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The Deadly Choices at Memorial

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The family of Emmett Everett in LaPlace, La. Carrie Everett, second from left, asked, 'Who gave them the right to play God?' (Paolo Pellegrin/Magnum Photos)

Mendez heard that Pou was looking for her. They sat down in an office with an open window. Pou looked distraught and told her that the LifeCare patients probably were not going to survive. Mendez told investigators that she responded, ‘‘I think you’re right.’’

Mendez said she watched Pou struggle with what she was saying, telling investigators that Pou told her that ‘‘the decision had been made to administer lethal doses’’ of morphine and other drugs. (Pou, through her lawyer, Richard Simmons Jr., denied mentioning ‘‘lethal doses.’’) Were the LifeCare patients being singled out? Mendez asked. She knew there were other sick patients at Memorial. Mendez recalled that Pou said ‘‘no’’ and that there was ‘‘no telling how far’’ it would go.

According to Mendez, Pou told her that she and other Memorial staff members were assuming responsibility for the patients on the seventh floor; the LifeCare nursing staff wasn’t involved and should leave. (Pou, through her lawyer, disputes Mendez’s account.) Mendez later said she had assumed that the hospital was under martial law, which was not the case, and that Pou was acting under military orders. Mendez left to dismiss her employees, she said, because she feared they would be forced downstairs by authorities.

Diane Robichaux, the senior leader on the LifeCare floor, later walked into the office, she recalled in interviews with investigators. (She declined to talk to me.) She and other LifeCare workers had gone downstairs at around 9:30 a.m. to ask Susan Mulderick when the LifeCare patients on the seventh floor would be evacuated. According to Robichaux, Mulderick said, ‘‘The plan is not to leave any living patients behind,’’ and told her to see Pou.

In Robichaux’s interview with investigators, she could not recall exactly what Pou told her, but she said that she understood that patients ‘‘were not going to be making it out of there.’’ She said that Pou did not use the word ‘‘euthanize.’’ Prompted by investigators, she said she thought Pou might have used the word ‘‘comfortable’’ in describing what she was trying to do for the patients.

Robichaux remembered Pou saying that the LifeCare patients were ‘‘not aware or not alert or something along those lines.’’ Robichaux recounted to investigators that she told Pou that that wasn’t true and said that one of LifeCare’s patients — Emmett Everett, a 380-pound man — was ‘‘very aware’’ of his surroundings. He had fed himself breakfast that morning and asked Robichaux, ‘‘So are we ready to rock and roll?’’

The 61-year-old Honduran-born manual laborer was at LifeCare awaiting colostomy surgery to ease chronic bowel obstruction, according to his medical records. Despite a freakish spinal-cord stroke that left him a paraplegic at age 50, his wife and nurses who worked with him say he maintained a good sense of humor and a rich family life, and he rarely complained. He, along with three of the other LifeCare patients on the floor, had no D.N.R. order.

Everett’s roommates had already been taken downstairs on their way to the helicopters, whose loud propellers sent a breeze through the windows on his side of the LifeCare floor. Several times he appealed to his nurse, ‘‘Don’t let them leave me behind.’’ His only complaint that morning was dizziness, a LifeCare worker told Pou.

‘‘Oh, my goodness,’’ a LifeCare employee recalled Pou replying.

Two Memorial nurses — identified as Cheri Landry and Lori Budo from the I.C.U. to investigators by a LifeCare pharmacist, Steven Harris — joined the discussion along with other LifeCare workers. (Through their lawyers, Landry and Budo declined to be interviewed. Harris never returned my calls.) They talked about how Everett was paralyzed and had complex medical problems and had been designated a ‘‘3’’ on the triage scale. According to Robichaux, the group concluded that Everett was too heavy to be maneuvered down the stairs, through the machine-room wall and onto a helicopter. Several medical staff members who helped lead boat and helicopter transport that day say they would certainly have found a way to evacuate Everett. They say they were never made aware of his presence.

In his interviews with investigators, Andre Gremillion, a LifeCare nurse, said that the female physician in the office (he didn’t know Pou’s name) asked if someone who knew Everett could explain to him that because he was so big they did not think they would be able to evacuate him. They asked Gremillion whether he could ‘‘give him something to help him relax and explain the situation.’’ Gremillion told investigators that he didn’t want to be the one who told Everett that ‘‘we would probably be leaving and he would be staying.’’ At that point, Gremillion said, he lost his composure.

Gremillion’s supervisor and friend, a LifeCare nursing director, Gina Isbell, told me she walked into the room around 11 a.m. and saw Gremillion crying and shaking his head. He brushed past her into the hallway, and Isbell followed, grabbing his arm and guiding him to an empty room. ‘‘I can’t do this,’’ he kept saying.

‘‘Do what?’’ Isbell asked. When Gremillion wouldn’t answer, Isbell tried to comfort him. ‘‘It’s going to be O.K.,’’ she said. ‘‘Everything’s going to be all right.’’

Isbell searched for Robichaux, her boss. ‘‘What is going on?’’ she asked, frantic. ‘‘Are they going to do something to our patients?’’

