The Deadly Choices at Memorial
The smell of death was overpowering the moment a relief worker cracked open one of the hospital chapel’s wooden doors. Inside, more than a dozen bodies lay motionless on low cots and on the ground, shrouded in white sheets. Here, a wisp of gray hair peeked out. There, a knee was flung akimbo. A pallid hand reached across a blue gown.
Within days, the grisly tableau became the focus of an investigation into what happened when the floodwaters of Hurricane Katrina marooned Memorial Medical Center in Uptown New Orleans. The hurricane knocked out power and running water and sent the temperatures inside above 100 degrees. Still, investigators were surprised at the number of bodies in the makeshift morgue and were stunned when health care workers charged that a well-regarded doctor and two respected nurses had hastened the deaths of some patients by injecting them with lethal doses of drugs. Mortuary workers eventually carried 45 corpses from Memorial, more than from any comparable-size hospital in the drowned city.
Investigators pored over the evidence, and in July 2006, nearly a year after Katrina, Louisiana Department of Justice agents arrested the doctor and the nurses in connection with the deaths of four patients. The physician, Anna Pou, defended herself on national television, saying her role was to ‘‘help’’ patients ‘‘through their pain,’’ a position she maintains today. After a New Orleans grand jury declined to indict her on second-degree murder charges, the case faded from view.
In the four years since Katrina, Pou has helped write and pass three laws in Louisiana that offer immunity to health care professionals from most civil lawsuits — though not in cases of willful misconduct — for their work in future disasters, from hurricanes to terrorist attacks to pandemic influenza. The laws also encourage prosecutors to await the findings of a medical panel before deciding whether to prosecute medical professionals. Pou has also been advising state and national medical organizations on disaster preparedness and legal reform; she has lectured on medicine and ethics at national conferences and addressed military medical trainees. In her advocacy, she argues for changing the standards of medical care in emergencies. She has said that informed consent is impossible during disasters and that doctors need to be able to evacuate the sickest or most severely injured patients last — along with those who have Do Not Resuscitate orders — an approach that she and her colleagues used as conditions worsened after Katrina.
Pou and others cite what happened at Memorial and Pou’s subsequent arrest — which she has referred to as a "personal tragedy" — to justify changing the standards of care during crises. But the story of what happened in the frantic days when Memorial was cut off from the world has not been fully told. Over the past two and a half years, I have obtained previously unavailable records and interviewed dozens of people who were involved in the events at Memorial and the investigation that followed.
The interviews and documents cast the story of Pou and her colleagues in a new light. It is now evident that more medical professionals were involved in the decision to inject patients — and far more patients were injected — than was previously understood. When the names on toxicology reports and autopsies are matched with recollections and documentation from the days after Katrina, it appears that at least 17 patients were injected with morphine or the sedative midazolam, or both, after a long-awaited rescue effort was at last emptying the hospital. A number of these patients were extremely ill and might not have survived the evacuation. Several were almost certainly not near death when they were injected, according to medical professionals who treated them at Memorial and an internist’s review of their charts and autopsies that was commissioned by investigators but never made public.
In the course of my reporting, I went to several events involving Pou, including two fund-raisers on her behalf, a conference and several of her appearances before the Louisiana Legislature. Pou also sat down with me for a long interview last year, but she has repeatedly declined to discuss any details related to patient deaths, citing three ongoing wrongful-death suits and the need for sensitivity in the cases of those who have not sued. She has prevented journalists from attending her lectures about Katrina and filed a brief with the Louisiana Supreme Court opposing the release of a 50,000-page file assembled by investigators on deaths at Memorial.
The full details of what Pou did, and why, may never be known. But the arguments she is making about disaster preparedness — that medical workers should be virtually immune from prosecution for good-faith work during devastating events and that lifesaving interventions, including evacuation, shouldn’t necessarily go to the sickest first — deserve closer attention. This is particularly important as health officials are now weighing, with little public discussion and insufficient scientific evidence, protocols for making the kind of agonizing decisions that will, no doubt, arise again.
At a recent national conference for hospital disaster planners, Pou asked a question: ‘‘How long should health care workers have to be with patients who may not survive?’’ The story of Memorial Medical Center raises other questions: Which patients should get a share of limited resources, and who decides? What does it mean to do the greatest good for the greatest number, and does that end justify all means? Where is the line between appropriate comfort care and mercy killing? How, if at all, should doctors and nurses be held accountable for their actions in the most desperate of circumstances, especially when their government fails them?
