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

by Sheri Fink

The hospital opened its doors to serve its stated, three-pronged mission: the alleviation of pain, the prolongation of life, and the relief of suffering.

But what happens when prolonging life causes suffering?

The homeowners’ association of the hard-hit Lakeview District demanded that the levees be raised and the drainage system strengthened so that “the ‘hand of God’ will not be blamed as often for what the hand of man has neglected to do.”

Wow, powerful

WATER SHORTAGES WILL MAKE HUMAN SUFFERING INCREDIBLE BY MODERN STANDARDS.”

It did

As with many teaching hospitals, something of a trade was involved. The patients, often poor, received care regardless of their ability to pay. In exchange, budding doctors learned their craft by practicing on them. The hospital served a prison population as well. It seemed like a good fit for Pou, who enjoyed teaching and had a passion for treating the poor, as her father had done.

Experimentation on underfunded and under supperted populations essentially

Intensive care grew to become a major specialty at Memorial and across the country. With it came new ethical challenges and a changing definition of what constituted “extraordinary measures” in medicine. When should life support be instituted?

“The ways and means of dying must be carefully considered,” Baltz commented

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.

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?

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.

How now to define death? When was it permissible, even right, to withhold or, more wrenchingly, withdraw life-sustaining care?

Emmett Everett, the 380-pound patient up in LifeCare who had been moved from Chalmette in St. Bernard Parish, was unable to reach his wife on her cell phone. He told his nurse he was worried about her.

:(

(The sight of low-wage cooks tending the stoves in the swelter with tied-up hair and cut-off sleeves and scrub pants had awed one executive who came down to the kitchen seeking extra food for a patient. An employee turned and asked, “What you need, baby?” as if it were any other day.)

Some headed to a darkened Winn-Dixie supermarket about eight blocks away and returned, arms laden with diapers, food, and drinks. One described this as “soul surviving, surviving for the soul.” Others considered it looting.

One Memorial administrator wrote an e-mail to her family describing what she had heard from the security supervisor that morning. They are locking down the whole hospital to keep the looters out. We are under marshall law so our security officers can shoot to kill if they want.

There were certain signs, devastating signs, that told Green that an ICU patient was “crashing” toward death. This was that sign. We did not dodge a bullet, she thought. Lake Pontchartrain is emptying into our city. Very bad news is coming. It was the moment that everything changed.

Spine chilling dread

JCAHO was a nonprofit organization that Memorial, like most hospitals in the United States, hired to accredit it every third year. A “Gold Seal of Approval” from the organization paved the way for state licensure and Medicare and Medicaid reimbursement for treating patients. The Gold Seal was not a rarefied designation. Some 99 percent of hospitals achieved it, and details of their inspection deficiencies were hidden from public view. Most of JCAHO’s revenues came from fees paid by the very hospitals it accredited. In some cases, its survey teams missed serious problems at hospitals that law enforcement investigators later uncovered.

Im sure theres no conflict of interest here at all. Kidding. This is disgusting.

We’re in this storm, Marse said in a brief homily for those gathered before him. And Jesus is with us, no matter what the outcome is. Marse couldn’t help noticing that the water outside the windows rose halfway up the side of a fire hydrant during the time he spoke.

Again... Chills

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.

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 judgment more than a medical one.

Sickening abuse of power. They knew.

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

The logic of someone who knows they did something wrong

Scott was taken to a patient unit on the fifth floor to wait.

Abandoned by his colleagues

A text message arrived a few hours later from Baton Rouge. All the babies had made it, including Gershanik’s. Baby Boy S’s oxygen level on arrival matched what it had been on the high-tech machines, thanks to the doctor’s life-support improvisations. The babies were more resilient than the doctor had imagined.

A miracle, but not a supernatural one. A miracle made possible by the passion and strength of the care team. A testament to the devotion of dpctors and nurses.

Why Tenet corporate permission should be required for LifeCare to use federal rescue assets was unclear.

Concepts of triage and medical rationing are a barometer of how those in power in a society value human life.

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?

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.

This situation struck the daughter as entirely different. “I didn’t mean for her to be left up here,” she told Pitre-Ryals. “When I made my mother a DNR, I did not know it meant ‘do not rescue.’

Even the families knew that it was wrong.

The stress of the disaster narrowed people’s fields of vision, as if they wore blinders to anyone’s experience but their own.

Achieving this level of comfort often required enough morphine that the drug markedly suppressed the patient’s breathing. The intent was to provide comfort, but the result was to hasten death, and Cook knew it.

Moral maze

“We gotta do something about this. We’re never going to get these people out.”

Gave up before it was over

Vera’s Do Not Resuscitate status was not the recent wish of a dying woman, but rather the result of a request she had made more than a decade earlier so that her heart would not be restarted if it stopped. Her heart was still beating.

It began to appear that people in hospitals and nursing homes accounted for a significant proportion of all deaths from the massive disaster.

The investigators were left to wonder why, however, the patients weren’t lifted onto gurneys and rolled into the more comfortable cancer center (or to air-conditioned cars and trucks).

Selfishness

Life and death in the critical first hours of a calamity typically hinged on the preparedness, resources, and abilities of those in the affected community with the power to help themselves and others in their vicinity. Those who did better were those who didn’t wait idly for help to arrive. In the end, with systems crashing and failing, what mattered most and had the greatest immediate effects were the actions and decisions made in the midst of a crisis by individuals.

Perhaps most important, Charity’s leaders avoided categorizing a group of patients as too ill to rescue. The sickest were taken out first instead of last.

Importance of mindset

By the rule of double effect, an act that could foreseeably cause both good and bad effects was morally permissible if solely the good effect was intended (and did not result from the harmful one), and the act, itself good or neutral, was undertaken in a proportionally grave situation.

After everything they had been through in those five days, to have their integrity questioned, to be facing the possibility of going before a criminal grand jury investigating a colleague for murder, was unbearable.

Salt in the wound

Emergencies are crucibles that contain and reveal the daily, slower-burning problems of medicine and beyond—our vulnerabilities; our trouble grappling with uncertainty, how we die, how we prioritize and divide what is most precious and vital and limited; even our biases and blindnesses.

However, mounting evidence suggests that the plans would not accurately direct care to patients who are most likely to survive with treatment, as is often presumed. Several researchers have studied how groups of ICU patients might fare under these emergency protocols. They asked doctors to categorize the patients in their ICUs during the relatively mild H1N1 “swine flu” pandemic as if it were an emergency and they needed to ration. The results were disturbing. The majority of patients who would have been tagged as “expectant” (i.e., likely to die or unable to be saved with the resources available; analogous to Memorial’s “category 3”) and been designated for withdrawal of ICU care and ventilator support in fact actually survived with continued treatment and were discharged from the hospital. In some cases, their ventilators would likely have been reassigned to a group of patients whose survival rate turned out to be lower. Even with clear guidelines to follow, triage officers often disagreed and lacked confidence in their categorization decisions.

Very interesting

It is hard for any of us to know how we would act under such terrible pressure. But we, at least, have the luxury to prepare and resolve how we would want to make the decisions.