Five Days at Memorial by Sheri Fink. (1/2)
Title: Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital.
Author: Sheri Fink.
Genre: Non-fiction, ethics, medicine, law, journalism.
Country: U.S.
Language: English.
Publication Date: 2013.
Summary: After Katrina struck and power failed, amid rising floodwater and heat, exhausted staff at Memorial Medical Center designated certain patients last for rescue. Months later, a doctor and two nurses were criminally accused of injecting some of those patients with life-ending drugs. The book, developed out of a 2009 news article and the culmination of six years of reporting, unspools the mystery, bringing the reader inside a hospital fighting for life and into the most charged questions in health care: which patients should be prioritized, and can health professionals ever be excused for hastening death? Transforming our understanding of human nature in crisis, the book exposes the hidden dilemmas of end-of-life care and reveals how ill-prepared we are for large-scale disasters-and how we can do better. (Refer to PART 2 for rest of the quotes).
My rating: 7.5/10
My review:
♥ What did the patients' family members want Thiele to do? There was no one left to ask; they had all been made to leave, told their loved ones were on their way to rescue.
The first thing, he thought, was the Golden Rule, do unto others as you would have them to unto to you. Thiele was Catholic and had been influenced by a Jesuit priest, Father Harry Thompson, a mentor who had taught him how to live and treat people. Thiele had also adopted a motto he had learned in medical school: "Heal Frequently, Cure Sometimes, Comfort Always." It seemed obvious what he had to do, robbed of control over almost everything except the ability to offer comfort.
♥ There were syringes and morphine and nurses in this make-shift unit in the second-floor lobby. An intensive care nurse he had known for years, Cheri Landry, the "Queen of the Night Shift"-a short, broad-faced woman of Cajun extraction who had been born at the hospital-had, he believed, brought medications down from the ICU. Thiele knew why these medications were here. He agreed with what was happening. Others didn't. The young internist who had helped him euthanize the cat refused to take part. He told her not to worry. He and others would take care of it.
In the days since the storm, New Orleans had become an irrational and uncivil environment. It seemed to Thiele the laws of man and the normal standards of medicine no longer applied. He had no time to provide what he consiudreedd appropriatye en-of-life care. He accepted the premise that the patients could not be moved and the staff had to go. He could not justify hanging a morphine drip and praying it didn't run out after everyone left and before the patient died, following an interval of acute suffering. He could rationalize what he was about to do as mere abbreviating a normal process of comfort care-cutting corners-but he knew that it was technically a crime. It didn't occur to him then to stay with the patients until they died naturally. That would have meant, he later said he believed, risking his life.
He offered his assistance to Dr. Pou, but at first she refused. She tried repeatedly to convince him to leave the area. "I want to be here," he insisted, and stayed.
With some of the doctors and nurses who remained, Thiele discussed what the doses should be. To his mind, they needed to inject enough medicine to ensure the patients died before everyone else left the hospital. He would push 10 mg of morphine and 5 mg of the fast-acting sedative drug Versed and go up from there as needed. Versed carried a "black box" warning from the FDA, the most serious type, stating that the drug could cause breathing to cease and should only be given in settings where patients were monitored and their doctors were prepared to resuscitate them. That was not the case here. Most of these patients had Do Not Resuscitate orders.
It took time to mix the drugs, start IVs, and prepare the syringes. He looked at the patients. They seemed lifeless apart from their breathing-some hyperventilating, some gasping irregularly. Not one spoke. One was moaning, delirious, but when someone asked what was wrong, she did not respond.
He took charge of four patients lined up on the side of the lobby closest to the windows: three elderly white women and a heavyset black man.
It had come to this. Dr. Thiele's mind began to form a question, perhaps in the faint awareness that there might be alternatives they had not considered when they set this course. Perhaps he realized at the moment of action that what seemed right didn't feel quite right; that a gulf existed between ending a life in theory and in practice.
He turned to the person beside him, the nurse manager of the ICUs who also served as the head of the hospital's bioethics committee. Karen Wynn was versed in adjudicating the most difficult questions of treatment at the end of life. She, too, had worked at the hospitals for decades. There was no better human being than Karen. At this most desperate moment, he trusted her with his question:
"Can we do this?" he would later remember asking her. "Do we really have to do this?"
♥ For certain New Orleanians, Memorial Medical Center was the place you went to ride out each hurricane that the loop current of the Gulf of Mexico launched like a pinball at the city. But chances are you wouldn't call it Memorial Medical Center. You'd call it "Baptist," its nickname since it had existed as Southern Baptist Hospital. Working a hurricane at 317-bed Baptist meant bringing along kids, parents and grandparents, dogs, cats and rabbits, and coolers and grocery bags packed with party chips, cheese dip, and muffulettas. You'd probably show up even if you weren't on duty. If you were a doctor and had outpatients who were unwell, you might check them in too, believing Baptist a safer refuge than their homes. Then you'd settle down on a cot or an air mattress, and the hurricane, which always seemed to arrive at night, would rage against the hospital and leave. The next day, the sun would rise and you would help clean up the debris and go home.
For nearly eighty years the steel and concrete hospital, armored in reddish-brown tapestry brick blazoned with gray stone and towering over the neighborhood near Claiborne and Napoleon Avenues, had defended those inside it against every punch the Gulf's weather systems had thrown. In 1965, it "took the century's worst storm in strede," weathering Hurricane Betsy "like a sturdy ship" and protecting more than one thousand people who sheltered inside, its administrator bragged in the hospital newsletter. A year before Katrina, when "[Hurricane] Ivan knocked, Memorial stood ready." As Cathy Green, a nurse in the surgical intensive care unit, told her worried adult daughter when Katrina threatened: "If I'm in trouble at Baptist Hospital, if Baptist Hospital fails, it means the entire city would be destroyed."
♥ Baptist had its own power plant. A smokestack rose seven stories above it. Workers prepared to feed the hospital's furnaces 20,000 gallons of oil per week.
Seven years earlier, missionary Clementine Morgan Kelly had stood before congregants at a church meeting and announced the conclusion she had reached after years of "prayerful study, deep thinking, hard labor," and visits to medical charity wards. "The crying need of the hour is a Baptist hospital for New Orleans," she said. "We shall never convince New Orleans of the seriousness of our purpose to give this city Christ's pure gospel, until we do missionary work through a Baptist hospital."
