friends with many people.
Then he fell.
Now, to be independent there are surprisingly few things you need to be able to do, but transferring yourself from bed to chair and back again is one of them. It doesn’t seem like much. It’s not reading or thinking or fixing computers, but if you can’t transfer, discharge is almost impossible. With his strong arms and the trapeze bar set over his bed, Paul could transfer himself: he would hoist his half body above the bed and swing himself into his chair. But it wasn’t easy, because all he had to land on was the stub of his left thigh. And that day he missed the chair, and he fell.
He didn’t hurt himself. He kept his wits, cushioned his fall and slid to the floor, but once on the floor, he couldn’t get back into his bed or chair. He had to call the nurses. They got him up and put him in his chair, but they asked me to tell him not to transfer himself anymore without asking for help.
I didn’t tell him. He was an independent man; he would figure something out for himself. And he did.
What he did was avoid going on any of the interviews that the social worker arranged for him at the skid-row hotels. After he fell, there was always something that prevented him. He was sick; he was busy; he was late and missed his ride. He never admitted that he couldn’t manage outside anymore, and the social worker kept setting up interviews, and he kept missing them. She asked me to remind Paul to go, but I didn’
t do that either. Because I began to see what Paul saw, that he couldn’t make it on the outside anymore, in those skid-row hotels, with only half a body. He’d lived in them, and they were tough, especially the first of the month, when the vulnerable and disabled got their cash. He would be an easy mark.
Still he and Donald continued to plan their DVD store: where it would be, what they would stock. He didn’t tell the social worker to stop looking for places, and he continued to read, smoke, work on his computer, and transfer himself from bed to chair and chair to bed.
Then he got a cough. I ordered a chest X-ray and went upstairs to look at it. I didn’t expect to see anything. But when I put that X-ray up, there was something. In his upper right lung, a crab-shaped spot, with legs spiraling out of a central body. It was, perhaps, an infection. But I didn’t think so. Most likely it was cancer, and, given his smoking, it was probably lung cancer, one of the worst.
I looked at that X-ray for a long while.
I thought about telling Paul. I thought about all the procedures he would have and I would go through with him: the surgeries, radiation, chemotherapy, and the 3 percent survival rate of lung cancer.
I just didn’t want to do it.
And this being Laguna Honda, I didn’t have to.
Because on my way down from X-ray, I met Dr. Benicia, the doctor in charge of our schedules. She was looking for me. She wanted to ask me: Would I consider returning to the admitting ward? As I knew, Dr. Dan had already left it for greener or maybe just more peaceful pastures, and Dr. Romero had been making do, somehow, more or less alone. But now she was tired, exhausted from fighting about admissions with Dr. Stein, and she wanted to leave.
I raised my eyebrows. Dr. Stein, did he have anything to do with this?
Dr. Benicia shrugged. Maybe. It was better for him if Dr. Romero wasn’t in the way of admissions, and he knew how much she liked the admitting ward. Anyway, she, Dr. Benicia, was hiring two fresh new young doctors from the university for it, but she also wanted to have a senior physician there who knew what the place was like. Would I come back?
I would.
So Dr. Romero and I exchanged places. I returned to the admitting ward, and she took over E6 and E4 and Paul, whom she knew well.
Ten days later Paul died.
It was a Paul kind of death.
Quiet, efficient, and when you come to think of it, very intelligent. He didn’t get sick, cry out, or cause any problems at all. It was an ordinary day, and he did his usual things: ate lunch; went out for a smoke; fell asleep in his wheelchair, head back, dozing. When the nurse tried to wake him for his afternoon medications, he was dead.
I heard the Code Blue to E4, and as I ran over, I went down my list of patients, wondering who it was. The last patient I expected to see, surrounded by anxious staff, was the legless mound of Paul, straddled by one doctor pushing on his chest, and surrounded by nurses trying to find a vein. They couldn’t find a vein, but it didn’t matter. He was dead, and we stopped the Code Blue very soon. Everyone else left, and I picked up his chart. Had there been mistakes? Had I missed something? No, there was nothing. Paul had simply died, probably from a heart attack due to his untreatable clotting disorder.
A week later Christina called to tell me that Paul’s memorial service would be that morning in the chapel. It was just for E4, because his family was making its own funeral arrangements. I kept track of the time, and at eleven o’clock I walked over to the chapel, sat down in a pew, and watched as the patients, staff, and nurses of E4 arrived. The patients rolled in and sat next to the pews in their wheelchairs. Christina, Allen, Lacy, and the other nurses and therapists from E4 hurried in and stood. No one said anything while we waited for the minister to appear. He didn’t appear, though, and after a while Christina looked at me. Would I say something?
I did say something, but I don’t remember what it was. It was short, and it was not eloquent.
After I finished, the minister was still not there, and we all looked at one another—patients, nurses, therapists, and I.
Then Lacy broke the silence. “Mr. Zed wrote a poem for Paul, didn’t you, David? Why don’t you read it to us?”
“Okay,” David said, fumbling a bit and unfolding a crumpled piece of paper.
