God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine

by Victoria Sweet

  The nurses had moved Ms. Gilroy from the open ward into one of the private rooms, I learned, which meant she must have been very agitated. When I came into her room I saw that they had also turned off the lights, pulled down the shades, and set up a large fan, blowing full blast. Although it was quiet, dark, and cool in the room, Ms. Gilroy, nevertheless, was lying on top of the sheets, stark naked. She was restless, tossing and turning and picking at the sheets, and sweat was beading off her body. When I tried to talk to her, she kept her eyes tightly shut and didn’t answer my questions, and when I tried to examine her, she screamed. I couldn’t examine her, not with my usual questions and answers, stethoscope and reflex hammer. It made me wonder how the nurses could have been getting her blood pressure, pulse, and temperature.

  After Mrs. Han, Mr. Conley was a little looser about sitters, and Ms. Gilroy did have a sitter, who was reading a magazine in a chair at the foot of the bed. But I wanted to sit myself. So I asked her to go out on break, and after she left, I pulled the chair right next to Ms. Gilroy and sat down.

  I sat for quite a while.

  The hospital was often hot but with the shades down, the lights off, and a fan on, it was cool in the room. At first. Yet as I sat there and the minutes passed, and I watched Ms. Gilroy toss and turn, shake her head from side to side, and throw off anything that touched her naked body, I, too, began to feel hot and restless. I began to feel as if I wanted to crawl out of my skin; as if there were something in my body—some toxin, some poison—that just had to get out. And at that moment, I realized that Ms. Gilroy was acting as if she’d been poisoned, as if there were a toxin in her body that had to get out.

  I wondered. Could she have been poisoned?

  An actual poisoning didn’t seem likely. Despite its checkered history, Laguna Honda had never yet had a poisoner. If Ms. Gilroy was being poisoned, it was by something internal: an obscure infection, a hallucinogen she’d gotten hold of, or, most likely, by some medication she was taking.

  So I left the room to get her chart; it was time to take a look. I brought it back, sat down again, and began to review what she’d been prescribed.

  Dr. Dan had not added any new medications to her regime; all he’d done was increase the ones she’d already been getting—the pain medications, sedatives, antipsychotics, and antidepressants. Nevertheless, Ms. Gilroy was being poisoned, I was more and more certain, and by something that made her hot, restless, agitated, and confused.

  Suddenly it occurred to me.

  Serotonin syndrome.

  I’d never seen it, but I’d read about it. Serotonin is a natural chemical made by the brain, and each one of Ms. Gilroy’s medications increased it. Taken all together and in escalating doses, they could have raised her brain serotonin to a toxic level, which would provoke the symptoms she had—agitation, confusion, hyperthermia. I sat and thought about it, while Ms. Gilroy moaned and picked at nonexistent bedclothes.

  My problem was that there was no test for serotonin syndrome—no blood test or X-ray. The only way I could diagnose it would be to take her off her medications, and this could be dangerous, because if she did have something else instead of serotonin syndrome—an unusual kind of stroke, for instance, or an infection, or something I hadn’t thought of—taking her off her medications would make her more, not less, agitated, and make her worse. But if she did have serotonin syndrome, then I had to stop her medications immediately because serotonin syndrome is fatal.

  I was sure enough, and after I explained my thinking to Dr. Dan, he agreed. I decreased Ms. Gilroy’s sedatives, antipsychotics, antidepressants, and pain medications just a little; within a few hours, she’d improved. I took her off all of them, and she calmed and cleared. Eventually she even went home again to her daughter, for a while.

  Like so many of my experiences at Laguna Honda, that sitting with Ms. Gilroy in her dark and cool room as she tossed and turned changed me and stayed with me. I thought about it a lot. I’d done so little for her, even less than I’d done for Steve. I hadn’t looked into her eyes, held her hand, or reviewed all her records. I’d done nothing at all. Except sit. But how effective that had been! The diagnosis had appeared without me sending her to the emergency room, without additional tests, scans, or biopsies. Somehow, just by sitting with her, I’d understood what was wrong.