A Shelter From the Storm
Memorial Medical Center was situated on one of the low points in the bowl that is New Orleans, three miles southwest of the city’s French Quarter and three feet below sea level. The esteemed community hospital sprawled across a neighborhood of double-shotgun houses. Several blocks from a housing project but a short walk to the genteel mansions of Uptown, it served a diverse clientele. Built in 1926 and known for decades as Southern Baptist, the hospital was renamed after being purchased in 1995 by Tenet Healthcare, a Dallas-based commercial chain. For generations, the hospital’s sturdy walls served as a shelter when hurricanes threatened: employees would bring their families and pets, as well as coolers packed with muffulettas.
By the time Katrina began lashing New Orleans in the early hours of Monday, Aug. 29, some 2,000 people were bunking in the hospital, including more than 200 patients and 600 workers. When the storm hit, patients screamed as windows shattered under a hail of rocks from nearby rooftops. The hospital groaned and shook violently.
At 4:55 a.m., the supply of city power to the hospital failed. Televisions in patient rooms flicked off. But Memorial’s auxiliary generators had already thumped to life and were humming reassuringly. The system was designed to power only emergency lights, certain critical equipment and a handful of outlets on each floor; the air-conditioning system shut down. By that night, the flooding receded from the surrounding streets. Memorial had sustained damage but remained functional. The hospital seemed to have weathered one more storm.
The Evacuation Begins
Anna Pou was a 49-year-old head- and neck-cancer surgeon whose strong work ethic earned respect from doctors and nurses alike. Tiny and passionate, with coiffed cinnamon hair and a penchant for pearls, Pou was funny and sociable, and she had put her patients at the center of her life.
The morning after Katrina hit, Tuesday, Aug. 30, a nurse called to Pou: ‘‘Look outside!’’ What Pou saw from the window was hard to believe: water gushing from the sewer grates. Other staff members gaped at the dark pool of water rimmed with garbage crawling up South Claiborne Avenue in the direction of the hospital.
Senior administrators quickly grasped the danger posed by the advancing waters and counseled L. René Goux, the chief executive of Memorial, to close the hospital. As at many American hospitals in flood zones, Memorial’s main emergency-power transfer switches were located only a few feet above ground level, leaving the electrical system vulnerable. ‘‘It won’t take much water in height to disable the majority of the medical center,’’ facilities personnel had warned after Hurricane Ivan in 2004. Fixing the problem would be costly; a few less-expensive improvements were made.
Susan Mulderick, a tall, no-nonsense 54-year-old nursing director, was the rotating ‘‘emergency-incident commander’’ designated for Katrina and was in charge — in consultation with the hospital’s top executives — of directing hospital operations during the crisis. The longtime chairwoman of the hospital’s emergency-preparedness committee, Mulderick had helped draft Memorial’s emergency plan. But the 246-page document offered no guidance for dealing with a complete power failure or for how to evacuate the hospital if the streets were flooded. Because Memorial’s chief of medical staff was away, Richard Deichmann, the hospital’s soft-spoken medical-department chairman, organized the physicians.
At 12:28 p.m., a Memorial administrator typed ‘‘HELP!!!!’’ and e-mailed colleagues at other Tenet hospitals outside New Orleans, warning that Memorial would have to evacuate more than 180 patients. Around the same time, Deichmann met with many of the roughly two dozen doctors at Memorial and several nurse managers in a stifling nurse-training room on the fourth floor, which became the hospital’s command center. The conversation turned to how the hospital should be emptied. The doctors quickly agreed that babies in the neonatal intensive-care unit, pregnant mothers and critically ill adult I.C.U. patients would be at great risk from the heat and should get first priority. Then Deichmann broached an idea that was nowhere in the hospital’s disaster plans. He suggested that all patients with Do Not Resuscitate orders should go last.
A D.N.R. order is signed by a doctor, almost always with the informed consent of a patient or health care proxy, and means one thing: A patient whose heartbeat or breathing has stopped should not be revived. A D.N.R. order is different from a living will, which under Louisiana law allows patients with a ‘‘terminal and irreversible condition’’ to request in advance that ‘‘life-sustaining procedures’’ be withheld or withdrawn.
