Thursday, January 26, 2012

Necessary evils

I was recently asked to assemble a program for a small hospital in a rural Western town, much to my delight. I like talking to the users (the people that actually work in and use a space/department/building) and then putting together a list of needed spaces and how big the spaces should be. (That list is called a program.) It's a funny thing to break down something as complex as a hospital into a simple list of rooms and sizes--these spaces all work together in different ways, depending on the size and type of facility. One hospital needs the surgery pick-up near the inpatient nurse station so that post-surgery patients can be watched by the after-hours staff, while another hospital needs a completely separate surgery pick-up from the inpatient functions because they have the after-hours staff to monitor it and don't want to creep out the visitors coming to visit any inpatients.

So having met with the hospital nursing staff, I go back to the office and start assembling the program. I go through the notes I took during the staff meeting. I'm working on the program for the emergency department, which is a department in which truly life-and-death decisions are made and work is done. I look at the notes: body holding room, 80 sf. Not everybody makes it out of the ED on their feet or to a patient room. Sometimes it's too late where they get there. Sometimes they arrive at the ED only for the staff to find out that they have a DNR* order.

A holding room, also in my notes, is different from a body holding room. Not everyone comes into the ED with all their faculties and can explain where it hurts, what happened when the pain started. Sometimes the chemicals--legal or not--flowing through their veins make it impossible to calm the patient down and solve the problem. Sometimes they have to be left in a room they can't damage while the chemicals run their course. Sometimes the problem isn't chemicals but the lack thereof--someone stops taking his or her antipsychotic meds and is suddenly threatening their 75-year-old mother with a knife, accusing her of working for Al Qaida.

I notice the words social worker office in my notes. Not everybody who comes to the ED does so because they fell out of a tree or have appendicitis or a possible heart attack. Some people come in with black eyes and bruised arms, and the only explanation the staff gets is, "she fell" or "he tripped." Sometimes a random x-ray reveals that a leg has been fractured several times and set wrong, no one treated the fractures. It's a vacant look, a healing split lip, a bruise covered by a sleeve too late to be hidden from the triage nurse, a flinch when the person who brought the patient in talks loudly or gestures broadly. The staff exchanges looks and nods, like third base coaches wearing scrubs, looks that say to each other silently: not on our watch. A call goes to the social worker, and then they get the cops on the phone.

When I draw and design these spaces later, the details emerge: locate the body holding room near a back corridor to the ED, provide impact-resistant drywall in the holding room with lockable cabinets, provide one-way glass from the social worker office into the playroom/conference room. We'll talk with the staff some more in a few months and hear the details of how they deal with the worst days of someone's life, over and over: we need to make sure they can't break the light fixture and stab someone with the light lens; we need some shelves to put stuffed animals on for pediatric patients; can we get a shower in this toilet room? Sometimes women have been...assaulted, and they need to, um, take a shower after their exam. And we need a cabinet to store some clothes in, because we have to give their clothes to the police. We need a quiet room for them to wait in for someone to pick them up. We can use that same room for bereavement, when someone comes to identify a body in the holding room.

For now, these are simple room names, two or three words with a number next to them: 80sf, 100sf, 60sf. A cost estimator will think about the finishes and quality of materials in these rooms. They'll be priced and added up, and the hospital will be told what it will cost to build their new facility, and the hospital will figure out if they can afford it or not, or how much can they afford right now. They will have to remove the emotion from the program, from the project, in order to make good decisions for both the short- and long-term. They'll meet and discuss the building in abstract terms in a conference room, and then the staff will go back to the ED to stitch up a suspicious cut over an eye, back to the patient wing to change a bedpan for a helpless father of four, pack to the imaging suite to explain to a woman and her husband that there's something bad about the lump the mammogram picked up, back to the clinic to say that we need to run an HIV test on your 14-year-old child...

...back to tell the grandfather that he can still do woodworking if he takes his meds and does his physical therapy, back to see that the 17-year-old's kidneys appear to be working since the surgery, back to tell the couple with four miscarriages that this one looks like it's staying and she's made it to the second trimester...back to looking at the worst and the best of the average daily human experience.

*DNR = Do Not Resuscitate: do not give life-saving measures to a patient or try to revive them if their vital signs fail.


ms. kitty said...

Wow, Pixie, what an exciting project you're starting in on! I'm thrilled for you! I hadn't realized just how much you had to be aware of the complexity of the human condition. I'm in awe.

Small Town said...

Wow! Very moving post. You been saving up for that one?