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

by Victoria Sweet

  I wondered: Whoever had requested or assented to Mr. Tam’s DNR—what did they mean by it? Did they mean this particular case?

  Not that it mattered, because there was the DNR, neatly written in the Advance Life Directive section of Mr. Tam’s chart, and here he was, dying. He was pretty much dead, actually, which seems an odd thing to say, like saying someone is pretty much pregnant. But it turns out that someone can be pretty much pregnant at first, just as the fertilized egg starts to divide, and in the same way, Meng Tam was pretty much dead.

  Or was he?

  He had no pulse, true. His circulation had failed, and he was getting colder by the second, but he was still breathing, calmly and smoothly.

  Then Dr. Mack said, “You know, if I move his leg a little, he goes into atrial fibrillation and his pulse comes back.”

  Dr. Mack did move Meng Tam’s leg, and I felt a pulse at the wrist, irregular and weak, but still, something. He put the leg down; the pulse disappeared; and Mr. Tam recommenced dying.

  Not only that, but with that movement and pulse, Mr. Tam’s eyelids fluttered open; his eyes rolled down; and he looked right at me. I looked back at him and for a moment we looked—really looked—at each other. And it was as if I saw him, all of him, present at the back of his eyes—not just his face, but his whole person, there in the back of his eyes—and as if he saw me, in my eyes, in the same way.

  We looked at each other, and Hildegard’s lines about dying came into my mind: “It is as if the soul, the anima, stands with one foot in this world and one in the next, uncertain whether to stay or go.” That was just it. Meng Tam was undecided. He was halfway between life and death. And as I looked into his eyes, which were soft, shining, almost a greenish color, I saw them become clear and still, like a shallow mountain pool after a rain, and I knew that he had decided to stay. I can’t tell you that I nodded, but I knew, and Meng Tam knew that I knew, that he was coming back.

  But he was a DNR, and Dr. Mack’s interpretation of DNR was that, in the event of a cardiac arrest—which this was—no resuscitative measures were to be used. I had a different interpretation of DNR, but Meng Tam’s bedside was no place for a philosophical discussion of the point.

  So I took an inventory of what we had—consciousness and breath; of what we didn’t have—the warmth and animation of the body; and of what we had in part—a pulse, now and again. Then I remembered how, in the days before Code Blues, at this point—at least in those old black-and-white movies—the doctor would slap the patient’s face, call his name, and shake him, as if you could slap, call, or shake someone back to life, just like you wake someone up.

  So that was what I did.

  I called Meng Tam’s name, and I shook him, and Dr. Mack started to move his legs. I even slapped his face a few times. And sure enough, Meng Tam’s pulse returned; it became quite steady; and then his eyes opened and stayed open, staring at me.

  Next I thought about the relationship between neurologic and cardiac function—the head and the heart. The nurse had positioned Meng Tam comfortably for death with his head on several pillows. This was fine for death but not for life because, although his pulse was now steady, his blood pressure wasn’t much, not enough to push the blood up against gravity into his brain. So I cranked the head of the bed all the way down until Meng Tam was as upside down as he could be, with gravity in his favor. Blood started to flow from his legs into his dusky face, which began to lighten from gray to almost pink, and his pulse became quite strong.

  Dr. Mack and I looked at each other. “Blankets,” I remembered from those same old movies and, what else? Ah, yes—hot water bottles; and so the nurse, who had been watching our nonresuscitation efforts, hurried to get warmed blankets and fresh sheets, and an IV pole and fluids. Now that Meng Tam was alive and not dead, we could use IVs.

  The nurse tucked the warm blankets around him and started an IV, while Dr. Mack and I jiggled him whenever his pulse faltered or his attention wavered. Slowly he pinked up and warmed up, and then, all of a sudden, he opened his eyes completely, looked at me, and smiled.

  The nurse shook his head and muttered, half to himself and half to me, “I’ve never seen anything like this.”

  Neither had I.