‘‘Yes, they are,’’ Isbell remembers Robichaux, in tears, saying. ‘‘Our patients aren’t going to be evacuated. They aren’t going to leave.’’ As the LifeCare administrators cleared the floor of all but a few senior staff members, Robichaux sent Isbell to the back staircase to make sure nobody re-entered. It was quiet there, and Isbell sat alone, drained and upset. Isbell said she thought about her patients, remembering with guilt a promise she made to the daughter of one of her favorites, Alice Hutzler, a 90-year-old woman who came to LifeCare for treatment of bedsores and pneumonia. Isbell fondly called her Miss Alice and had told Hutzler’s daughter that she would take good care of her mother. Now Isbell prayed that help would come before Hutzler and her other patients died.

According to statements made to investigators by Steven Harris, the LifeCare pharmacist, Pou brought numerous vials of morphine to the seventh floor. According to investigators, a proffer from Harris’s lawyer said that Harris gave her additional morphine and midazolam — a fast-acting drug used to induce anesthesia before surgery or to sedate patients for medical procedures. Like morphine, midazolam depresses breathing; doctors are warned to be extremely careful when combining the two drugs.

Kristy Johnson, LifeCare’s director of physical medicine, said she saw what happened next. She told Justice Department investigators that she watched Pou and two nurses draw fluid from vials into syringes. Then Johnson guided them to Emmett Everett in Room 7307. Johnson said she had never seen a physician look as nervous as Pou did. As they walked, she told investigators, she heard Pou say that she was going to give him something ‘‘to help him with his dizziness.’’ Pou disappeared into Everett’s room and shut the door.

As they worked their way down the seventh-floor hallway, Johnson held some of the patients’ hands and said a prayer as Pou or a Memorial nurse gave injections. Wilda McManus, whose daughter Angela had tried in vain to rescind her mother’s D.N.R. order, had a serious blood infection. (Earlier, Angela was ordered to leave her mother and go downstairs to evacuate.) ‘‘I am going to give you something to make you feel better,’’ Pou told Wilda, according to Johnson.

Johnson took one of the Memorial nurses into Room 7305. ‘‘This is Ms. Hutzler,’’ Johnson said, touching the woman’s hand and saying a ‘‘little prayer.’’ Johnson tried not to look down at what the nurse was doing, but she saw the nurse inject Hutzler’s roommate, Rose Savoie, a 90-year-old woman with acute bronchitis and a history of kidney problems. A LifeCare nurse later told investigators that both women were alert and stable as of late that morning. ‘‘That burns,’’ Savoie murmured.

Dr. Bryant King at his home in Indianapolis. He was angered by the way patients and other citizens were treated by the hospital. (Paolo Pellegrin/Magnum Photos)According to Memorial workers on the second floor, about a dozen patients who were designated as ‘‘3’s’’ remained in the lobby by the A.T.M. Other Memorial patients were being evacuated with help from volunteers and medical staff, including Bryant King. Around noon, King told me, he saw Anna Pou holding a handful of syringes and telling a patient near the A.T.M., ‘‘I’m going to give you something to make you feel better.’’ King remembered an earlier conversation with a colleague who, after speaking with Mulderick and Pou, asked him what he thought of hastening patients’ deaths. That was not a doctor’s job, he replied. Patients were hot and uncomfortable, and a few might be terminally ill, but he didn’t think they were in the kind of pain that calls for sedation, let alone mercy killing. When he saw Pou with the syringes, he assumed she was doing just that and said to anyone within earshot: ‘‘I’m getting out of here. This is crazy!’’ King grabbed his bag and stormed downstairs to get on a boat.

Bill Armington, the neuroradiologist, watched King go and was upset at him for leaving. Armington suspected that euthanasia might occur, in part, he told me, because Cook told him earlier that there had been a discussion of  ‘‘things that only doctors talk about.’’ Armington headed for the helipad, “stirred up,’’ as he recalls, ‘‘to intensify my efforts to get people off the roof.’’ Neither Armington nor King intervened directly, though King had earlier sent out text messages to friends and family asking them to tell the media that doctors were discussing giving medication to dying patients to help accelerate their deaths. King told me that he didn’t think his opinion, which hadn’t mattered when he argued against turning away the hospital’s neighbors, would have mattered.

Only a few nurses and three doctors remained on the second floor: Pou; a young internist named Kathleen Fournier; and John Thiele, a 53-year-old pulmonologist, who had never before spoken publicly about his Katrina experiences until we had two lengthy interviews in the last year. Thiele told me that on Thursday morning, he saw Susan Mulderick walking out of the emergency room. ‘‘John, everybody has to be out of here tonight,’’ he said she told him. He said René Goux told him the same thing. Mulderick, through her lawyer, and Goux both say that they were not given a deadline to empty the hospital and that their goal was to focus their exhausted colleagues on the evacuation. ‘‘We’d experienced the helicopters’ stopping flying to us,’’ Goux told me, ‘‘and I didn’t want that to occur again.’’

Around a corner from where the patients lay on the second floor, Thiele and Fournier struggled to euthanize two cats whose owners brought them to the hospital and were forced to leave them behind. Thiele trained a needle toward the heart of a clawing cat held by Fournier, he told me later. While they were working, Thiele recalls Fournier telling him that Mulderick had spoken with her about something to the effect of putting patients ‘‘out of their misery’’ and that she did not want to participate. (Fournier declined to talk with me.) Thiele told her that he understood, and that he and others would handle it. Mulderick’s lawyer says that Mulderick did ask a physician about giving something to patients to ‘‘make them more comfortable,’’ but that, however, was not ‘‘code for euthanasia.’’