  I began to try it with my other patients. Just sitting.

  Just sitting was not the same thing as sitting, however. It’s a little hard to explain. It was sitting, but it was not sitting and doing something—reading or talking—and it wasn’t the “just sitting” of Zen either, which is a strenuous, focused vacancy. It was, I decided, like the mental state of knitting, but it was most like waiting for a train in Switzerland. I remembered that well. Sitting on a bench, with ticket purchased and in your pocket, knowing that the train will arrive on time; there is nothing more to worry about and nothing more to do. The activity of the train station flows around you, and you observe, but not intently; you are aware, but not focused. People come and go; there is a hustle and bustle; but it is not your hustle and bustle.

  That was “just sitting,” and after Ms. Gilroy, I took the time to “just sit” in this way with all my patients. Especially if they took a turn for the worse, or if a nurse or a family member was worried that something wasn’t quite right. I would leave my cell phone in the nursing station, turn off my beeper, move a chair next to the patient, and sit down. Not for long—five or ten minutes. Sometimes the patient would want to chat, and we would chat, and sometimes I would study the patient’s face, bedclothes, and bureau. But mostly I would just sit. And something, somehow, would happen. It would become clear what, if anything, was wrong with the patient and what, if anything, I could do about it.

  I can’t say for sure that Dr. Dan was impressed after Ms. Gilroy, but he did look at me differently. He never again presented one of my patients when he knew I was in the hospital, and during the many hours of meetings he sat through every day, he had me take care of his patients.

  It didn’t take Dr. Dan long to catch up with the politics at the hospital.

  He met with Mr. Conley; he went over the last year’s budget and the dicey budget for the next year. He studied the Chambers settlement, the latest state survey, and the investigations of the Department of Justice. He met with the new marketing department and began going to the Health Commission meetings, the administrators’ meetings, and the builder’s meetings.

  There were many decisions to be made, Dr. Dan decided, and one that had to be unmade. Because of Chambers, the hospital had to downsize from 1,030 patients to 780, and Mr. Conley’s idea of doing that over several years did not make sense. The downsizing had to happen before the new buildings were completed, and the only way to do that was to stop admitting patients. It took him a while, but finally he convinced Mr. Conley that at the beginning of the next year, admissions to Laguna Honda would cease. The only new patients would be to rehabilitation, hospice, or the AIDS wards.

  Next he turned his attention to planning. Every patient should know in advance where he or she was going to go, he decided, and so the organization of the new hospital had to be thought out in advance. Which floors would house men, which women, which the hospice patients, the AIDS patients, the demented patients? To do that, however, he had to know every patient’s disabilities and medical conditions, age, gender, and sex preference (it was San Francisco, after all). Dr. Dan did not organize a subcommittee to do all this; he did not consult with administration or nursing. Instead, he put together a form, typed it up, printed out 1,030 copies, and went to every ward himself and filled out a form on every patient.

  I was amazed when he told me this, one slow afternoon in our office. He went and examined every patient in the hospital?

  No, of course not. He couldn’t do that. He got the information he needed from the charts.

  In only a few weeks he’d sketched out each floor of the new facility and assigned every patient to his or her future bed there.r />
  Then he took on the problem of Clarendon Hall, which was to be demolished the next year to make way for the new buildings. Its 180 patients had to be moved to the old hospital as soon as possible. Had Dr. Dan tried to maintain the nursing model of clustering patients together by diagnosis, this would have been impossible, but he did not. Instead, whenever a bed opened up, he filled it with some patient from Clarendon, regardless of diagnosis, disability, or gender. Soon, men and women, the ambulatory elderly and the demented, the drug-abusing psychotics, and the developmentally disabled were right next to one another on the same ward. It wasn’t optimal, or maybe it was; at any rate, it was very efficient, and Dr. Dan was able to start closing down Clarendon right away.

  His last problem was the budget.