  I’d been at many resuscitations, some of them successful, but never in the quiet and stillness of Meng Tam’s; never with the time and space to watch the soul, the anima, stop in that dark tunnel with the light at its end and waver. Being with Meng Tam when he heard my voice, watching as he weighed forward or backward, Death or Life, and seeing the flicker of decision in the back of his eyes. Feeling that moment of turning and then observing him revivify—pulse, blood pressure, color, consciousness, smile.

  It was more than catching life as a force or substance; it was catching life as a particular energy, as Meng Tam’s energy. About to disappear, implode, pass through an impenetrable door; see its hand on the door knob and, half out the door, stop, turn back to say one last thing, and then watch it all in reverse. The pulse pick up, the blood pressure elevate, the color go from dusky to pink, the brightness come back into the eyes. It was an experience of pure life, as distinct from anything life does—move or talk or be—except, of course, for breathe, which was the one thing that Meng Tam did very well.

  In my first autopsy I’d been surprised by the difference between the dead body and the live Mr. Baker I’d known. There was something missing—that I missed, and that I’d missed. And now with Mr. Tam I’d caught it; seen it go toward death, stop, change its mind, and come back. I’d seen the anima—that which animates the body and the mind.

  Hildegard has an illumination that shows the anima as a ghostly blur leaving the mouth in that last breath of death; and she has another illumination of that same ghostly anima flowing into the fetus in the womb. What she meant was that when the anima leaves the body is the moment of death and when it enters the body is the moment of birth. Which, according to medieval medicine, was the moment that the heart starts to beat; the moment, from our point of view, when those few hundred cells leak calcium and sodium for the first time, twitch, and send that electric current around the heart, and the heart makes the first of its two billion usually perfect beats.

  Meng Tam survived and even flourished.

  Dr. Mack kept me informed of his slow but steady progress. He began to talk a bit and walk a bit, and Dr. Mack had extravagant hopes that one day Meng Tam would talk enough to tell us about his life and walk enough to walk out of the hospital. On the anniversary of his nondeath, I went around to see him. He looked well. He was calm, alert, and attentive, and when I greeted him, he looked at me and smiled.

  Not too long after Meng’s resuscitation, workmen began taking apart Clarendon Hall. Mr. Conley announced that they would start on the inside, removing any reusable, transplantable items—pipes, sinks, stoves, lights. Once that was completed, they would disconnect the utilities: water, gas, and, last, electricity. Then they would begin on the outside, taking away windows and window frames, doors, brass fixtures, copper—anything useful or salable. When they had finished, the building would be demolished, and we were all invited.

  Twelve

  THE SPIRIT OF GOD’S HOTEL

  THE MONTHS PASSED.

  Dr. Dan, now freed from admitting patients, grappled with the surrounding chaos like the flawed knight he was. He arrived at the hospital even earlier and left even later. After he laid off the nighttime doctors and assigned the daytime doctors to their shifts, he himself took the most shifts and the worst. On Christmas Day he came in to the hospital to hand out the presents, one by one.

  The daytime doctors did start coming in at night, with covering doctors taking care of our patients on the days we were on nighttime duty, and the clear lines of command about whose decision should prevail began to blur. Some days patients had one doctor, and other days another. Medications were changed frequently; important details—laboratory reports, clinical changes in patients—began to be missed. The nurses were confused abo
ut whom to call when a patient got sick; the families were confused; we were confused. Pretty soon, Dr. Dan started rehiring the night and weekend doctors he’d laid off. Fortunately, this being the city, he was able to use a different part of his budget to rehire them, so on paper it still looked like the medical department had been cut by one-third.

  The city accepted the Department of Justice settlement, and the ten-year investigation was closed. The new marketing department began formulating our first branding campaign, and the destruction of Clarendon Hall was about to begin. Soon the old hospital I’d known would be gone. I started to ask myself: What could I take with me? How could I pass its lessons along?