Thiele didn’t know Pou by name, but she looked to him like the physician in charge on the second floor. He told me that Pou told him that the Category 3 patients were not going to be moved. He said he thought they appeared close to death and would not have survived an evacuation. He was terrified, he said, of what would happen to them if they were left behind. He expected that the people firing guns into the chaos of New Orleans — ‘‘the animals,’’ he called them — would storm the hospital, looking for drugs after everyone else was gone. ‘‘I figured, What would they do, these crazy black people who think they’ve been oppressed for all these years by white people? I mean if they’re capable of shooting at somebody, why are they not capable of raping them or, or, you know, dismembering them? What’s to prevent them from doing things like that?’’

The laws of man had broken down, Thiele concluded, and only the laws of God applied.

‘‘Can I help you?’’ he says he asked Pou several times.

‘‘No,’’ she said, according to Thiele. ‘‘You don’t have to be here.’’

‘‘I want to be here,’’ Thiele insisted. ‘‘I want to help you.’’

Thiele practiced palliative-care medicine and was certified to teach it. He told me that he knew that what they were about to do, though it seemed right to him, was technically ‘‘a crime.’’ He said that ‘‘the goal was death; our goal was to let these people die.’’

Thiele saw that morphine, midazolam and syringes had been set up on a table near the A.T.M. There were about a dozen patients, and he took charge of the four closest to the windows — three elderly white women and a heavyset African-American man — starting IVs on those who didn’t have one. Apart from their breathing and the soft moans of one, the patients appeared ‘‘lifeless’’ and did not respond to him. Thiele saw Pou and several nurses working on patients lying near the hallway.

Thiele wavered for a moment. He turned to Karen Wynn, the I.C.U. nurse manager at Memorial who led the hospital’s ethics committee. ‘‘Can we do this?’’ he remembers asking the highly respected nurse.

Wynn felt that they needed to medicate the patients, she said when she described her experiences publicly for the first time in interviews with me over the past year. She acknowledged having heard rumors that patients were being euthanized, but she said no one had told her that that was what was happening to these patients and that her only aim was to make patients comfortable by sedating them. Wynn said she did not fear staying in the hospital after the 5 p.m. curfew announced by the State Police — she had already decided to ignore the evacuation deadline and stay at the hospital until everyone alive had been taken out. Instead, she said, she was motivated by how bad the patients looked.

Wynn described turning to an elderly woman who was unconscious with labored breathing. She then prepared a syringe with morphine and midazolam, pushed it slowly into the woman’s IV line and watched her breathing ease. The woman died a short time later, which didn’t disturb Wynn because she had appeared to be close to death. Wynn told me that at that point all the staff could offer was ‘‘comfort, peace and dignity.’’ She said: ‘‘We did the best we could do. It was the right thing to do under the circumstances.’’

She added: “But even if it had been euthanasia, it’s not something we don’t really do every day — it just goes under a different name.’’

Thiele gave other patients a shot of morphine and midazolam at doses he said were higher than what he normally used in the I.C.U. He held their hands and reassured them, ‘‘It’s all right to go.’’ Most patients, Thiele told me, died within minutes of being medicated. But the heavyset African-American man didn’t.

Bodies were placed in Memorial's chapel on the second floor of the hospital. (Tony Carnes/Christianity Today)His mouth was open, his breathing was labored and everyone could hear his awful death rattle. Thiele tried more morphine. He tried prayer. He put his hand on the man’s forehead; Wynn and another nurse manager took the man’s hands in theirs. Together they chanted: ‘‘Hail Mary, full of grace. The Lord is with thee.’’ They recited the Lord’s Prayer. They prayed for the man to die.

The man kept breathing, and Wynn says she and her colleagues took that as a sign. ‘‘God said, ‘O.K., but I’m not ready for him.’ Or he wasn’t ready.’’ She remembers passing him through the hole in the machine-room wall on his way to the evacuation helicopters.

Thiele has a different memory of what happened. ‘‘We covered his face with a towel’’ until he stopped breathing, Thiele told me.

He says that it took less than a minute for the man to die and that he didn’t suffer. ‘‘This was totally against every fiber in my body,’’ Thiele told me, but he also said he knew what he did was right. ‘‘We were abandoned by the government, we were abandoned by Tenet, and clearly nobody was going to take care of these people in their dying moments.’’ He added, ‘‘I did what I would have wanted done to me if the roles were reversed.’’

Both Thiele and Wynn recall that they, Pou and the other nurses covered the bodies of the dead and carried them into the chapel, filling it. Thiele said the remaining bodies were wrapped in sheets and placed on the floor in the corridor and in a nearby room.

‘‘It was very respectful,’’ Thiele told me. ‘‘It’s not like you would think.’’

That afternoon, Memorial’s pathologist and laboratory director walked though the hospital, floor by floor, to record the locations of the dead and make sure that nobody alive was left behind. They found Pou on the seventh floor with a nurse. Pou was working on the IV of a patient who seemed barely alive. The laboratory director told investigators that Pou asked for help moving the patient; the pathologist remembered it differently and said in a deposition that he offered Pou help with evacuating the patient, but Pou did not respond, and later, when he asked her again, she said she needed to speak with an anesthesiologist first.