The Southern Baptist press spread Kelly's idea to a receptive church already engaged in a hospital-building movement. New Orlenians of other religions supported the idea too. Almost eight hundred city dwellers donated money to purchase land for the new hospital.
♥ Around the turn of the twentieth century, $15.3 million had been spent on drains, canals, and pumps to help transform the soggy, typhoid-and malaria-ridden basin between the Mississippi River and Lake Pontchartrain into a modern city. Since then, rapid development had paved over ground that had once absorbed rainfall, but when the hospital opened, the city hadn't increased its pimping capacity in a decade.
The 11,700 densely populated acres in the uptown drainage section of the city that encircled Baptist were served by a single pumping station that lifted the water into a relief canal that channeled it to another pumping station, which raised the water high enough to flow into Lake Pontchartrain. An upgrade in the area's pumping and canaling capacity had been envisioned to go along with the development, but while buildings went up, the work below ground lay undone. With no storms of great magnitude, the improvements had not been prioritized.
♥ A storm hit on Easter weekend, days before the river's predicted rise. In less than twenty-four hours, 14.01 inches of rain fell. It was the greatest total twenty-four-hour rainfall in more than half a century of record keeping-nearly a quarter of the rainfall for a typical year. Only once in the eight decades that followed would daily rainfall surpass April 16, 1927, in New Orleans.
♥ The swell of water from the upper Mississippi reached Louisiana two weeks after the Good Friday storm. On orders from the State of Louisiana, workers dynamited a levee below New Orleans to relieve pressure on the levees protecting the city, sacrificing the Parishes of St. Bernard and Plaquemines to save New Orleans at the behest of the city's business elite, who then failed to deliver promised restitution. This launched a grudge that would persist into the next century. The Mississippi River floods of 1927 led to one of the most expensive peacetime legislative initiatives of its time, the 1928 Flood COntrol Act. It tasked the Army Corps of Engineers with improving the levee and flood-control systems of the lower Mississippi River, giving the federal government full responsibility for the river, and granting the Corps immunity from liability for damage that might result from its work. Decades later, the Corps became more involved in flood protection projects for the city of New Orleans, including the drainage canals leading to Lake Pontchartrain.
Over the years and decades following the 1927 storm, the Sewerage and Water Board obtained funds to improve the New Orleans drainage system. One of its engineers designed the world's largest pump, and fourteen of them were custom-made for the city. Drainage capacity had nearly quadrupled by the end of the twentieth century to more than 45,000 cubic feet per second.
♥ Burgess had taken up nursing to support her children after working jobs as various as taxi dispatcher and secretary to a mortician. But practicing nursing in mid-twentieth-century New Orleans had presented an unsettling paradox for a woman like Burgess with light-brown skin; she could care for patients at many of the private hospitals, but could not receive care at them. Though Jannie Burgess was born just a few months after Memorial opened in 1926 as Southern Baptist Hospital, it would be more than four decades before she could be a patient there.
♥ Over the years, Baltz continued the dialogue with colleagues. LifeCare leased the seventh floor of the main building in 1997, establishing the long-term acute care hospital within the main hospital. A Medicare payment change created incentives for these types of business arrangements, and they proliferated at hospitals around the country. Baltz engaged in spirited debates over coffee with colleagues who believed excessive resources were being poured into LifeCare's typically elderly, infirm patient population. "We spend too much on these turkeys," one of them said. "We ought to let them go."
"You have no right to decide who lives and who dies," Baltz would answer. Through these conversations, he learned that some of his fellow doctors adhered to what Baltz thought of as "Governor Lamm philosophy." In 1984, at a time of growing budget deficits and ballooning medical coasts, Colorado governor Richard Lamm criticized the use of expensive, high-tech medicine to keep some patients alive almost indefinitely, regardless of their age or prognosis. At a meeting of the Colorado Health Lawyers Association, Lamm bolstered his argument by citing a recent critique of antiaging research penned by the prominent University of Chicago bioethicist Dr. Leon R. Kass, who suggested that even healthy life extension could strain society and deprive the young of jobs. "We've got a duty to die," Lamm said, "and get out of the way with all of our machines and artificial hearts and everything else like that and let the other society, our kids, build a reasonable life."
Lamm's words were picked up by an attentive Denver Post reporter and caused a nationwide furor. With the appearance of crash carts and the expansion of intensive care medicine in the 1960s and '70s, hospitals had become adept at keeping sick people alive longer. Medicare covered the new technologies regardless of cost, and by the 1980s some policymakers worried about the projected growth in medical spending. Lamm's comments awakened the public to the problem and demonstrated the tension between the "business motive" and medicine's burgeoning end-of-life dilemmas.
Still, Lamm's rationing directive rankled for many reasons. To limit lifesaving care would be to deny the human impulse to rescue individuals in extremis. To handicap the race for new treatments that might prolong life would be to call off the eternal search for the elixir of immortality.
Plus it would be bad for capitalism. At the time, the US-Soviet war urge was sublimated into battles for technological innovation. We were going to the moon. Why not also cure cancer or raise the dead?
Also the relatively recent eugenic and Nazi subversions of science and medicine-their conceptions of "lives not worth living" and the sick logic of riddling society of certain of its members to enhance the perceived health of the larger body-had ingrained in Americans an aversion to assigning lower values to certain lives.
On the other side, with drug and device developers figuring out how each organ that threatened to quit could be repaired or replaced, the practice of life support surged ahead of the practice of relieving pain, both physical and existential. Patients weren't given much of a say in how much of this new medicine they really wanted if they became critically ill and unable to speak for themselves.
And there were deeper, more unsettling questions. How now to define death? When was it permissible, even right, to withhold or, more wrenchingly, withdraw life-sustaining care? For a few weeks after a reporter cast Lamm's remarks before them, regular Americans looked these questions in the eye.
They quickly looked away.
♥ Pou joined her at the windows overlooking Clara Street. Water was gushing out of the sewer vents. They stared in disbelief. Then they jogged up three flights of stairs to the eighth floor to get a better look at the neighborhood. Water was flowing up Claiborne Avenue, a main city artery just north of the hospital.
Faces appeared at windows all over Memorial. Some doctors would later say the sight of the water advancing toward the hospital, pushing the hurricane debris ahead of it, was like something out of a movie: a glob of murderous slime from a '60s sci-fi thriller, or the mist-cloaked Angel of Death wafting down Egyptian streets to envelop the homes of firstborn sons in Cecil B. DeMille's The Ten Commandments. To a LifeCare patient's daughter, Angela McManus, who was standing on Memorial's smoking balcony, the blackness overtaking the ground looked like the advancing shadow of a cloud.