  I could think of two ways. First was the ecomedicine project I’d been musing about for so long. It could test my hypothesis that Slow Medicine provides as good a medical outcome as does Modern Efficient Health Care, while being less expensive and more satisfying for patients, families, and staff. I would set it up as a separate ecomedicine unit—the ECU—and apply what I’d learned over the years to a two-year group of patients: a careful workup, minimal medications, tincture of time, and the little things. I would track the savings from correct diagnoses instead of incorrect ones, and the consequent decrease in medications—with their costly side effects and adverse reactions—against the expense of well-staffed medical and nursing care, plus excellent food and drink. It would be a proof of principle.

  I told Dr. Dan about my idea. He liked it and was delighted to anoint me “director of the ecomedicine project.” Although, he warned me, my project wouldn’t be the next thing. The move to the new facility would take up everyone’s time and energy for a few years. It might be the next next thing, though, after everyone had settled in, and the health-care pendulum reached its apogee and began to swing back.

  I could think of a second way to pass along the lessons of the old hospital. I could tell its stories and its story. So I began putting together a timeline of my years there, which soon wrapped itself around the four walls of my study.

  I was just starting to write God’s Hotel when workmen began demolishing the century-old Clarendon Hall.

  They started with its west and south wings, harvesting windows and window frames, faucets and sinks; then they moved to the East Wing. They took Clarendon Hall apart the way termites take things apart, leaving the outside intact until the end. Then they disconnected the water, gas, and electricity. It reminded me of what happens when a patient is declared brain-dead: The healthy organs are harvested, then the oxygen is disconnected, the IV taken out, and the EKG turned off. After that, the workmen began on the outside, taking away copper pipes and clay tiles, sculptural elements, landscape. Finally Clarendon Hall was ready.

  Since I’d missed the barbecue for the blowing-up of the bridge that once connected Clarendon to the main building, I made sure to be present for its demolition. When the day came, I walked over. From the outside, the building still looked as elegant as ever, an Edwardian one hundred years old.

  With a few others, I stood behind the wire fence and watched. The greenery around the building had been taken away, and in the dirt that remained was a machine that looked like a praying mantis made out of metal. It lumbered with neck jutting out and jaws open until it came to a corner of the building. It stopped, took a bite out of the tiled roof, tore a piece off with a little jerk, and threw it on the ground. Then it lumbered to its next position, took another bite, and threw the next piece on the ground. It went all round the building like this, and the insides of Clarendon were gradually exposed. It was a tough old building, though, and pieces of cement and old steel rebar stuck out of its walls for quite a while. But bit by bit it diminished. By the end of the day, Clarendon Hall was rubble; by the next week, the rubble had been cleared, the foundation filled in, and the ground made ready for whatever would come next.

  Two weeks later, Sister Miriam resigned. She did not go gentle into her good night, however. Instead, she wrote an article for the local newspaper about how it broke her heart to say good-bye to the beautiful spirit of Clarendon. It was a symbol of the unique and warm atmosphere of Laguna Honda that for so long had served the city’s most vulnerable population, she wrote. And she warned: Draconian cuts were being made to the hospital, though oh-so-quietly. The number of patients had already been cut by a third; the hospice chaplain laid off; the day program terminated—all due to the “budget crisis.” Yet there was still enough money to hire Wide Angle Communications—the mayor’s communication consultant—to support “the hospital’s journey from institution to community.” Citizens should keep a close eye on what was going on at Laguna Honda, she ended.

  In addition to her article, Sister Miriam nominated her successor, Sister Margaret. In appearance, Sister Margaret was as different from Sister Miriam as she could be. Black skin, black hair, dark eyes, lilting Jamaican accent, small blue and white veil perched modestly on her head. But in temperament, they were just alike, as administration would soon discover.

  Meanwhile, Mr. Conley was working on next year’s budget. It would be different from any other budget the hospital had ever had, he thought, because, with the next year’s move to the new facility, it would have to fund both new and old hospitals at the same time. He was wrong about the move, but right about the budget. It would be different from any other budget the hospital had ever had because, for the first time, the budget would be cut.