Remember how I told you that Laguna Honda had one of just about every kind of patient? Well, Mr. Zed was our manic Jewish New York intellectual. I should really title him Dr. Zed, because before his mania got the best of him, he’d completed a PhD in linguistics.
David was a big man, tall and wide, with the thick, weepy legs that had been his ticket to the hospital. He had a square face, brown curly hair turning gray, and narrow brown eyes. His voice was husky, with a light Brooklyn accent. He cleared his throat and read his poem:
Farewell, Captain Bennett, now Paul, Human Star-Man.
The stars are yours; you may enter any Stargate.
You shall explore 7,000 galaxies, which is only your beginning.
All the magic of Jupiter, Andromeda, and the Clingon Empire are yours to explore.
And, Captain Paul, you shall return happily as both a Monolith and a Child-of-the-Stars!
After he finished, it was still. No one stirred. His vision of Captain Paul—Human Star-Man, with legs back and even with wings, exploring galaxies and planets and the Klingon Empire—was irresistible.
The minister never did show up, and after a while, we all left the chapel—patients, nurses, doctors—on our crutches, in our wheelchairs, or, if we were lucky, on both our sound, strong legs.
A few days later Christina found me in my office. With tears in her eyes, she handed me a color-Xeroxed piece of paper folded in two. It was Paul’s funeral notice.
A photo of Paul was on the front, with the dates of his birth and death underneath. He must have been very young when it was taken; baby-faced and handsome, he stared out of it with clear brown eyes and long black lashes. What I didn’t expect was that he was dressed in full-dress Marine uniform—white cap with black brim set on his forehead, dark blue jacket with red piping and gold buttons. He’d never told me or anyone that he’d been a Marine, and how Mr. Zed had pictured him as Captain Paul was a manic mystery.
As I looked into his eyes, so clear, so unwavering under the white cap, I understood finally what I’d felt from him. He’d always approached me with that same clear gaze. At first, irritably and angrily; later, openly and expectantly; toward the end, quietly. I can’t say I knew what made him tick, who he was or what he thought about; and yet I knew that clear Self behind his eyes, that proud, uncompromising Paul Self, different from all others. Even as a young man it was there. In the eyes of that proud Marine, I could see my Paul.
What he’d taught me, I understood at that moment, was integrity—from integer, wholeness—from integro—untouched, unhurt. It wasn’t that I’d lacked integrity before I knew him, but I’d accepted the teaching that a good doctor does not get too close to his patient. He or she does not jump into the mix, but keeps some distance, watches for the “countertransference,” does not get drawn in.
There is much truth in that wisdom passed down by generations of doctors. The Hippocratic physician does not fall in love with his patients, or in hate either. He keeps their secrets no matter how heinous; he does not have dinner with his patients or buy them presents. He remains “other” to their lives, their families, their neuroses.
It is a good ground rule. For a patient to be able to turn to someone kind but distant, caring but calm, wise but not attached, is important, is necessary. But it requires that the doctor maintain a certain distance, and this means not quite being yourself.
Paul didn’t operate that way, and with him, after a while, I didn’t either. His integrity evoked mine, and it was not something I wanted to give up any longer. I didn’t want to reestablish distance; I didn’t want to be a Hippocratic physician; with my patients, I wanted to be myself.
Whether that was possible for a doctor, I didn’t yet know.
I would soon find out.
Ten
IT’S A WONDERFUL COUNTRY
IT WAS A THRILL to walk through the doors of the admitting ward once again. I hadn’t been inside it for years. After Dr. Romero went back to it from her medical directorship, she shut its doors, and what had once been a place everyone went to for a second opinion, or maybe just for a late-afternoon chat, became off-limits.
Dr. Romero herself became kind of off-limits. She had closed the doors, and no one knew what was up with her. All we did know was that no one worked as hard as she did; no one gave of herself as much. I fixed glasses and bought Cokes for patients; Dr. Curtis bought shoes; all of us brought in food from home. But Dr. Romero did more. When necessary, she became medical director and dealt with the seamy side of the hospital, which was not its patients but its politics. When a doctor was needed to spend the night, she volunteered. She fought against the changes she thought were bad for the hospital, and mostly she was right. She was relentless in her ideals.
After she became a devotee of Dr. Kay’s project of Edenizing the hospital—of making it more like the garden of Eden, with plants, animals, nature, and quiet—she did as much as she could to Edenize the admitting ward. She obtained headphones for the televisions of the patients so that the ward would be quiet; she lined the corridor with green plants; and she put caged birds in the television room and the doctors’ office. But until I was walking down the corridor once again and got to our office, that was all I knew.
The door of the doctors’ office was locked. I didn’t even know it had a lock. But I found the key and opened it.
It hadn’t changed much. The yellowed shade, half drawn over the window, was still there; so was the computer and the counter desk. Mrs. McCoy’s plant was still there, grown all across the wall, and was now over by the bookcase, which appeared to be a still life of Dr. Romero’s years there. The bookcase was filled to overflowing with books, conference folders, patient charts, expired medications, suture removal kits, and boxes of gloves. The only thing that had changed in the office was a huge old oak desk that had replaced our rickety ones, and the oak cabinet next to it, which was covered with bird droppings.
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 26