♥ Susan Mulderick announced that up to fifteen feet was expected around the hospital. Despite Memorial's flood-prone electrical system, its voluminous set of emergency plans did not contemplate the precise scenario they were facing, almost as if it would have been too horrible to countenance. Mulderick's emergency committee had ranked hurricanes, floods, and power outages among the highest-priority emergencies, but the hospital's preparedness plan for hurricanes did not anticipate flooding. The flooding plan did not anticipate the need to evacuate. The evacuation plan did not anticipate a potential loss of power or communications. Most critically, the hurricane plan relied on the assumption that the hospital's hours, although they were never tested to run that long. The entire 273-page set of twenty separate plans offered no guidance for dealing with a complete power failure or for how to evacuate the hospital if the streets were flooded. There was no mention of using helicopters. There was no contract or arrangement for a company to supply them.
♥ In the 1990s, less than a page of JCAHO's thick book of hospital accreditation standards was devoted to emergency preparedness, which was a decidedly unsexy field. Disaster managers were thought of as earnest, basement-dwelling creatures who drew up emergency plans and imposed fire drills that interrupted other people's work. Hospital leaders kept their distance.
When JCAHO proposed new emergency standards for the new millennium, hospital executives around the country protested them, fearing a costly, unfunded mandate. "Leave us alone!" was their message to JCAHO officials. "We're prepared."
..The 9/11 attacks and the subsequent mailings of anthrax-laced letters to politicians, media organizations, and others, which sickened nearly two dozen people and killed five of them, led to a focus on particular types of hospital readiness. By 2005, more than a billion dollars had been made available to the nation's roughly five thousand hospitals to promote bioterrorism preparedness. Memorial's most detailed and by far its longest emergency planning scenario was written shortly after the 2001 attacks. This bioterrorism plan ran 101 pages, as opposed to the 11 pages devoted to hurricanes.
JCAHO had nothing to say about how realistic emergency plans had to be. Like biblical passages, the standards were written in a way that invited a generous range of interpretations. For the most part, surveyors did not check whether a hospital had the resources to do what it said it would do. Still, JCAHO's new standards far exceeded federal requirements, meaning that hospital readers looking to avoid meeting the new mandates could seek accreditation from one of JCAHO's competitors.
♥ Hospital emergency plans were supposed to be based on a yearly analysis of vulnerability to a variety of potential emergencies or "hazards." Every year since 2001, Mulderick had convened Memorial's emergency preparedness committee to go over a three-page form covering some forty-seven events, from volcanic eruptions to nonfunctioning fire alarms and an undefined "VIP situation." Unlike some other hospitals, Memorial had never hired an objective outsider for this task. Instead, Mulderick and her committee evaluated their own preparedness at a time they were under pressure from above to save money. The template the committee used could be downloaded for free from the Internet, and other New Orleans hospitals also used it. Mulderick and her committee produced a matrix of scores estimating probability, risk, and preparedness for each even. The latest rendering was rife with multiplication errors.
Mulderick's committee had rated the hospital's preparedness for power outages, generator failure, and floods as "good"-the top ranking on the scale. In designing their plans, committee members would later say they thought more about the constellation for emergencies that had happened rather than the worst things that could happen.
♥ Memorial's doctors, meeting earlier, had established an exception to the protocol of prioritizing the sickest patients and those whose lives relied on machines. They had decided that all patients with Do Not Resuscitate orders would be prioritized last for evacuation. There were four DNR patients in the ICU, including Breckenridge and Jannie Burgess, the African American nurse who had once cared for patients at hospitals where she herself could not be treated.
A DNR order was signed by a doctor, almost always with the informed consent of a patient or health-care proxy. Informed consent was a legal concept established beginning in the 1950s in the United States. It was designed to protect patient autonomy in medical decision making, in the context of historical abuses. Doctors were required to disclose the nature, risks, benefits, and alternatives of the medical interventions they proposed. A DNR order meant one thing: a patient whose heartbeat or breathing had stopped should not be revived. A DNR order was different from a living will, which under Louisiana law allowed patients with a "terminal and irreversible condition" to request in advance that "life-sustaining procedures" be withheld or withdrawn.
But the doctor who suggested at the meeting that DNR patients go last had a different understanding, he later explained. Medical chairman Richard Deichmann said that he thought the law required patients with DNR orders to have a certified terminal or irreversible condition, and at Memorial he believed they should go last because they would have had the "least to lose" compared with other patients if calamity struck-a value judgement more than a medical one.
Other doctors at the meeting had agreed with Deichmann's plan. Bill Armington, a neuroradiologist, later said he thought that patients who did not wish their lives to be prolonged by extraordinary measures wouldn't want to be saved at the expense of others-though there was nothing in the orders or in Memorial's disaster plans that stated this.
♥ The pilot announced that he had to stop for fuel. Gershanik couldn't believe it. They landed at a refueling site for petroleum-industry helicopters. A planned five-minute stop stretched into ten, then fifteen, then twenty-five minutes. Gershanik pulled out his penlight and shined it on the baby. Still alive. He swung the light to the baby's oxygen tank. Nearly empty. Two US Army helicopters had landed after them, but were getting served first. Gershanik protested to the pilot. "Sir, the babies are not going to make it." The pilot told him the Army helicopters were rescuing people from rooftops. Otherwise they'll die as well."
For a moment, Gershanik considered the larger reality, the competing priorities that had emerged as waters suffocated an entire city. He was only doing what is ingrained in a doctor-advocating for his own patients-but now he saw that the struggle to save lives extended far beyond the two critically ill neonates in the helicopter, or Memorial's entire population of sick babies, or even the whole hospital, much as it had seemed like the universe when he was back there. He used the delay to switch oxygen tanks with some difficulty. He apologized for his impatience.
♥ They expected the patients would start moving between three and eight a.m.
Nobody wrote it directly in a message, but some employees began to worry that the choice of which patients went out first could affect their medical outcomes. AS realization dawned on Memorial's incident commander, Susan Mulderick, that day. The variability in the sizes of helicopters that were landing and the length of time it was taking to move patients to the helipad left her with one conclusion: not all of the patients would be getting out alive.
