The hospital was built in the years after World War II. Its ceilings are low, corridors long and corners sharp — all possible stress triggers for those who have been in combat.
Not to mention that a hospital waiting room can make anyone edgy.
But the Veterans Affairs hospital in Fresno has found a way to make the experience easier: live music.
A musician playing amid the hustle and bustle is familiar to anyone who has ever sat at a cafe with entertainment or taken the subway. But this has proved to be more. The hospital set out to provide simple distraction, but soon doctors noticed a marked improvement in many of their patients, especially those with post-traumatic stress disorder or traumatic brain injury.
Dr. Hani Khouzam, a psychiatrist who treats both disorders, said patients have been arriving for appointments so notably calmer that it takes him longer to make a diagnosis — something he welcomes.
"You have to understand what it means for a combat veteran to be agitated in the waiting room. Their pupils are dilated. They are angry or waiting for something to happen," he said. "But when we have live music that day, they come to me far more relaxed. It's like an amazing miracle, and I don't say that lightly."
On a recent day in a busy main reception area, grandfathers waited for blood work and a young veteran was whisked through on a gurney, face-down and in restraints — possibly headed for a locked psychiatric unit. Jon Sharp, a classical guitarist, played Francisco Tarrega's "Recuerdos de la Alhambra," which begins in wistful melancholy and builds to an uplifting melody.
George Flores, head of the hospital's police force and himself an Iraq War veteran, paused to listen.
"Don't ask me how. It's doctor stuff," he said. "But I know the music makes our job easier."
Ervin G. Loman, a Korean War veteran, held a magazine to his face, but he wasn't reading it. He continuously looked slowly to the left, paused, then swiveled his head to the right. He'd driven more than an hour from Los Banos for diabetes treatment, then spent an hour looking for a parking space.
"It got me a little uptight, and that can — well, I don't want to think about it, I close it out — but I'm on alert like all those many years ago. This is mild," he said with a laugh. "The music is relaxing me. I hope it's a help to the younger ones. They've been to hell, and we all carry that demon."
There is an established health field of musical therapy that has been documented as helping patients with autism, Parkinson's or Alzheimer's disease, as well as those who have lost the ability of speech because of brain trauma. Rep. Gabrielle Giffords (D-Ariz.) relearned to talk largely through musical therapy after a gunman shot her through the head at close range last year.
But the benefits of the music at the Fresno hospital were more happenstance than intended therapy. First, hospital officials used funds donated for improving the hospital's aesthetics to bring in a harp player. When people seemed to like that, they added a classical guitar player. They were just trying to cheer the place up a bit.
The "amazing surprise," Khouzam said, has been that the random playing of live music in the waiting room — doctors and therapists have not seen the same result with recorded music — helped patients with psychological damage from war.
Daniel J. Levitin, a neuroscientist at McGill University in Montreal and author of "This is Your Brain on Music," suspects that the music not only masks triggers of trauma but also is adjusting patients' brain chemistry.
"We know that music that isn't adrenaline-pumping releases powerful hormones: dopamine and prolactin," he said. "Obviously, it isn't a controlled scientific study ... but something there is working."
Nick Carey, 28, who was in charge of convoy security in Iraq and later traveled with Marine One, the helicopter that carries the president, knows about waiting-room triggers.
"It isn't one thing. It's all of them. The hum of the air conditioner takes you back to being in a vehicle 20 hours a day never knowing when something might happen. It's all the sounds that you may recognize, but it takes you a second to identify them. They take you back to searching a house wondering what the sound is behind that wall," said Carey, a business management student who also works at the hospital through a work-study program.
He's from Coarsegold, a small Sierra foothill town where people are likely to graduate from high school with the same people with whom they started kindergarten. It's the kind of place that added to the Central Valley's large number of returning veterans. (The Fresno VA hospital has California's highest percentage of patients who are veterans of the Iraq and Afghanistan wars.)
"It doesn't sound right to say the small towns are more patriotic, but they do hold military service in honor," he said, noting that near his town there is a gas station with a wooden plaque for everyone who joined and that many of the people he knew in school went over.
Carey has not been diagnosed with post-traumatic stress, only with hyper-attentiveness, but he wonders whether that's because he doesn't talk about the times he needs to go to his car and just breathe for a while. He's worried about his younger brother, who recently returned from Iraq and listens to loud music with a driving fast beat all the time, much as he first did upon his return.
That's the reason he too thinks the music in the hospital waiting room may be about more than drowning out sounds that can be triggers.
"When you come back, everything around you seems slow and flat. You crave adrenaline. But the kind of music they're playing at the hospital gets into you and slows your body down," Carey said.
"Everybody likes the ocean and crashing waves, but this music takes me to the lake by my house in the early morning when the water is perfectly smooth and calm. I've noticed a big difference between the days when the music is there and the days that it is not."