Dr. John Walsh, a surgeon, told me that he was sitting on a bench, too tired to move, when Pou and the pathologist came downstairs. Pou looked upset. She sat down beside him. ‘‘What’s wrong?’’ he asked. He said she mentioned something about a patient, or patients, dying and about someone, or some people, questioning her.

Walsh had known Pou for about only a year, but he knew, he told me, that she was compassionate and dedicated to her patients. ‘‘I’m sure you did the right thing,’’ he remembers telling her. ‘‘It’ll work itself out. It’ll all turn out O.K.’’

I just don’t understand this type of decision making.  I am not a medical professional, nor am I here to judge. However, I don’t understand the logic behind evacuating the sickest patients last.  I would think that they would get top priority.  No matter how I look at this, the reasoning seems illogical…

Jessica O'Neill

Aug. 27, 2009, 2:39 p.m.

While our deeper human compassion might suggest to us that the most in need, the most sick, should be rescued first, the reality is very different for good reasons.  Those most likely to survive the trip (i.e. the ‘most well’) get first priority so that the very limited resources involved in a rescues are used on a greater number.  Those who find themselves at the end of such a triage are in further diminishing categories of survivability.  International triage standards for any mass casualty situation (think bombing, train crash, etc) is to not focus on the most heavily injured but on those most likely to survive with as little as possible intervention from the 1st responder.  To have it any other way would mean, for example, that a responder might be ‘stuck’ performing CPR etc on someone not likely to survive when they could be using their training towards helping the 10 other victims with less-life threaten injuries. 

As we have further distanced ourselves from death in this society, few who read this article have see the very tail end of what we call ‘life’: heavy machinery, constant supervision, lack of mobility, electricity…all things which quickly become near-impossible to secure resources during a disaster on the scale of Katrina.  We may all derive some small comfort from the fact that most hospitals are well equipped to handle disaster (in fact, full evacuation is almost unheard of for a medical facility pre-Katrina for good reason) but that doesn’t ease the disease we have when we hear of such utterly heartbreaking ethical decisions.

My elderly father had been a dues-paying member of a famous HMO for 40 years when he broke his hip.  The Triage Nurse denied him access to the HMO’s hospital.  Two days later he died.  This was NOT any kind of emergency situation like Katrina.  As a society we should become more honest in our discussions and debates about how the medical community is actually treating our elderly.

A tragic situation like Katrina simply does not relieve caregivers of the obligation to follow the law.  The deliberate ending of the life of a patient is a criminal act.  Instead of changing the law to grant an exception for medical personnel in disasters, existing law should be enforced.  For prosecutors to refuse to present their strongest witnesses is tantamount to dereliction of duty.  If the account in this story is true, there seems little alternative but to release the 50,000 pages of evidence and to pursue a federal criminal prosecution.

audrey fisher

Aug. 29, 2009, 1 p.m.

What would have happened if all of the healthcare professionals had walked away to save their own families as one physician did?  Did he face prosecution?  NO.

Although this article is heart wrenching, people who were there will (unconsciously) nuance their stories to justify their own actions of their participation in that event.  That is normal human behavior.

I am curious if those who want prosecution of those arrested from Memorial are also seeking prosecution of those who authorized torture of detainees on foreign soil. 

From the comfort of an armchair, it is easy to pronounce judgement, but for those who were directly and intimately involved, I am betting they have their own misgivings (what could I have done better or different) and are working to assure that their own nightmare never has to be contemplated by others.

Should the citizens of NewOrleans be suing the state or FEMA for leaving them at the Civic Center or moving them to a highway without food/water, taking them to the airport and abandoning them there?  Must we always seek retribution for perceived wrongs against us?

I don’t have all the answers, but at least I do have questions.  I don’t condone any of the negative occurrences post Katrina, but prosecuting one physician does not seem to be the answer either.

As a nurse in a neuro intensive care, where many of our patients are admitted with catastrophic brain injury, I have hastened the deaths of patients by pharmaceutical means to provide comfort to them after life support is withdrawn.  I have even gone so far as to hasten a death this way to provide comfort for a grieving spouse when I was sure that the patient couldn’t possibly have any subjective experience of discomfort, but the appearence of their death was torture for the surviving spouse.  I am comfortable with hastening death where appropriate.  I cannot fathom administering a lethal cocktail to someone who can talk to me while I’m doing so, even if they consented to the death, much less as a covert act of so-called mercy.

My moral outrage, however, coexists uneasily with an understanding of how hard being a physician or nurse is under ideal circumstances. I cannot imagine trying to do it without electricity or other essential resources for days on end, with no sense of when the ordeal would end.

I guess I could forgive abandoning the patients until or unless more help was forthcoming. This too goes against my professional code of ethics, but it’s preferable to the grisly alternative.

Patricia Minson

Aug. 29, 2009, 11:25 p.m.

Is this the kind of work ProPublica plans to bring us? An insipidly narrow and cynical indictment of doctors trying to do the right thing? Little public good will emerge from this story. Doctors will become even more fearful of legal action than they already are, prompting them to order more futile, defensive measures for terminally ill patients and further driving up health care costs. Is the point of this story, to further bankrupt our health care system?