♥ A reporter described people jumping barricades into the floodwaters trying to flee.
They said the conditions in the Superdome are breaking down, and it is a madhouse. Now, again, this is all hearsay from the folks who are leaving the 'dome, that there have been a couple of murders, people committing suicide jumping from the balconies, rapes, everything.
The New Orleans police captain called in on the radio to say those reports were false. Still, Gov. Kathleen Blanco announced at a nighttime news conference that roughly 20,000 people were stranded in the Superdome with no power and deteriorating sanitary conditions, and the building needed to be evacuated, particularly people with medical conditions who had been told to take shelter there. "The 'dome is degenerating, the conditions are degenerating rapidly, and there are too many people in there," she said.
♥ The night was wasted. Now even the most exhausted found it impossible to sleep. After the futile jaunt downstairs, Ewing Cook felt a new level of anxiety, not good for his damaged heart. He lay awake in his office near the hospital's engineering plant and listened to the roar of its diesel generators, the ticking of Memorial's own weakening heart.
♥ The Coast Guard auxiliary volunteer working beside her, Michael Richard, had an even harder time accepting the decision. As Memorial's generators failed one by one, he had spent hours finding hospitals to take the patients and laboring to convince hospital leaders to allow the rescues to proceed. It had shocked him when one told him that the hospital's priority was to evacuate first its own patients-her responsibility was to them, not to these sickest patients belonging to another company who were going to die anyway. Holy crap, he thought. She wants to walk away and let them die. Was it all a question of money? "Hold on," he'd told her. He put the phone down and pretended to consult a superior about this decision. He didn't feel he had to speak with anyone. He knew exactly what was right. He picked the phone up again. "Absolutely not," he said. "You're going to take the most critical out first." She insisted it was her choice to make. He told her it wasn't. Maybe it wasn't his, either, but he didn't care. He couldn't imagine her making this call and living with it later. He thought the decision would scar her conscience. He was raised Christian; he was raised to take care of those most in need.
♥ Mark was upset. He believed his mother needed an IV to hydrate her and deliver antibiotics for a stubborn urinary infection, but he'd been told the hospital could no longer provide intravenous fluids. Though his mother was a LifeCare patient, Mark complained to a Memorial administrator, who explained that the hospital was in a survival mode now, not a treating mode. "Do you just flip a switch and you're not a hospital anymore?" Mark asked.
♥ They were divided into three groups to help speed the evacuation. Those in fairly good health who could sit up or walk would be categorized as "1"s and prioritized first for evacuation. Those who were sicker and would need more assistance were "2"s. A final group of patients were assigned "3"s and were slated to be evacuated last. That group included those whom doctors judged to be very ill and also, as doctors had agreed on Tuesday, those with DNR orders.
..A dozen and a half or so "3"s were moved to a corner of the second-floor lobby near a Hibernia Bank ATM and a planter filled with striped green dieffenbachia. Patients awaiting evacuation would continue to be cared for-their diapers would be changed, they would be fanned, often by family members of the staff, and given sips of water if they could drink-but once the patients were moved out of their rooms on Wednesday, most other medical interventions were limited. The idea of indicating somebody's destiny by a number struck at least one passing doctor, neuroradiologist Bill Armington, as expeditious but distasteful.
Pou and her coworkers were performing triage, a word once used by the French in reference to the sorting of coffee beans and later applied to the battlefield by Napoleon Bonaparte's chief surgeon, Baron Dominique-Jean Larrey. Triage came to be used in accidents and disasters when the number of those injured exceeded available resources. Surprisingly, perhaps, there was no consensus on how best to do this.
Concepts of triage and medical rationing are a barometer of how those in power in a society value human life. During World War II, the British military limited the use of scarce penicillin to pilots and bomber crews. Before lifesaving kidney dialysis became widely available in the United States, some hospital committees secretly favored age, gender, marital status, education, occupation, and "future potential" into treatment decisions to promote the "greatest good" for the community. When this practice attracted broader public attention in the 1960s, academics condemned one Seattle clinic for ruling out "creative non-conformists... [who] have historically contributed so much to the making of America. The Pacific Northwest is no place for a Henry David Thoreau with bad kidneys."
♥ In the United States at the time of Katrina, at least nine well-recognized triage systems existed to prioritize patients in the case of mass casualties. Because of the difficulty of investigating outcomes, including deaths, in emergencies-and perhaps because of the potential for political embarrassment or due to a lack of financial incentives-almost no research had been done to see whether any of the commonly used triage systems achieved their intended goals or even that they didn't paradoxically worsen overall survival. Most systems called for people with relatively minor injuries to wait while medical personnel attended to patients in the worst shape. This was Baron Larrey's original concept of triage as described in his memoirs of an October 1806 battle in Jena, Prussia, between Napoleon's forces and the Fourth Coalition. "They who are injured in a less degree may wait until their brethren in arms, who are badly mutilated, have been operated on and dressed," he wrote. "Those who are dangerously wounded should receive the first attention, without regard to rank or distinction," an idea in keeping with the French Revolutionary concept égalité.
British naval surgeon John Wilson introduced another triage tier several decades later in 1846 when he decided to withhold surgery from patients for whom it would likely be unsuccessful. In 2005, a few triage systems incorporated this idea, calling for medical workers to forgo treating or evacuating injured patients who were seen as having little chance of survival given the resources at hand. That category was intended for use during a devastating event such as a war-zone truck bombing in which there were far more severely injured victims than ambulances or medics.
Consigning certain sicker patients to go last has its risks, however. Predicting how a patient will fare is inexact and subject to biases. In one very small study of triage, experienced rescuers were asked to categorize the same patients and came up with widely different lists. Many patients who could have survived were mistakenly deemed unsalvageable by some rescuers. And patients' conditions can change; more resources can become available to help those whose situations at first appear hopeless. The importance of reassessing each person is easy to forget once a ranking is assigned.
Designating a category of patients as beyond help creates the tragic possibility that a patient with a chance of survival will be miscategorized and left to die. To avoid this, most experts have concluded that patients seen to have little chance of survival must still be treated or evacuated-after those with severe injuries who need immediate attention to survive, but before those with significant injuries who can wait.
Pou and her colleagues had little if any training in triage systems and were not guided by any particular protocol. Pou viewed the sorting system they developed as heart-wrenching. To her, changing the evacuation order from sickest first to sickest last resulted from a sense among the doctors that they would not be able to save anyone.
