Marveling at my Greeters

For the last month, my morning has always started the same. I turn my key clockwise until the light turns green and the door unlocks. Before opening the door, I carefully make sure no patient has crossed the yellow line and will AWOL the moment the pink door opens. I quickly slip in and close the door, letting myself into the unit, while gripping my coffee in my hand. And my day begins.

In may ways, it's like Groundhog Day, it is the same routine over and over again.

***

And it always starts with my greeters, who have become a part of my routine. *Lena and Joe, without fail, have been there to draw me into their world, daily reminders of this new habitat I visit.

From the common room, Lena stares at me. She is a forty-something year old woman, with the mental capacity of a child. She intermittently laughs, claps, or throws tantrums. Her frizzy black and gray hair is pulled back in a pony tail and she wears a stained white t-shirt that tightens around her mid section. Today she wears blue hospital pants instead of her usual patterned dress. The daily antipsychotic medications have calmed her down, but caused her to gain weight and retain water; her face is swollen and she looks sedated as she pouts with her arms crossed across her chest. This morning, she ran up to me to give me a hug. Later on, she finds me while I interview a patient to give me some of her half-eaten animal crackers. I politely decline and she moves on to offer the food to one of her peers.

In many ways, she appears blissfully unaware of her mental illness and the discussions that happen each morning during acuity rounds that focus on transferring her to another facility. "She was evaluated, but they don't think she is eligible for placement," her providers say. So, she has taken residence in the unit. As far as she knows, the unit is her world; her major concerns are when she gets to eat and if she can get an extra soda.

There there is Joe. An older gentleman in his seventies, whose face has been thinned down to the bones. With his dark eyes and bony face, he reminds me of my childhood image of a walking skeleton, who lurks in the shadows. He speaks no English and when he talks, you can barely understand what he says; he has barely any teeth. He likes to opens his mouth, which reveals the darkness of his oral cavity. His yellow skin is accentuated by his silver hair. You intermittently hear the gurgles from his throat when he sits quietly to watch the afternoon Court TV.

He is infamous for his pranks, which have included clogging sinks, jamming locks, and hiding things. He always wears the same dark blue jacket with red stripes over blue pants. He shuffles around the unit with small steps, shifting from one chair to another. Each morning, he utters something incomprehensible to call my attention. Each day, his goal has been the same- "get out of the hospital."

But for some reason, he has remained in the hospital, becoming a resident of the unit.

Similar to how the greeters have become a part of the unit, they have become a part of my world.

***
At 9:30 AM every day, the chairs and sofas are arranged in a circle. Patients emerge from their rooms to congregate for the community meeting. Some patients stroll in after being prompted, some wander after being waken up, while other patients are already seated from the previous stretch session. The providers join the meeting later.

It's the same process every morning. Go around the circle, introduce yourself, tell everyone how you are doing, and state a goal for the day.

Today, many patients were feeling good. A common goal was to get out of the hospital, or go to the patio. One patient declared he wanted "to take over the world." Another patient, said, "F*%@ you all. I do not belong here."

It's also a time to bring up community issues, read the unit rules, and orient new patients to the staff and daily schedule. Today, occupational therapy had scheduled an art exercise and a movie matinee for the afternoon. Patients would be able to select the movie to be played.

You can learn from the community meeting. You get a sense of the patient's mood, their goals, and how they interact in a group setting. I could see Lena pouting at me from the corner of the room. Joe arrived late and slowly made his way to his usual seat. Today his goal, like every other day, is the same. "I want to get out of the hospital," he said in the few English words he knows.

"If the weather holds up, we'll go out to the patio. You need a patio pass to go. To get a pass, participate in your care and go to groups," said the occupational therapist.

To conclude the community meeting, one of the patients picked an affirmation from the "I Can Can." Today, the laminated card echoed Aristotle's words. "In all things of nature there is something of the marvelous."

"You can marvel at your recovery. That concludes community meeting. Now, go have a good day." the group leader said.

***
The patio is in the center of the seventh floor surrounded by the units. You have to use your key to enter and leave the patio. The square area has a basketball hoop and a seating area made of metallic-shaped blue sofas. There is a painting on concrete the wall of a nature scene. The patio can be viewed through the windows from inside the unit.

Lena and Joe had both earned patio passes and were outside in the patio. Everyone was standing in a circle completing a series of stretches. I joined the circle, feeling weird standing still. I was reminded of the childhood game, Simon Says, where you imitate the action that someone tells you to do. During the exercise, we each went around the circle and choose a stretch and we all followed. I was amused, when the taller more fit patient, had the patients run in place; many of the patients could not keep his pace. The more unsteady patient had us roll our heads. I choose the calf stretch, since my legs were tight from my morning run. Lena had us put our arms in the air and move side to side. She was uncoordinated and clapped afterwards.

She always know how to put a smile on my face.

It's an odd scene. A bunch of grown adults locked out, standing in a circle and performing stretching exercises. I could see the staff watching us from inside.
It's a strange feeling to be watched.

***
Although I did not directly take care of Lena and Joe, I feel as though I have come to know them vicariously through our daily interactions. They have been the constant during my time in the unit. My other patients have come and gone. But Lena and Joe have been in the unit on conservatorships, completely distanced from the outside world. The unit has transformed into their homes; they have outlived many previous residents and medical students.

They will repeat this same cycle when they are transferred to another facility during the remainder of their lives. I wonder what their lives were like before they were admitted to the unit.

Lena and Joe remind me about some of the greatest responsibilities we possess as physicians. We are charged with making decisions for our patients, who are gravely disabled, either because of medical or mental illness. Joe and Lena can not function in the world we live in; they would be unable to feed themselves, take their medications, communicate with others appropriately, pay their bills, ride the bus, and find their way around the city. They are severely impaired and vulnerable. We become their conservators, taking on a parental role in these patient's lives, figuring out what we view as being in the patient's best interests. And it comes down to one thing--institutionalization.

For these patients, I feel we are placed in a precarious position. We are limited by our lack of understanding of our patient's true wishes. They have no family and our patient's can not clearly communicate with us and they lack insight into their illness. We resort to using the medications in our tool box. And when the medicine fails, we have to move to the next step, placing our patients in a facility. It's a bitter bill we swallow when we have exhausted all of our placement options, even when our patients do not want to go. What other options do we have?

It's a daily reality we confront on the unit. Today it's Lena and Joe. Tomorrow a new patient will arrive in the unit with a similar story (and probably the same outcome). And the cycle continues.
***

On my last day, Joe and Lena were in the community room watching Court TV. They were there greeting me, reminders of the world I was about to leave and the reality of the inpatient unit. As I walked out of the unit for the last time, I marveled at the lives of my greeters.

*Names have been changed to protect patient identities*