Also, one has to consider the tactics of the reporter. Surely many of the doctors and nurses who spoke most frankly about end-of-life care would never have done so had they known Fink was intent on a hit piece. It seems unavoidable that she misrepresented the angle of the story to her sources.

I work in a hospital as a Respiratory Therapist…

To read this account, suboptimal as so many people refused to talk to the reporter, can have you shudder at the thought of what this must have been like. 

Too bad that there couldn’t be some broad immunity for everyone, a fund established to pay out any civil claims decided, so that EVERYBODY involved could give full testimony as to what happened.  What happened and why needs to be fully explored and analyzed so that the appropriate logistical and ethical lessons can be learned.  Instead it degenerated into a legal/bureaucratic/PR/civil suit morass. 

If you are forced to leave a patient ..(though in this case a lot of the racist fear and hysteria was whipped up needlessly)...

And the patient will suffer and die a horrible death unattended…

Can there then be a pro-active form of palliative care when one if forced by circumstances to act in a way that ensures future suffering doesn’t occur…but the immediate goal then becomes the death of the patient.  ?? 

And, when this decision is made for a large number of patients, can then “the task” get away from your ethical center—such that one doesn’t see the trees for the forest?  A slippery slope where crossing the Rubicon without clear boundaries cascades? 

We’ve all seen war movies (OK some of us) where a horribly injured soldier on the battlefield is shot by his comrades in order to alleviate the suffering.  We don’t call it murder.

On the one hand, as I read this, I did try to put myself in the shoes of the staff: utterly squalid conditions that were unlike anything they had ever encountered, lack of sleep, misinformation, fear, and yes, barely contained biases (Dr. Thiele?), all of which together hindered effective decision making.  I think, given the complete failure of civil government at all levels during hurricane Katrina, it would have been inappropriate to single her out, or those who worked with her.

And yet, I am deeply disquieted by Dr. Pou’s determined effort to “rehabilitate” herself and to immunize her own decision making not just from the law, but from public opinion.  Her efforts then and now have to be viewed in light of some other factors:

Why did these doctors feel they had the right to assume control and shut out others like Dr. King, with less radical ideas? 

What possible justification did they have for trying to prevent people from rescuing their own family members under circumstances that were as extreme as they now claim? 

Why didn’t these doctors make an effort to take sleeping shifts so that they could operate at a higher level at other times? 

Why were staff who were willing to stay told they had to leave? 

Even to a layperson, Dr. Pou’s decision to view a DNR order as determinative is an inappropriate shortcut to making an actual, informed decision. 

As I read this, I kept thinking of Dr. Pou as the character in “The Fall/La Chute” by Albert Camus: having faced an ethical challenge, her real failing is to continue to defend and protect herself rather than to understand the inadequacy of her own response, however understandable at the time, and try to make sure she or others like her don’t have to face such awful circumstances in the future. 

Sorry, Dr. Pou, however difficult it might have been, I am certain I don’t want you taking care of me or anybody I love.  Your streak of self-rationalization runs to deep.

I am a physician who was at another hospital in Orleans Parish during Katrina.  Though I and the others at my hospital where also faced with dire circumstances, the experience was entirely different.  Medical care continued, the hospital had clear leadership, and even family members and non-staff pitched in to get the job done. 

I am horrified at the actions of many of the physicians at Memorial Hospital described in this story.  Public opinion in New Orleans has always been on the side of the healthcare providers in this story, but I cannot condone—in any circumstance—the active administration of medications intended to cause death.

I read the whole story. A harrowing ordeal to say the least.

I think the police hold some responsibility for ordering everyone out by 5 p.m., ordering the impossible. If they were informed of the circumstances then they were in fact ordering these people to abandon these patients alive.

Martial law had not been declared so it doesn’t seem the police had any position to give such an order. They could have strongly recommended yes but to order the patients to be abandoned and to say that they would not protect the medical staff and patients inside from civil unrest? No. The civil suit should be put on the police.

Question #1. Were the police informed of the situation before they ordered the hospital to be abandon?

Plus, with a near empty hospital and intermittent gunfire outside the building, they had a wide array of objects to block all doors and stairways with to secure for one more night. Plus it is said in the story that L. René Goux the chief executive of the hospital distributed guns to security and maintenance staff without any reference to where the guns came from.

Question #2. If the guns didn’t then arrive from an outside source, just what is Goux doing with so many guns, a weapons cache at a hospital? If this is common for hospitals doesn’t that make the hospital, staff and patients a target for a criminal takeover and a mass kill with their own guns or an outright hostage situation?

Question #3. What is Dr. Ewing Cook, a senior physician at the hospital doing carrying a handgun? Isn’t that antithetical to the principles of a doctor to not inflict harm in the event of the Hippocratic Oath? Some doctors don’t take that oath since it isn’t a requirement anyway so whether Cook did or not is unknown to me.

The saddest part for me is, had I been there these people would have been at the helipad even if the heaviest was 350 pounds. Explaining that is a matter of grade school science class and a last stoke of whatever food and water is left for the final haul. If that is all gone then even a shot of amphetamine from the doc would have been better than nothing. Had they died then it would have been for lack of a helicopter instead of a lack of knowledge of how to move heavy things and even more so with gravity doing most of the work.

These patients were left behind dead so the most compelling question of all for me is, considering that these people were literally exhausted and could not go on which is why they did what they did, when the morgue detail arrived the story said that all these people on the 7th floor were down there in the chapel.