♥ But what does the "greatest good" mean when it comes to medicine? Is it the number of lives saved? Years of life saved? Best "quality" years of life saved? Or something else?
The goal of maximizing net good for a population has its roots in the utilitarian philosophy developed by Jeremy Bentham and John Stuart Mill in the eighteenth and nineteenth centuries. More recent philosophers have warned that this approach, if applied to lifesaving medical care in disasters, may require an unacceptable level of sacrifice from those most in need of assistance. These thinkers favor an approach modeled on the principles of justice set out by John Rawls in the late twentieth century (although Rawls himself did not apply them to medical care). The idea is to distribute care based on need. Those in the most imminent danger of dying without care have a bigger claim to the pool of air, much as French surgeon Larrey articulated, even if that inconveniences a larger number of patients with less urgent conditions who have to wait. This is the approach taken in most American emergency rooms in non-disaster settings.
Other philosophers have gone further afield, arguing that potentially lifesaving resources should be allocated randomly, because everyone deserves an equal chance to survive, and because it is dangerous to endow groups of people with the power to assign who lives and who dies. This argument sparked a debate that played out in the pages of philosophy journals for a decade beginning in the late 1970s. Proponents rejected the popular idea that the number of lives saved should be a central consideration when prioritizing rescues. The writer of an influential paper, John M. Taurek, also argued that suffering is not cumulative between individuals-for example, that it is impossible to add up the suffering of a large number of people with minor headaches to equal the suffering of a single person with a migraine, as a utilitarian might do. This concept was also elegantly expressed many years earlier by the author C.S. Lewis, who wrote:
There is no such thing as a sum of suffering, for no one suffers it. When we have reached the maximum that a single person can suffer, we have, no doubt, reached something very horrible, but we have reached all the suffering there can ever be in the universe. The addition of a million fellow-sufferers adds no more pain.
The quandary of disaster triage had an analogue in everyday American medicine: the allocation of transplant organs. The United Network for Organ Sharing invited both doctors and laypeople to help design allocation schemes as part of an ethics committee. According to medical ethicist Robert M. Veatch, members of the general public typically favored giving organs to those in the direst need, even if these patients were less likely to survive or lived at a great distance from where organs became available. In contrast, health professionals tended to favor systems aimed at directing available organs to the patients most liklely to benefit medically from them. To achieve this, the professionals were more willing to accept that many of the sickest patients would die without transplants, as would patients who had less of a chance of acquiring a well-matched organ because they were members of ethnic groups that had a higher rate of need or a lower rate of donation (a problem mitigated by the development of newer anti-rejection drugs). The approach could also disadvantage members of groups whose outcomes tended to be poorer, including, in the case of kidney transplants, those of lower socioeconomic status.
Although no allocation method could ever enlist universal agreement, the process of devising a method, at least, can be made more just. In the case of organ transplantation, including both doctors and laypeople in decision making resulted on policies that prioritized a mixture of both justice and efficiency. Who decides how care is allocated is critically important because it is, at its heart, a question of moral priorities.
At Memorial, however, in the disaster's vise, only medical professionals had a say in how patients would be categorized for evacuation. Once the decisions were made, no system was established to share the information with the people who would be most affected by it.
In some cases it was actively kept from them.
♥ As they neared the boats, many people asked questions of Karen Wynn. "Where we goin'? Where we goin'?" She didn't know where. It frustrated her when people on the cusp of freedom suddenly hesitated to leave the hospital. They seemed more comfortable with the hell they knew than with the unknown journey that awaited them.
..The stress of the disaster narrowed people's fields of vision, as if they wore blinders to anyone's experience but their own. Again and again, Wynn saw signs that others were not appreciating the gravity of the situation inside Memorial.
♥ Karen Wynn saw that the hospital had all the people it could handle. She did not detect a note of racism in the refusals, even as the people being turned away were nearly all African American, as was she. King, by contrast, was offended largely because the people they were turning away had dark skin. As the only African American doctor on duty and one of very few who worked at the hospital, he believed introducing color into his argument would only make everyone touchy, and so he did not. This was a universal issue: the hospital was harboring dogs and cats while babies floated on unsteady skiffs, surrounded by polluted water.
♥ The question of what to do with the hospital's sickest patients was also being raised by others. By the afternoon, with few helicopters landing, these patients were languishing. Incident commander Susan Mulderick, who had worked with Cook for decades, shared her own concerns with him. He would later remember her telling him, "We gotta do something about this. We're never going to get these people out."
Cook sat on the emergency room ramp smoking cigars with another doctor, John Kokemor. The patients were lined up in wheelchairs or sitting behind their walkers on mismatched chairs. In their similar blue-patterned hospital gowns, they reminded Cook of a church choir. Help was coming too slowly. There were too many people who needed to leave and weren't going to make it. It was a desperate situation and Cook saw only two choices: quicken their deaths or abandon them. It had gotten to that point. You couldn't just leave them. The humane thing seemed to be to put 'em out.
♥ At first, some staff members had been warned they could be charged with destroying hospital property if they broke windows. Now, patients were moved back, and uninformed men and other eager volunteers crashed chairs, two-by-fours, and an oxygen tank through the tall glass panes into the surrounding moat, punishing the building that had failed to protect them.
♥ A doctor came and peered at the lady's chart. "She has lung cancer," he said quickly. He turned to Green and closed the woman's chart. "She's not going anywhere." He looked at the oxygen tank and shook his head no. "That's it," he said, and chopped air with his hand. There would be no more respiratory treatments. This oxygen cylinder, its gauge indicating a quarter tank left, would be the last.
Green felt numb. She took the lady's hand and held it. The decision not to move her to safety or support her with oxygen felt personal. Two dozen or so of Green's relatives were in St. Bernard Parish, an area she's heard on the radio was the worst and first hit by the flooding. Several times, Green's young adult daughter, who lived in a different state, had reached her on a cell phone. "Mommy," she cried, "I really think something happened to Granny. I just have this horrible feeling."
Green saw the sick lady before her as somebody's mother, somebody's grandmother. Many people probably loved this lady. Green felt love for her and she didn't even know her. The woman was precious, whether she had six months to live, or a year to live, whatever it was.
Green stood up and walked to another patient. She couldn't stand to watch this lady die on the ground, in a parking garage, in an American city, because nobody came to get her. She didn't want to know this lady's name.