  Now a budget crisis came every year and had a pattern. It would begin with terrifying predictions of immense deficits, which would increase as the unions negotiated their contracts and politicians jockeyed for staff. There would be demonstrations against proposed cuts, and a deeper projected deficit would be announced, followed by pleading and compromise. Then, along about May, there would be the stunning discovery of millions of dollars of revenue that the controller had somehow overlooked, with reconciliation, smiles, and a budget bigger than the year before.

  But this year the budget crisis was different. Times were, in fact, bad. People would, in fact, be laid off, and public health services would, in fact, be cut. The only question was: Which ones?

  The medical department was in a particularly bad position. Dr. Stein did not like us and would not save us from any cuts. Dr. Dan had already laid off the night and weekend doctors, and we had no administrative staff whose positions he could merge and rename. Plus, in preparation for the move, the number of our patients was going to be decreased by 20 percent. So it was hard for Dr. Dan to get around the fact that he would have to cut his doctors by that same amount.

  Except that the doctors did generate revenue when we saw patients, and Dr. Dan reasoned that if he could show Mr. Conley that the medical department paid for itself, at least partially, it would decrease the number of doctors he would have to lay off. So Dr. Dan began collecting data on each physician’s services. Since this was not on any computer, it meant that he had to go around to every ward and look at every chart, and keep an account of what each of his doctors produced. Soon his “Productivity Reports” began to appear in our wooden mailboxes, proving how much we earned every month for the city, in theory. Although not in practice, because the billing department had no idea how much it billed for our services or any other services, nor how much it received. However, according to his accounting, the medical department earned one-half of its budget, and Dr. Dan hoped for a happy result to his efforts.

  Which made me conclude that Dr. Dan was a closet idealist. Because his figures did not matter to Mr. Conley, and Dr. Dan still had to cut five physicians from his budget.

  Whom would he cut? What criteria would he use? Dr. Dan spent a weekend reflecting. He would use seniority, he decided, but not mainly; he wanted young blood as well as old, energy as well as experience. He would look at board certification, comfort in doing procedures, willingness to work full-time, and other unspecified characteristics. He sketched out a form, printed it out, and called a meeting of the medical staff.

  It was a short meeting. Dr. Dan explained t
he budget problem and handed out his forms. We looked at them. Were they mandatory?

  No, they were voluntary. Although it would be easier for him to make his decision if everyone filled out a form. If someone didn’t fill out a form—well, he would just have to fill it out himself.

  After the meeting, a big sign appeared in Jerrie’s office reminding us to fill in the forms, and there was a folder below the sign that stayed almost empty.

  Then Dr. Dan called another meeting.

  The budget had taken a turn for the worse, he announced, and Dr. Stein was demanding that in addition to the five doctors to be laid off in the next budget, four additional doctors had to be laid off this year. He would let us know who they would be the next week. And now Mr. Conley had a few things to tell us.

  Then Mr. Conley came into the room. He looked tired. His red hair was thinner and grayer and so was his beard; his eyes were weary, and his voice was hoarse. He wanted to let us know that marketing had presented its branding campaign, and we now had a tagline and a value statement. Our new tagline was: “Laguna Honda—A Community of Care,” which, he was sure we would agree, was a good description of the place. Our new value statement was: “Our Residents Come First.” Marketing was still working on our new logo, our new mission, and our new name.

  At this, the medical staff came to life. Heads came up from charts, journals, and tabletops. Mr. Conley was taken aback by the sudden attention.

  Yes, a new name. Laguna Honda had to be repositioned and rebranded; it would not do for the new facility to be seen as an old-fashioned almshouse for the poor. The new Laguna Honda was going to be a Center of Excellence, focusing on health, wellness, and rehabilitation; and marketing had decided, therefore, that “Hospital” should be taken out of our name.