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

by Sheri Fink

The patient bays were vacant, the nurses gone, the hospital evacuated before the storm. Electrical transfer switches still sat in the basement, but one lesson from Katrina had been learned.

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.

highly organized local command center and was offering proactive and robust assistance not only to its own hospitals but also others in the region. This much was different from the support that Tenet and LifeCare headquarters provided to their hospitals at the time of Katrina.

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.

FIFTY PATIENTS, six outlets. How to decide? Evans had access to something the doctors at Memorial did not. In 2008, citing the arrests of the Memorial health professionals and fears that a severe influenza outbreak could emerge and force providers, again, into making life-and-death choices between patients, New York planners published a protocol for rationing ventilators. The guidelines, devised by experts in disaster medicine, bioethics, and public policy, were designed to go into effect if the United States was ever struck by a pandemic comparable to the 1918 Spanish flu outbreak, which sickened more than a quarter of the population, overwhelmed hospitals, and killed an estimated 50 million people worldwide—the most deadly disease event in recent history. When state health department officials ran exercises based on scenarios involving H5N1 avian influenza—a strain

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,

executive orders for the governor to sign in an emergency to allow hospitals to turn away patients, protect doctors faced with limiting care, and permit health officials to seize drugs and quarantine individuals. Other states, including Louisiana—thanks to the advocacy of Dr. Anna Pou—and Indiana, have addressed these issues with legislation.

After the grand jury refused to indict Pou, she made good on her promise to fight to protect medical workers who serve in disasters, capitalizing on the statewide support she enjoyed.

because legislators had passed immunity provisions that were interpreted as virtually absolute, more than a half million post-Katrina flood victims lost their fight for billions of dollars in compensation.

As the Louisiana legislators considered changing state law based on Pou’s experience, none of them inquired as to what had actually happened on September 1, 2005. She has never publicly discussed it, even later after suits brought by three families, including the Everetts, against Pou along with other parties were settled; the families had to agree to keep silent about the terms. Legislators took turns thanking Pou on the record for her Katrina service; one called the former attorney general’s treatment of her “inexcusable.” The bills Pou and her attorney Rick Simmons helped write passed unanimously. They immunize Louisiana health-care professionals from most civil lawsuits (though not in cases of willful misconduct) for their work “in accordance with disaster medicine protocol.”

In other words, there was slim if any evidence that taking away ventilators or other resources from patients with a lower triage priority actually would have saved more lives. Moreover, in some instances just the opposite appeared to have been the case.

Based on utilitarian calculations alone, it had been logical to remove LeBrun’s source of oxygen. But the health professionals involved in the decision were not willing to face her and tell her about it or be there to implement it. Issuing “a death sentence” is easier than executing

They discovered something surprising. Hospice leaders had planned to move the sickest patients first. But those patients and their families chose to allow the healthier patients to go first.

Health professionals, who tend to favor utilitarian efficiency in the distribution of limited goods, such as organs, shouldn’t be making life-and-death value judgments alone, Daugherty thought, particularly in the backyard of Johns Hopkins Hospital, a low-income neighborhood where public trust in medicine is poor even at the best of times, a legacy of ethically questionable research studies and historical discrimination.

In less than a week he was off the ventilator, saying he was relieved to be alive, highlighting the complexity of end-of-life decision making, of predicting in advance what we would want in a situation we have never faced. He requested his DNR be removed. He lived a few more months, and his granddaughter, a twenty-one-year-old college student studying musical performance, described in a eulogy what that time meant to both of them as she spent her summer vacation visiting him in the hospital, a rehab unit, and a skilled nursing facility: “We talked about politics, economics, current events, gossip, books, movies, the past, the future. He taught me about social responsibility and his past. I taught him about opera and music. We even talked about boys and relationships. When he gave advice, it was always good and, more important, wise. […] I will continue to live my life as if I’m going to tell him about it.”

The authors argued that Katrina and other cases had shown that while crisis conditions may justify limiting access to scarce treatments, medical providers have a duty to care for patients in emergencies, to treat them fairly, and to steward resources.

What will save more lives will be doing everything possible to avoid having to deal the hand, by taking steps to minimize the need to compromise standards, and promote the ability to rebound as quickly as possible to normalcy. One of the greatest tragedies of what happened at Memorial may well be that the plan to inject patients went ahead at precisely the time when the helicopters at last arrived in force, expanding the available resources.

The failure to emphasize situational awareness in disaster response—maintaining the ability to “see” in the midst of a crisis—concerns some experts, including Dr. Frederick “Skip” Burkle

In 2014, a $13.8 million, three-year contract was awarded to a company to develop a cheaper, easier-to-use ventilator. Already at least one firm, St. Louis–based Allied Healthcare Products, was marketing a line of ventilators specifically for use in disasters.

Of the twenty-six patients known to have been cared for in hospitals in the United States and Europe, fewer than 20 percent died. That contrasted with a fatality rate of well over half of patients in many treatment units in West Africa, where thousands were treated.

Although Ebola was identified in 1976, had been up to 90 percent fatal in previous outbreaks in rural Africa, and was viewed as a potential bioterrorist threat, experimental vaccines and treatments were in an early stage of development when the epidemic was recognized in early 2014. Public health surveillance systems throughout the world remained weak and underfunded. The World Health Organization, forced to decrease its budget during a global financial crisis, had cut its epidemic response units disproportionately.

Within a year of the outbreak’s recognition, Ebola had directly killed more than 10,000 people, and many other people were thought to have died because hospitals, clinics, and immunization campaigns shut down. The epidemic also revealed vulnerabilities in the US health system.

Bellevue had reopened in late 2012, nearly a month after Hurricane Sandy filled its basement with millions of gallons of floodwaters. In the end, creative thinking turned out to be the most important, lifesaving aspect of what happened there after the generator fuel pumps failed. Volunteers formed a chain and passed fuel up thirteen flights of stairs to feed the generators manually.

Life and death in the immediate aftermath of a crisis most often depends on the preparedness, performance, and decision making of the individuals on the scene. 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.