♥ When Matherne discovered that at least two hospitals had lost power on Tuesday, she made her best guess about who could help. She searched out liaisons from the Coast Guard and National Guard and asked them to rescue the hospitals' trapped occupants.
One serviceman told her they were in a safe building. They had supplies. Matherne hadn't expected to have to do any convincing. "They don't have electricity!" she said. "You can't take care of patients without electricity."
She noticed the people in uniforms at the command center avoiding her after that. She knew her outburst had violated the emergency officials' code of cool. It occurred to her that the Guardsmen had resigned themselves to the idea that some flood victims were going to die. These officials, too, felt helpless. They were performing an awful triage of their own.
♥ Meanwhile, other Tenet executives attempted to convince government officials to prioritize the evacuation of Memorial and the company's other marooned hospitals. Staff at every agency seemed happy to nudge another agency. Someone from a senator's office offered to appeal to Gov. Kathleen Blanco and the Centers for Medicare & Medicaid Services. But people at the Centers for Medicare & Medicaid Services directed Tenet to contact the head of the appropriate hospital association. That association, the Federation of American Hospitals, appealed to the US Department of Health and Human Services, which appealed back, on behalf of patients in general, to the Federation, the American Hospital Association, the nation's hospitals, and the Federal Emergency Management Agency. Billionaire Ross Perot, whose son was a Tenet contractor, appealed to the Coast Guard and the Navy. There was no locus of responsibility. Fingers point every which way, much as they had when New Orleans flooded in the 1920s.
♥ "The hunger, the anger, the rage is growing among people who have nothing, and if they have nothing they get violent and they get angry," Jefferson Parish Aaron Broussard said, appealing to the governor for more armed military police: "Basic jungle human instincts are beginning to creep in because they lack food, they lack a decent environment, a shelter."
..Two guests referred to the people remaining in the city as zombies. Cohen described them as "a mass of humanity, slowly wandering."
"It's like Night of the Living Dead," Oliver Thomas, the city council president of New Orleans, said. "And you look at the look in their eyes; they're stressed, they're hungry, they're thirsty. The governor has asked for armed reinforcements."
An organized group of criminals, "hordes of 'em," Thomas said, seemed to have waited out the storm in order to start breaking and entering. "I heard one lady say maybe this is Sodom and Gomorrah."
♥ Overnight, a patent stopped breathing and died on the floor where Pou was fanning. Pou would later remember thinking, We live in the greatest country in the world and yet the sick could basically be abandoned like this. As she, too, awaited rescue, she felt sad, frustrated, and helpless.
..Here, even King recognized Katrina's shattering of the sterile, digital, odorless, dehumidified, gloved, and gowned illusion of mastery over death and suffering doctors typically maintained. The smashed windows and lack of power left them exposed, like an army field hospital, to the elements. Knitted together for safety overnight, they felt as isolated as if they were under fire.
♥ "We need to have a little bit more of a surgeon's attitude," Walsh said. Surgeons were men and women of action. The group of doctors in the suite opted for insubordination over inaction.
♥ One of the emergency medicine doctors, Karen Cockerham, interpreted Mulderick's words the same way as Richard Deichmann did and as the radiologist did. However, Cockerham agreed with the idea of euthanizing patients, which was what she was sure was being proposed when she listened to Mulderick on the ER ramp. When is somebody going to say it? she's been thinking. It's the thing nobody wants to say. The ER doctor looked around and saw others nod and nobody objecting. This is the United States, she thought, and was surprised at what was being said so frankly, out in the open, with maybe a couple dozen people around. She wondered how smart that was, but she thought that euthanasia needed to be considered. It was obvious to her, although she couldn't, in her normal life, have imagined it being a viable option. Now it seemed, while not the only option, perhaps the only humane one. She felt confident it was the right thing even before this conversation, and no doubt, she thought, others were thinking it, too.
Why? Because time had come to feel magnified. She was no longer able to envision what would happen when life returned to normal; many people seemed to be wondering whether that would ever happen. Having an end would give them a reference point for their options. Yes, she had heard they would all get out that day, but she couldn't see it, couldn't believe it, wasn't convinced by the CEO or by Susan.
Conditions seemed increasingly unstable. The doctor felt not only unsafe, but also vulnerable. She had fleeting thoughts that at any moment prior to being saved something even more catastrophic would occur-perhaps some sudden, secondary natural consequence of the disaster. This building could explode, she thought, or somebody could come in and hold us up and take everything we have and decide to shoot us. Her two-year-old was safe with her husband out of town, and she worried increasingly about putting herself in harm's way when she had a responsibility to return to them. She'd heard gunshots outside the hospital, which she knew was turning away neighbors seeking rescue, and she envisioned racial tensions rising. She was sure these already existed because once she-a pale blond student craving a late night biscuit-had stopped at a chicken restaurant a half mile from the hospital near the Magnolia public housing project, and a lady warned her, honey, to get on out of here.
In the second-floor lobby, where she stopped several times to help, the temperature felt like more than a hundred degrees. Even breaking windows in the glass oven had not improved air circulation that much. It was awful. She saw skinny patients lying almost naked, so that the people tending to them could keep them cooler and could more quickly clean up their waste. Some of the patients looked like the cadavers she recalled from gross anatomy in medical school. She was sure they had no idea what was going on, and that they had bedsores from lying in place without a good mattress and someone regularly shifting their bodies from side to side.
She knew what she would want in their place, she would say, "If I were one of those little bitty, skinny, debilitated, confused poor little ladies, I mean let me go to heaven. Don't do that to me. I've lived my life, I'm not going to be watching TV or reading a book or even carrying on a conversation. I got to look forward to being in bed anyway, please don't do that to me."
Somebody had already made that choice for the dogs. Why, she wondered, should we treat the dogs better than we treat the people?
She thought it almost criminal what they were doing to these people, putting them through a torturous process of suffering. And these were people, she would later explain, "who in the best-case scenario might be able to nod or something, but not people who can look forward to going through this horrible ordeal and enjoying anything or being aware of life." They were the type of people she thought shouldn't be resuscitated anyway, "people who have no quality of life in the best-case scenario, even if they make it through this horrible ordeal." Didn't military guys take a cyanide capsule to war, to have an option to avoid torture? And those, she reflected, would be people who would have hope for a meaningful life after their horrible torture. The people she saw on the second floor would, she thought, "have horrible torture and no meaningful life." She knew it was torture, because the heat was hard enough on her, too, that, when she took breaks from working, she sought refuge in her air-conditioned car, grateful for having topped off her gas tank before the storm.
