Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital

“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.”

Disasters kick the crutches out from our cherished beliefs about the continuity of normal life. When we face sudden existential threats, the normal can seem haunted, and the unusual, terrifying. The sight of waters slowly inundating streets brings upon the watchers a sense of doom.

“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.”

The evacuation triage system settled on by the doctors contains an unusual and controversial element: the most critical patients, usually cared for first, will, in this instance, be helped last. The reasoning is that they are too fragile and likely to die en route, thus wasting a precious seat on scarce rescue vehicles.

“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?”

Deciding who will be saved and who must wait is fraught with arbitrary judgments about the value of individuals. It involves questions that may ultimately be unanswerable. Any such system will likely be utilitarian—seeking the greatest good for the greatest number—but what that good ought to be, and how the people involved should be categorized for rescue or death, are issues that have no firm consensus.

“In fact the distinction between murder and medical care often came down to the intent of the person administering the drug.”

Fink illustrates the underlying issues regarding Dr. Pou’s actions to hasten the deaths of critically ill patients—do they constitute a crime even if her intentions are the best during an emergency? While she was not indicted on a federal level, the family members of euthanized patients, as well as others, believe she committed murder.

“‘I gave her medicine so I could get rid of her faster, get the nurses off the floor,’ he would say.”

Staffers, desperate about their patients and their own safety, begin to conflate the death of the patients with the rescue of the medical personnel. It’s clear that the decisions and actions on the seventh floor are made in a hurry, and that the reasoning is clouded by multiple considerations in a fast-moving emergency.

“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.”

This is the central ethical argument in favor of euthanizing the critical patients at Memorial’s seventh floor and, later, on the second floor. The doctors are in a bind and believe they must do something drastic to resolve the dilemma.

“Multiple agencies and officials appeared to be maintaining separate priority lists for hospital evacuations, which perhaps explained why Memorial was variously first, second, or last on ‘the list.’”

In the chaos of disaster, rescue becomes uncoordinated. Conflicting reports received by Memorial hospital may have contributed to the decision to euthanize patients, when in the end there turned out to be enough rescue vehicles to accommodate those victims.

“Conditions in Memorial are deteriorating fast. We may lose 30-45 patients overnight. There is rampant looting in the streets and the hospitals do not have security to protect. It has become our priority to get all patients and employees/families out of Memorial.”

Part of the confusion comes from misinformation. Reports of widespread looting and worse turn out to be false, but these stories have an effect on Memorial personnel, encouraging them to believe their situation is even more dire than it already is.

“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?”

The doctors and nurses at Memorial begin to argue among themselves and with themselves over what to do with the most critical patients. Focus falls on these patients’ pain and suffering, and debate centers on whether it is worse to abandon them or euthanize them.

“For five days she and her colleagues had tried so hard to keep everyone alive. She didn’t want to accept that they couldn’t save everyone who had made it this far. A colleague told her that they were under martial law. Isbell believed she had to follow orders. She did what she was instructed to do.”

The Memorial tragedy hits the nurses hard. Their professional lives are dedicated to keeping patients alive and comfortable, and now conditions work against their every effort. For some caregivers, only direct commands from people in authority wearing guns can get them to walk away from their patients. As it turns out, the martial-law assertion proves false, but by then it is too late.

“Several nurses familiar with the patients who were injected believed that after they had survived everything so far, there was no reason they couldn’t still make it to safety. Most of the other employees milling around the second floor seemed to think what was happening was horrible but necessary. One employee even suggested that the objectors weren’t being realistic and needed to grow up.”

Opinions are by no means uniform among Memorial staff on what to do with the critical patients. In the shock of the emergency, decisions are taken that later prove to have been premature. The debaters who should have won the argument are, instead, ignored and marginalized.

“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?”

According to Fink, the answer is that all of these factors play a role. It’s hard to place blame when so many things go wrong at once. On the other hand, a chief characteristic of a disaster is that many things do go awry at the same time. It’s only when all checks and balances and all redundant resources are overwhelmed that an opening emerges for a tragedy.

“The LifeCare witnesses had confirmed one another’s stories. They all alleged that Dr. Pou had come up to the seventh floor to end the lives of the nine surviving patients, and two recalled that Pou had told them directly that ‘lethal’ was her intention.”

The testimony of nurses who allege intent on the part of Pou is powerful but not enough to convict, let alone indict, especially given the reluctance of the coroner to present his full findings of homicide. Much of the evidence against Dr. Pou is withheld from the grand jury by a district attorney who doesn’t want to prosecute a popular physician.

“The scenario was familiar to students of mass disasters around the world. Systems always failed. The official response was always unconscionably slow. Coordination and communication were particularly bad. These were truths Americans had come to accept about other people’s disasters. It was shocking to see the scenario play out at home.”