Question #4. Now, how did the dead get down 7 flights of stairs to be the chapel after the medical staff had left?

As this is a forum for offering comment and opinion, here are mine: I agree and disagree.

I agree that Dr Pou, Ms Landry and Ms Budo are not the only ones culpable, but if the Nuremburg defense was not viable then, it is no more viable now: doing what one has been told or what was “suggested” is still a matter of criminality. If anything, this investigation shows that the culpability was a bit more widespread and complicated than at first believed, and the original source of the idea should also be held responsible. Also, the person who “managed” this emergency should be cited for the poor organization of emergency response that allowed people to be in such straits that they even considered this as a correct choice. There were some excellent suggestions above, and thank goodness we have better plans and preparation now.

I can’t even begin to imagine the breakdown in character that is necessary to sacrifice the lives of others to save yourself, especially if that is in direct contradiction to the ethics of your chosen profession. And I’m sorry, but the CMH usually goes to the soldier who either put his own life at risk to save others or sacrificed himself to save his comrades, not the man who regrettingly pulls the trigger on his fallen. Giving the man a grenade or leaving him with a gun at least gives him a choice, but I could argue this point when it is tangential, at best.

These folks were not offered a choice; I’m willing to bet, however, that if presented with it, THEY at least would have been more willing than their caregivers to sacrifice themselves for the “Greater Good”.

Dr Pou’s question about how long should a care provider stay with a terminal patient? Until the end, and only until the naturally occurring end.

The thing is, Dr Pou, you don’t know when that will be. No one on earth knows. And no matter how you choose to end your own pain and confusion over this matter, you cannot stand in what you did and call it right. Learning from a mistake requires owning it.

For those of you who disagree with me, that is your right. Kindly announce that to me before I agree to be your patient, if you are a health care provider, and I will be happy to find someone else who is more in line with my ethics. I would rather do that than attempt retribution when you fail to live up to my expectations. I am not litigious; lawsuits don’t undo the past, they just give some folks hesitation that doesn’t need to be there.

See, I expect you (even a doctor) to be human, and I expect you to make mistakes. But I also expect you to do everything you can to save my life, as my care giver, and not make as your purpose to end my life for your convenience.

I am not a doctor, and it may be that you will doubt what I have to say next. That is all right; I can’t make this palatable to everyone.

I am a mother, and I am a protector. When the situation calls for it, I am a warrior. I would not leave these patients and would face down ANYONE who dared to tell me that I should. I would not allow anyone to administer a lethal dose of anything to anyone in my care. I would be the last the leave the hospital, not my patients. Triage would also demand, I should think, that those in immediate danger of loss of life get immediate care, and that those who aren’t “as sick”, as long as they are stable, can remain so until another patient’s crisis has passed. It’s not rocket science—its prioritization based on what you’re commmitted to do.

It isn’t a matter of circumstance or condition, backed up toilets, lack of sleep, poor planning, fatigue or malnourishment. It’s a matter of integrity, and how well you back up your integrity with your will. To allow anything else to be a determinant is a lie.

My hat’s off to the physician who realized in retrospect that he shouldn’t have left when he did; he at least realized what he did, and probably won’t repeat it.

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I can’t help but pose a question concerning Emmett Everett.

As far as the story goes he was a paraplegic in his legs and not his arms since he fed himself breakfast, was talkative and aware of his surroundings and in good spirits, miserably uncomfortable like everyone else but not dying of anything and was not recovering from surgery since he had been operated on yet.

He was chosen to die because of his weight and I think that was unnecessary and unacceptable. Given a wheelchair his status was probably ambulatory but was assigned as a 3.

He had use of his arms so there was no harm in telling him anywhere between 5 pm and 9 pm (staff left) the facts of the situation, and leaving him with a couple of guns and ammunition so that he would have a fighting chance in the event any of the rouges outside the hospital got in there and sadly, in a worst case scenario would have had the means to end his own life, of which if I was the doctor, would be a far better alternative than a homicide charge on me.

It is said that Emmett Everett even pleaded for his life, “Don’t let them leave me behind.” That would have been enough for me to engage to Coast Guard to try and help get him out of there.

Being told that I imagine myself as Emmett Everett and what I might have said, “I understand, you guys are exhausted and I weigh 380 pounds. When the helicopter arrives please ask the Coast Guard guys who are strong soldiers and not exhausted to help get me out of here.”

If I were the doctor I would have done just that and if the Coast Guard refused I again would have offered Emmett Everett a couple guns and ammo to hold him until the Coast Guard can get back with a couple guys to get him out of there.

That’s why I think there is or was no rhyme or reason for Emmett Everett’s death since he could have held his own until morning.

Question #1. Was any intention to kill Emmett Everett put off until the last minute and euthanized after the Coast Guard was asked to help get him out but refused or did they entirely skip asking the Coast Guard to help in getting him out, taking it for granted that the Coast Guard would say no anyway and euthanized him?

Question #2. Was Everett told of the situation and offered any food/water, guns and ammo to hold him alone until the next day on the premise that the Coast Guard would be informed of his presence and would be back in the morning with more help.

Question #3. Would the Coast Guard have helped get Everett off the 7th floor and onto the chopper if they had been asked to?