She would later recall having said something to Susan Mulderick about what they needed to think about doing, but Mulderick told her it was being taken care of.
♥ The weary doctors discussed the category 3 patients. These included some of the patients from Memorial and LifeCare who remained in the staging areas, and nine patients who had never been brought down from LifeCare. To Cook, Pou seemed worried that they wouldn't be able to get them out. Cook hadn't been to LifeCare since Katrina struck, and that was on purpose. He had not been asked to go there, had no patients there, and knew that any doctor brave enough to venture upstairs would face difficult, gut-wrenching decisions. He considered LifeCare patients to be "chronically deathbound" at the best of times and knew they would have been horribly affected by the heat. Plenty of staff and volunteers remained at Memorial, but they were exhausted, and Cook couldn't imagine how they would carry nine patients down five flights of stairs before the end of the day. Nobody from outside had arrived to help with that task. If there were other ways to evacuate these patients, other ways to care for them, Cook wasn't seeing them.
Cook told Pou how to administer a combination of morphine and a benzodiazepine sedative. He later said he believed that Pou understood that he was telling her how to help the patients "go to sleep and die."
..The drug combination "cuts down your respiration so you gradually stop breathing and go out," he would say. He viewed it as a way to ease the patients out of a terrible situation.
♥ She told him about her conversation with Susan Mulderick and Anna Pou.
"I can't be a part of anything like that," King said. "I disagree one hundred percent." The idea was stupidity itself. They had only been there two days since the floodwaters rose, and they were dry and had food and water.
He told her that hastening death was not a doctor's job. He knew the situation was grave and that pretty much everyone, including staff, was miserable. He'd carried the man's body to the chapel before sunrise. But he, unlike Pou, Fournier, and Mulderick, had gone upstairs and visited every patient on the seventh floor to assign a triage category. The remaining patients were hot and uncomfortable, a few might be terminally ill, and it was hard on the staff to care for them and see them like this, but he didn't think they were in the kind of pain that called for sedation, let alone mercy killing.
In normal times, doctors occasionally sedated very sick patients to unconsciousness in cases of intractable anxiety, breathlessness, and pain, and sometimes even to make caring for certain patients less taxing on nurses who would otherwise constantly need to monitor patients' suffering or guard against the possibility that their movements would disrupt a spaghetti-like mass of tubes and lines. But taking away patients' ability to monitor their own well-being and express themselves could render them even more helpless than a baby or an animal to communicate when something was wrong. And they might seem less alive, less worth saving.
"I'm a Catholic," Fournier said, "but not a great Catholic."
"Well that's between you and your God," King replied.
♥ Hospital visitors and staff continued to leave from the ER ramp. The surgery chief, anesthesiologist, and plant-operations chief who had left early in the morning returned with an additional boat they had found, and maintenance workers hotwired it. Now staff members were permitted to leave with their pets. It was too late for many. It hadn't been necessary to euthanize them after all.
♥ Wynn didn't cry. OK, so what if they are euthanizing? she'd though. Unlike that nurse, who managed a regular medical unit, Wynn lived in the world of the ICU, where many patients didn't get better. Death was often scheduled, orchestrated, the result of decisions to switch off machines.
Withdrawing life support was something Wynn had grown extremely comfortable with from her work in the ICU under the tutelage of Dr. Ewing Cook. She considered him masterful and compassionate in his approach to end-of-life care. They both served on Memorial's bioethics committee, of which she was the longtime chair because, she sometimes told people, nobody else wanted to do it. Committee members were called in to consult in cases where end-of-life treatment dilemmas arose. The situation seemed analogous now, the only difference being that family members were usually there to receive the message that Wynn had heard Cook, unafraid of bearing bad news, deliver so many times. "We've done everything possible for her. Now the only option is to make her comfortable."
Wynn had, many times, told the same thing to other doctors. One Memorial oncologist performed bone-marrow transplants and was crushed whenever he couldn't make his patients better. A pretty young woman had grown so bloated and bruised she looked like a monster, no longer human, struggling and holding on to the last bit of life on the ventilator. When patients like this were so disfigured they appeared to be dying cell by cell from the inside out-so bad that Wynn couldn't bear going into their rooms to examine them-she would approach the doctor. "It's time," she'd say. "We need to go and talk to the family."
♥ It began to appear that people in hospitals and nursing homes accounted for a significant portion of all deaths from the massive disaster.
As the outlines of this medical tragedy sharpened, there was an urgent need to understand its causes before the next catastrophe occurred in New Orleans or elsewhere in the country. Were deaths at hospitals and nursing homes regrettable results of an act of nature, a chaotic government response, and poorly constructed flood protection overlaid on a degraded environment? Or had lax oversight allowed individual or corporate greed to play a role? Did some hospital and nursing home leaders decide not to evacuate before the storm primarily to avoid the substantial costs of emptying and closing health facilities? Were emergency plans not followed, important pre-storm investments not made, and health workers not properly prepared?
♥ Not until after the bodies were retrieved and the attorney general's office launched an investigation did Tenet officials print out medical chart "face sheets" with names, addresses, and family contacts of the dead, and assign various employees to notify them. The callers received a set of instructions:
1. Speak in general terms.
2. Never give opinions!
3. May be first time family has had contact with anyone about loved one.
4. The loved ones know nothing except news media information.
5. Loved ones are usually angry.
6. Tell truth, i.e., Patient may have died due to lack of electricity or high temperatures, etc.
The employee was to introduce himself or herself, verify the family member's relationship with the patient, and: "Reveal information: patient expired between the hurricane and evacuation of patients from the facility."
The document included guidance for handling tough questions, including why notification was occurring more than two weeks after the deaths: "All information electronic; however, computer server stored in New Orleans. Did not ever plan for a whole city to shut down."
The employee was to tell each family: "Your loved one was cared for throughout. Your loved one was identified and shrouded and placed in our chapel area. Your loved one was treated with dignity."
If a family member questioned the decision not to evacuate before the hurricane, it was based on "risk to the patient." The decision to evacuate after Katrina had been mandated by government officials: "In situations like this disaster, the government takes control. The state retrieved your loved one and brought to the parish's coroner office. Eventually, all deceased will be taken to St. Gabriel, LA (southwest of Baton Rouge), where a thorough medical exam will be performed and a cause of death will be identified. A death certificate will be available. Once a cause of death has been determined, state officials will contact the family."