The rule of thumb is that, in a disaster, everything will go wrong. Institutions, however, practice on the basis that only a limited number of resources will fail. It is hard to practice any other way, as the rehearsal might itself collapse into chaos. Yet chaos is the watchword during an actual catastrophe. For this reason alone, it can be expected that disaster relief will always tend to be disorganized, uneven, and late.

“Am I trying to relieve my suffering or that patient’s suffering? Therefore, physicians need that clear-cut ethical boundary that says no, we’re not out looking for excuses to end other people’s lives.”

Rex Greene, MD, a medical ethicist, believes doctors should not have the leeway to administer death drugs: such a privilege could lead, in a crisis, to exhausted physicians rashly euthanizing patients because, as one healthcare worker put it:“[W]e wanted them out of our misery” (339).

“This wasn’t a case of investigate, arrest, and you’re done. Look at the overall picture here, he’d tell her: a city underwater, politics in the background, multimillion-dollar corporate interests, the medical profession on trial. He had tried to warn her not to get emotionally involved, that the case would tear her heart out. And now it had.”

The attempt to prosecute Dr. Pou for murder faces many obstacles, most of which have nothing to do with evidence or the facts of the case. Indeed, the grand jury investigation is stymied by the district attorney’s reluctance to provide the jury with all the evidence. One witness, coroner Charles Minyard, refuses to state unequivocally that homicides have occurred, when he knows full well that they have. The public loves Dr. Pou and doesn’t want her prosecuted; doctors and nurses campaign to have the charges dropped. The implication is that innocence and guilt are sometimes decided outside the courtroom.

“Mr. Everett. He was the problem. He was an outright homicide. Minyard would stake his life on it.”

Orleans Parish coroner Frank Minyard examines the evidence and concludes that at least one or two patients on Memorial hospital’s seventh floor have been deliberately killed. Everett is put down because he is considered too heavy to carry to the rescue vehicles. He is in no need of extreme doses of morphine and sedatives; his death may be more about convenience in an emergency than about relieving him of suffering.

“Memorial staff had been criticized for playing God. Green knew they were asked to play God every day in the ICU. She didn’t believe in killing people, but she saw no valor in prolonging death by not giving painkillers.”

After Katrina, nurse Cathy Green works at other hospitals, where she discovers the policy is more conservative than the looser practice at Memorial.

“For now the lessons seemed to be that in a disaster if you’re a doctor, you’re in charge. If you feel giving large doses of morphine and Versed are appropriate, go ahead. It’s your call. ‘Is this what we want young doctors to learn?’ he asked. ‘It’s a goddamn precedent, a very dangerous, bad precedent.’”

Forensic expert Cyril Wecht argues that society should not give doctors too much leeway, lest they become complacent or, worse, arrogant during an emergency and begin to issue directives that cause more harm than they prevent.

“After everything that should have been learned about those horrific days in New Orleans, another hospital in a major American city now found itself without power, its staff fighting to keep alive their most desperately sick patients.”

Out-of-sight, out-of-mind is, if not a motto, an attitude among bureaucrats in big-city hospitals that may one day have to face the unthinkable. Seven years after Katrina, Hurricane Sandy puts New York hospitals in the same situation as that faced by New Orleans. In New York, the results are somewhat better, but many of the same planning mistakes have put the facilities in grave danger.

“Setting out guidelines in advance of a crisis was a way to avoid putting exhausted, stressed frontline health professionals in the position of having to come up with criteria for making tough decisions in the midst of a crisis, as the ragged staff at Memorial Medical Center had to do after Hurricane Katrina.”

In a way, there can never be enough practice for emergencies since disasters always wreak havoc on the best-laid plans. Each such event adds to the lessons learned, but there may never be a simulation powerful enough to evoke the terror, disorientation, discouragement, and exhaustion of the real thing.

“‘Rather than thinking about exceptional moral rules for exceptional moral situations,’ Harvard’s Dr. Lachlan Forrow, who is also a palliative care specialist, wrote, ‘we should almost always see exceptional moral situations as opportunities for us to show exceptionally deep commitment to our deepest moral values.’”

Fink maintains that the rules we establish to protect the weak are often the first rules tossed out in an emergency—although that is precisely the moment when such rules are most needed.

“In a disaster, triage is about deciding what the goals of dividing resources should be for the larger population—whether maximizing number of lives saved, years of lives saved, quality of life, fairness, social trust, or other factors. The larger community may emerge with ideas different from those held by small groups of medical professionals.”

Doctors have a duty, long established, that prohibits arbitrary withholding of resources or, worse, active use of resources to kill patients. Beyond that, it is up to the society as a whole to decide what it wants from medical care and how doctors should make decisions during crises.