A few points.  Comparing Dr. Pou’s defense to the one at Nuremberg (“I was just following orders”) is a bit much.  What happened at New Orleans was not the outgrowth of some underlying philosophy or genocidal mindset (like Germany, Sudan, Rawanda, Bosnia, etc.).  The healthcare clinicians were put in a very difficult and unexpected situation.  A lack of command, bad decisions snowballing down slippery slopes, etc. 

While I admire the job the reporter did it is also patently clear so many people declined to be interviewed such that I don’t think we still have the whole truth…or enough to really come to an informed analysis of what went wrong. 

Instead the convoluted and torturous plot goes on…Murder charges filed, murder charges dropped, Dr. Pou wins PR war, then Dr. Pou loses PR war, civil suits languish in court over the years.  Ten years from now someone writes a fairly comprehensive book about it.  Most people say “what is that about?”. 

Dr. Pou and the nurses were charged with murder.  They fought back legally and from a PR angle.  As described in the article they won the legal fight, but still have PR issues and civil suits pending. 

I participate in some Disaster Preparedness email groups.  There are discussions about triage if a severe and deadly pandemic strikes—-should we take patients off ventilators who are very sick and almost certainly going to die anyway in order to use them on a patient who might be saved and has a better chance of recovery with a meaningful quality of life?  Imagine the ICU is filled with patients on ventilators fitting the following profile——90 year old post cardiovascular surgery for CABG and AVR, with heart failure, renal failure, kidney failure.  being evaluated for obviously marked neurologic defects.  Wealthy patient and family who have insisted “everything be done” because “he’s a fighter”. 

Meanwhile down in the ER a bunch of flu victims are being intubated and need to be moved to the ICU and be placed on ventilators.  Many of them are undocumented. 

There are guidelines being developed today in order to address triage in this situation—-taking some patients off ventilators in order to make room for others.  (and if a panel has come up with this guideline?).  Those patients removed from mechanical ventilation will have to be given enough medicine to relieve the resultant distress and suffering.  I am not making this up or advocating it, it’s what on the disaster menu. 

Sounds like the subplot for a movie.

Again I feel that this particular incident should be handled by a Truth Commission of sorts.  Grant immunity from prosecution for all, grant immunity from professional licensure revokation to all, a fund to handle any civil claims.  Then elicit a full and truthful (as can be) accounting from all involved.  Use such to analyze, come up with lessons and guidelines. 

The other aspect of this story which I find interesting is the cascade of false (racist) rumors which were then whipped up and seized upon predictably by certain types of personalities.  If you watch “The Office” I’m speaking about the character played by Rain Wilson—Dwight Schrute.  When a major disaster strikes the Dwight Schrutes come out of the woodwork.  You know the kind..they get a warm fuzzy feeling when they talk about how there were summary executions during the SF 06 Earthquake for looters. 

In Ms. Finks article there was a consistent thread of “Schrutism” running through.

Jeff Whitnack:  I noticed the same thing—to the point that the response was what I would call “overdetermined,” or as much the result of the staff’s fears stoked by certain individuals, as it was
required by actual objective circumstance.  The fact that doctors were traipsing around with guns, and rejecting as “denialism” the efforts of others to maintain normal routine treatment as much as possible, is a sign that this is exactly what happened.

As another commenter noted, this was the only hospital out of several similarly affected in which anything so horrible happened.  That, right there, is a powerful sign that organizations and people failed at Memorial.  Perhaps focusing on what other hospitals did to avoid the result at Memorial would be a more useful exercise, which would also, happily, undermine Dr. Pou’s claim to insight as an expert in lifeboat medical ethics.

Just as the staff in this hospital made decisions without consulting those under their care - or others who might have held differing opinions - Dr.Fink points out that the U.S. medical community is proceeding with developing protocols for patient care during a disaster without consulting the public they serve.
Thank you, Dr. Fink, for bringing this important issue to light in such a powerful and profound way. Hopefully your hard work will pay off in provoking greater public debate about these protocols before decisions are made that have the potential to affect all of us.

Did Dr. Fink point that out as regards disaster preparedness?  I must have missed that. 

I don’t know what the mechanism would be for “consulting the public they serve” as regards disaster preparedness, in the context especially of resource allocation and re-allocation per triage.  Would this be a bill in Congress, state referendums, etc.  Is there any way that some bill or referendum would ever be anything other than a muddled document which wouldn’t cover all the bases anyway? 

There is a response from Dr. Pou’s attorney to the recent NY Times article.

The link is

http://www.drannapou.com/legalreply.html

Lots of slippery slopes.  Dr. Pou was charged with murder and then reacted with a combination Legal and PR campaign (as would anybody).  Then there is ongoing civil matters as well.  But it’s probably another in a series of slippery slopes as she then gets invited to speak as a “Poster Child” for disaster response (a whole cottage industry and don’t get me started on that!). 

Don’t get me wrong—I think Dr. Pou probably has a lot of valuable information and experience to impart….but not necessarily as an expert but rather more as an “Accidental Tourist”.  And it needs to be done with full and open information—something not possible for her now.