♥ Simmons wanted to ensure that nobody else had the chance to discover what Pou had confided. There would be no more unrestricted discussions with people aside from him, no more unmediated forays into the media. Even Pou's husband would be kept, to a certain extent, in the dark.
Protecting Pou would mean marshaling the facts and safe-guarding them until the time was appropriate to release them. Simmons began constructing what he would refer to as her "defense camp," and Pou retreated into it. Lines were being drawn.
Those seeking to discover and expose the truth were on the other side.
♥ A volunteer coroner from Wisconsin had told Nelson an autopsy had been performed on her mother. Nelson asked why. The coroner said euthanasia was suspected.
"I don't think that any circumstance justifies euthanasia," she told Rider and Schafer, even though her mother had been close to death. Killing someone was breaking God's law. Kathryn, her mother's longtime caregiver, would have known more than anyone what Elaine would have wanted and whether she was suffering. Nobody had asked her opinion. Her mother was extremely strong and believed in always doing right, the kind of lady who slipped a dollar into each purse she donated to Goodwill so that whoever ended up with it would have a little something extra. Kathryn had no doubt her mother would want the truth to emerge.
♥ The patients' blood pressures were so low, their veins had collapsed like empty fire hoses. Apart from their breathing and the soft moans of one, they appeared lifeless and did not respond to him.
A nurse cleaned a patient's IV port with an alcohol swab before giving an injection. The unintentional irony of the gesture struck him. What infection could have time to develop in a patient about to die?
Moral clarity was easier to maintain in concept than in execution. When the moment of truth came, he wavered. That's when he turned to nurse manager Karen Wynn, trusting her experience in the ICU and her leadership of the hospital's ethics committee. "Can we do this?" he asked. He was grateful for her assent.
Thiele gave patients a shot of morphine and midazolam at doses higher than what he normally used in the ICU. He held their hands and reassured them, "It's all right to go." Most patients died within minutes of being medicated. But the heavyset black man with the labored breathing hadn't.
Thiele gave additional shots of morphine, he thought perhaps 100 mg. He chanted Hail Marys with Karen Wynn. The man kept breathing. Perhaps his circulation was so poor that the drug wasn't getting into him.
Thiele covered his face with a towel.
He remembered it took less than a minute for the man to stop breathing and die.
It had gone against every fiber in his body to smother the man. It was something he had never thought he would ever have to do in any circumstance, was not in his "database." Though he'd felt what he had done was right, immediately afterward the question of whether it was indeed right continued to play in his mind. Can we do this? If the man was unaware of what was going on, if he would have died in an hour anyway, how cruel was it to have suffocated him?
Thiele left the hospital that Tuesday evening by helicopter and landed at the airport, where the patients he had injected-had they survived-would have gone.
Beneath a skylight in an open concourse, patients lay everywhere on litters and on the carpeted ground. They sat propped in wheelchairs and in hard airport seats, some moaning, most motionless. The stench of urine, overflowing diapers, and feces-soiled garments suffused the swampy air. Brain-surgery patients. Transplant-surgery patients. Patients with breathing tubes in their throats who needed oxygen, respiratory therapists, and ventilators. Hundreds had arrived and continued to arrive from the city's hospitals and nursing homes. Thousands of hungry, thirsty, sodden evacuees, separated from their medicines for hypertension, diabetes, schizophrenia, and other ailments, camped under signs for Jesters Bar and Grill, Back Alley Jazz, and other airport concessions. Their voices swelled and rose, as did, in many cases, their blood pressures and their blood-sugar levels. The skeleton medical staff of doctors, nurses, and paramedics, many at work for more than two days without sleep, ranted at one another in exhaustion.
Thiele and a nurse who had accompanied him offered to help. Stay outta the area; a female doctor shooed them. We got it covered. The intermittent federal employees-members of Disaster Medical Assistance Teams, or DMATs, who underwent specialized training-were not supposed to work with unvetted outsiders. There was no good system for checking whether or not someone who walked up to offer medical assistance might be unqualified. Per protocol, the teams at the airport turned away Thiele and other doctors and nurses, even as their members were utterly overwhelmed.
A DMAT had arrived that Tuesday to join three other DMATs that had established the field hospital early Wednesday morning. Three dozen paramedics, nurses, and a few doctors who had trained and drilled and volunteered to respond in times of national emergency routed the site in disbelief. Many cried. Their supply caches, driven rather than flown from the West Coast, were late and short. Minute after minute, the helicopters landed and the patients kept arriving from hospitals and nursing homes, many times more than the volunteers had been told would come, ten times more than anyone who worked with DMAT knew could possibly be cared for. Where were the departing flights to take these patients to real hospitals? Supplies ran out within a day. And they had no communications with superiors, no provisions for resupply.
Federal officials outside New Orleans touted the work of the DMATs in news interviews.
That Tuesday night passed in moans and screams and death. No time to move the bodies. THiele lay listening. His moral charity returned. If the patients he had injected with morphine and midazolam at Memorial had come, instead, to this place, they would only have suffered and died.
Can we do this? After the disaster, the question had shifted for Thiele from a moral to a legal one, the price of conviction in the currency of consequences. His attorney warded off the attorney general's advances while THiele-his home destroyed, and out of a job because of the hospital's closure-sought the means to pay him.
♥ The interviews with hospital workers were full of such small, important, and maddening inconsistencies, memory's transmogrifications. Rider's job was as impossible as collecting fragments of a fractured mirror and then, somehow, inferring what image had once appeared there.
♥ The urge to learn what had become of a loved one who perished in a large disaster or crisis was so essentially human that it had led to the development of a special field of DNA identification focused on mass casualties. The techniques drew from anthropology, forensics, molecular biology, generics, and computer science. They had been applied, at great cost, to the jumbled bones from mass graves in Bosnia-Herzegovina; waterlogged corpses from the beaches of post-tsunami Phuket, Thailand; and the fragments-sifted through for years-from Ground Zero in New York City. A DNA sample from Russell's left tibia had been taken to help confirm the identity of his body. Unique skin marks were also noted, and a skull and crossbones tattoo on Russell's left arm seemed to have been wryly placed for the occasion of his autopsy. It said: AS YOU ARE I WAS. AS I AM YOU WILL BE.