  Of course, the budget was an issue every year. But with so many fewer patients, in the next year’s budget real cuts would be necessary—in theory, one-third fewer patients should mean that one-third of the staff would be cut. In practice, though, one-third fewer patients did not make for one-third less work for the quality assurance team, the marketing team, or administration. Given the upcoming move, the Department of Justice’s demands, and the Chambers settlement, the demands on nonclinical staff would only increase, and Dr. Stein had already given Mr. Conley an additional ten million dollars for more administrative staff. However, the clinical staff who took care of patients could be decreased, and Mr. Conley gave Dr. Dan the job of cutting the medical staff by one-third.

  Dr. Dan didn’t want to. He went over the budget many times—the medical staff’s budget of 2.5 million dollars and the hospital’s budget of 170 million dollars—looking for cuts that wouldn’t cut. He found only a few. Finally he had an idea. If the daytime doctors covered the hospital at night and on weekends, using some of their daytime hours to do so, he could lay off the night and weekend doctors and that would make his one-third. True, many of the night doctors had been at the hospital for decades, and it would be difficult for the daytime doctors to take care of the same number of patients during the day and also come in at night. But it would be better than cutting the regular staff, and he would take quite a few of the night shifts himself.

  We would manage somehow, he told us at our next medical staff meeting. Besides, our new schedules wouldn’t start until the middle of the next year, when the new budget cycle would begin.

  He did have one piece of good news. The Department of Justice had accepted the Chambers settlement and was closing its ten-year investigation. It still had two additional demands, however. First, the city would agree never to use the new Laguna Honda for its homeless, even if the homeless needed its care. Instead, the city would provide whatever it took for the homeless to stay in the community—housing, medical clinics, community centers, outreach teams, mobile behavioral teams, whatever. Second, the city would agree to implement the Health Management Associates recommendations, and that, Dr. Dan said, concerned all of us.

  Everyone at the meeting looked blank.

  Well, maybe no one but he had ever read them, Dr. Dan admitted. Health Management Associates was the group that Dr. Stein had hired years before, and their original report had had many recommendations. Although it wasn’t clear which recommendations the Department of Justice meant, Dr. Dan thought most likely the recommendation to create a “continuum of care” by merging Laguna Honda with the MHRF, and then, after the move to the new facility, merging the County Hospital with Laguna Honda.

  So?

  Well, that would mean that we would lose our independence as a separate hospital, Dr. Dan explained. After those two mergers, Dr. Stein would be in charge of Laguna Honda as well as the County Hospital, and we would have to apply to him to be on the medical staff.

  A frisson went around the room. There were quite a few doctors there whom Dr. Stein did not like, all that much.

  These were a lot of changes, both actual and potential. Fortunately, another year had passed, and it was time for Rosalind and me to pack our bags and finish our pilgrimage to Compostela.

  The last section starts with a ten-day walk across the meseta, a high plateau in northern Spain known to be physically and spiritually challenging. In the pilgrimage literature, walking the meseta was compared to those times in life when life is just a drag—tiring, dispiriting, depressing. Rosalind and I had read about it; we knew about it and were prepared for it.

  The thing was, the meseta was tedious. Dry, dusty, and hot. Long. The villages along the way were not nice; the churches were locked; and our fellow pilgrims! We were very disappointed. They were not the spiritual, solemn, and singing pilgrims of our last three years. They were partygoers, and they hurried across the meseta to the day’s stopping place to drink. Some of them even gave up on the meseta and went from place to place by taxi.

  After a few days, I began to have doubts. Why was I walking across France and Spain in this medieval way? It was not comfortable; it was not pleasant; it was not spiritual. Why not take a taxi? We’d still get to Compostela, and we’d still get our Compostelas. Rosalind felt the same way, and so we talked. We didn’t want to skip anything, we decided. You never know. Perhaps walking across the meseta was necessary. Perhaps we would miss something important by taxi.