Kudos to Dr. Fink for taking on this complex piece of investigative reporting. I’m not sure what I find more shocking: the decisions made at Memorial, or the response among many that these doctors and nurses be “left alone” and lauded as heroes for their actions.
  I was a physician at Charity Hospital during Katrina, and I am still struggling to understand WHY the situation at Memorial became what is described in this article. In the many meetings among our hospital staff during that difficult week (we actually had regular meetings every four hours), there was never any discussion or even thought that we would stop treating patients medically, administer lethal doses of medication, or leave before every patient was evacuated alive. Only two patients out of hundreds of patients died during that week—-unlike the nearly 1 out of every 4 who perished at Memorial.
  What were the circumstances that led to such different outcomes? The conditions at Charity were not better—in fact, our generators failed two days earlier (Monday Aug 29th) and the hospital was not evacuated until a day after Memorial (Friday). Nor were the patients less acutely ill—since Charity was a Level One Trauma Center, the patients were actually the “sickest of the sick” and included many ventilator-dependent ICU patients and people with end-stage AIDS. Certainly, revisiting the situation in the hospitals during this disaster is important so we can identify the mistakes, and so we are not doomed to repeat them.
    It is absurd for people to suggest that in such difficult conditions, doctors and nurses are beyond scrutiny and should not be held accountable for their actions. Yes, I hold many government officials responsible for the atrocious lack of response. I am angry that my patients had to wait nearly a week in inhumane conditions while we tried to practice medicine in a very basic way. But I am also furious when I read statements from Dr. Cook that he “couldn’t imagine” the staff carrying down nine patients from the 5th floor. There is a saying in medicine that you should treat the patient as you would treat a family member.  It may be trite, but if Mr. Everett was your father or son or brother, who among us would not do everything possible to bring him down the stairs to waiting rescue? We had several paralyzed patients on my floor, and even a nearly 400 lb man with a broken hip in the hospital—I cannot imagine leaving them behind, or “hastening” their deaths.
    It seems like Drs. Cook and Thiele at least, and maybe others at Memorial, feel comfortable with what happened. The rest of us, however, will continue to be haunted by the horrific events there. I can only hope my residents and medical students will read such accounts in order to learn about how, during a disaster, human compassion can deteriorate so quickly.

If there ever were to be a “Truth Commission” of sorts—-and perhaps the culmination of courtroom and media exposure will provide us all with a delayed and convoluted version of such—-it would be a good idea to compare and contrast the differences between Charity and Memorial, and other local hospitals during the disaster.

One thing that strikes me is that, after reading the story by Fink, the very idea of there being Q4 Meetings at Memorial strikes one as both necessary and bizarre at the same time.  Bizarre both in the sense of logistics and in that the group mindset or “leadership” had already set a far different tone.  But very necessary almost as akin to a surgical pause.  But a different tipping point had already occurred at Memorial. 

I am reminded a bit of the “banality of evil” when Eichman’s trial was described.  This is another step removed in that the banality of whatever evil took place lacks any ideological foundation.  It was just a change in workflow. 

At Memorial the impression I get is of a dual scenario—- rats deserting a sinking ship and musical chairs.  Dr. Pou got left without a chair and “holding the bag”.

Well the comments have winded down, but something to add.  I just happened to be watching the movie “The Mist”, based on a Stephen King short story.  It has many themes similar to this topic.  A mist is generated as part of a rip in the universe, allowing many ravenous creatures to come across.  Scores of people are trapped in a supermarket and fighting for survival or escape.  The religious zealot who gets the mob riled up could be compared to the Dwight Schrute influence…the closing scene could be augmented by the father being arrested….then there is the dialogue at 1 hour 12 minutes in…

You don’t have much faith in humanity, do you?

None whatsoever

I can’t accept this, people are basically good, decent.  My God David, we’re a civilized society!

As long as the machines are working and you can dial 911.  But you take those things away….you scare the shit out of them….

I suspect comments have wound down due to Kiersta’s eloquent, powerful, factual and moving response.

NICOLE MCMANUS

Sep. 13, 2009, 3:06 p.m.

‘‘How long should health care workers have to be with patients who may not survive?’’ This is one question that boils my blood. At first, I hated this lady by the name of Ana Pou… how dare she take people’s lives into her own hands? Act as if she is God? But my faith will not let me give her that much of my energy! Romans 12:19 is all that I can think of when any stories arise about this “supposed” doctor Ana Pou. She has the nerve to get laws passed that would justify her acts in 2005. She never said she didn’t euthanized anyone, she just replies, she ‘‘helped’’ patients ‘‘through their pain.’’ Yes, she helped the DNR patients through their pain… just like veterinarians help wounded animals when they are in pain. She DNR-ed those patients (not Do Not Resuscitate… She Did Not Rescue). She made a decision that will FOREVER be with me and my family (especially my aunt who had to leave my grandmother’s side)!!! She Did Not Rescue my grandmother!!! She “helped” my grandmother “through her pain.” By “helping” my grandmother, I no longer have a grandmother. She is home with my Father and grandfather! The day I have to say RIP Wilda Faye Sims McManus is on September 1, 2005… who knows what day or time she actually went into eternal sleep, due to the lethal cocktail Ana Pou and those two nurses injected my grandmother with? She will get hers in the end… Vengeance is not mine, it’s the Lord’s! I pray for my family and the other families who lost a family member during this time… my heart goes out to you!

This article is part of an ongoing investigation:
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Deadly Choices

In the tragedy of Katrina, one hospital faced choices with the gravest of consequences.

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