  It turned out I did get something special from the meseta. I got more accustomed to the heat and more muscled. I also got more determined. My goal was fixed: I would walk to Compostela—no matter what. And with my goal fixed, without self-doubt and the minute-by-minute attention to frustrations and disappointments, I discovered something. Underneath the surface actions, events, and partying of the path was silence. Even when it was noisy, that silence was underneath activity. That quiet was solid and always accessible. I could depend on it; I could return to it at any time, in any emergency. It was the quiet of pilgrimage, and it was worth the meseta.

  Finally, after nine days of walking through dust, we saw the cooling mountains ahead. We attained them, walked over them, and entered a different country, a country you can only get to by walking.

  On the day we arrived at Compostela it was raining. The outskirts of the city were modern, but we crossed a bridge and then it became the Middle Ages. We passed a bearded, smiling pilgrim and his smiling dog, who’d come the whole way, too. We walked under a stone arch and began to hear the bagpipe music of Galicia. Then the path opened up into a cobblestoned square and, looming over us, was Saint James’s twelfth-century cathedral.

  We did the usual pilgrim things.

  We touched the marble foot of Saint James. Behind the altar we put our arms through two holes and hugged the thirteenth-century statue of Santiago, which was dressed in gold and jewels. We went to the Pilgrim’s Mass and saw the Botafumeiro fall. We walked over to the bishop’s office, where our Créancial was scrutinized and where we received our Compostela, the Latin scroll that forgave us our sins. And we went to the evening vigil.

  I’d read in our guidebook that on Saturday night there was a special pilgrim’s vigil at the cathedral at ten PM. That’s late for a pilgrim, and it was raining; our hotel was comfortable; still we went out. We didn’t find anyone in front of the cathedral, but when we walked around it, there was a group of pilgrims in the rain, standing in front of the south door. A few minutes later, the door opened, and a little monk appeared and beckoned us inside.

  Us?

  We all looked around.

  He nodded.

  He walked inside, and the small group followed him. Except for us, the cathedral was empty. He took us through another side door into the dark cloister. A charcoal brazier was on the stones, and he gestured for us to sit down around it. Then he handed out black cards and told us they would symbolize the sins we wanted to get rid of. He would light the brazier; we would go around the circle and, in whatever language we spoke, tell the sin we were casting into the fire.

  Is worry a sin? I asked myself. I sure would like to get rid of it. I decided that it was. Worry about the future seemed uncharitable somehow, toward God, after everything I�
�d experienced on the pilgrimage—so many days I’d worried would be bad had turned out so well! And so many days when my good anticipations had turned out so bad! I didn’t know whether worry was a sin, but I threw it in the brazier.

  Although our pilgrimage to Santiago was over, our pilgriming was not, because there was one last bit we wanted to do—to walk to Finisterre, Land’s End, the end of the medieval earth. From the medieval perspective, this was the farthest west you could go in Europe; after Finisterre, nothing got in the way until Cathay and India. I wanted to see it. So we set off.

  It was a three-day walk, and though it wasn’t lonely exactly, it was quite isolated. There were no other pilgrims on the path, no towns or villages, and the forests we walked through had been burned that summer. There were lots of patches of blackened, acrid-smelling ground and blackened tree trunks.

  We smelled the ocean before we saw it, moist and salty. Fog was rolling through, but when we climbed up a ridge, it lifted, and there it was. The ocean. Silver blue, stretched out forever, nothing modern to remind us, just a little fishing village on the edge, one fishing boat hugging the coastline. We climbed down to the beach and gathered cockleshells, and then we walked the very last bit to Finisterre. A pole marked the spot, where other pilgrims had left their walking sticks. We left ours.

  Then I went off to sit for a while at the edge.

  It was very satisfying. We had made it. To the very end of the medieval earth. There was no place else to go. The ocean stretched out as far as I could see, all the way to the shores of a continent that the medievals had no inkling of. When they’d sat where I was sitting, looking out at the ocean, they’d imagined Cathay and its silk, India and its spices. It was land’s end because for them there was only one land, with Europe at one end and Asia at the other. They knew the earth was spherical, and they knew that if any sailor had been brave enough to leave the sight of the shore, he would, eventually, have come to the other side, to Asia.