But Deichmann had a different understanding, he told me not long ago. He said that patients with D.N.R. orders had terminal or irreversible conditions, 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. Other doctors at the meeting agreed with Deichmann’s plan. Bill Armington, a neuroradiologist, told me 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 that stated this. At the time, those attending the meeting didn’t see it as a momentous decision, since rescuers were expected to evacuate everyone in the hospital within a few hours.
There was an important party missing from the conversation. For years, a health care company known as LifeCare Hospitals of New Orleans had been leasing the seventh floor at Memorial. LifeCare operated a ‘‘hospital within a hospital’’ for critically ill or injured patients in need of 24-hour care and intensive therapy over a long period. LifeCare was known for helping to rehabilitate patients on ventilators until they could breathe on their own. LifeCare’s goal was to assist patients until they improved enough to return home or to nursing facilities; it was not a hospice.
The 82-bed unit credentialed its own doctors, most of whom also worked at Memorial. It had its own administrators, nurses, pharmacists and supply chain. It also had its own philosophy: LifeCare deployed the full array of modern technology to keep alive its often elderly and debilitated patients. Horace Baltz, one of the longest-serving doctors at Memorial, told me of spirited debates among doctors over coffee about what some of his colleagues considered to be excessive resources being poured into hopeless cases. ‘‘We spend too much on these turkeys,’’ he said some would say. ‘‘We ought to let them go.’’
Many of the 52 patients at LifeCare were bedbound or required electric ventilators to breathe, and clearly, they would be at significant risk if the hospital lost power in its elevators. The doctors I spoke to who attended the meeting with Deichmann did not recall discussing evacuating LifeCare patients specifically, despite the fact that some of the doctors at the meeting worked with both Memorial and LifeCare patients.
In the afternoon, helicopters from the Coast Guard and private ambulance companies began landing on a long-unused helipad atop an eight-story parking garage adjacent to the hospital. The pilots were impatient — thousands of people needed help across the city. The intensive-care unit on the eighth floor rang out with shouts for patients: ‘‘We need some more! Helicopters are waiting!’’
A crew of doctors, nurses and family members carried Memorial patients down flights of stairs and wheeled them to the hospital wing where the last working elevator brought them to the second floor. Each patient was then maneuvered onto a stretcher and passed through a roughly three-by-three-foot opening in the machine-room wall that offered a shortcut to the parking garage. Many patients were placed in the back of a pickup truck, which drove to the top of the garage. Two flights of metal steps led to the helipad.
At LifeCare that afternoon, confusion reigned. The company had its own ‘‘incident commander,’’ Diane Robichaux, an assistant administrator who was seven months pregnant. At first everything seemed fine; Robichaux established computer communications with LifeCare’s corporate offices in Texas and was assured that LifeCare patients would be included in any FEMA evacuation of Memorial. But as the day wore on, the texts between LifeCare staff members and headquarters grew frantic as it became clear that the government’s rescue efforts and communications were in chaos.
According to the messages, Robichaux asked Memorial administrators to add her 52 patients to transport plans being organized with the Coast Guard. An executive at the hospital told Robichaux that permission would be requested from Memorial’s corporate owner, Tenet Healthcare. ‘‘I hope and pray this is not a long process for getting their approval,’’ Robichaux said in an e-mail message to her colleagues at headquarters. (A Tenet spokesman, David Matthews, wrote me in an e-mail message that LifeCare staff members turned down several offers of evacuation assistance from Memorial staff members on Tuesday afternoon.)
The doctors had now spent days on duty, under stress and sleeping little. Ewing Cook, one of the hospital’s most senior physicians, told me that he decided that in order to lessen the burden on nurses, all but the most critical treatments and care should be discontinued. When Bryant King, a 35-year-old internist who was new to Memorial, came to check on one of his patients on the fourth floor, he canceled the senior doctor’s order to turn off his patient’s heart monitor. When Cook found out, he was furious and thought that the junior doctor did not understand the circumstances. He directed the nurse to reinstate his instructions.
It was dark when the last of the Memorial patients who had been chosen for immediate evacuation were finally gone. Later that night, the Coast Guard offered to evacuate more patients, but those in charge at Memorial declined. The helipad had minimal lighting and no guard rail, and the staff needed rest.
Memorial had shaved its patient census from 187 to about 130. On the seventh floor, all 52 LifeCare patients remained, including seven on ventilators. ‘‘Been on the phone with Tenet,’’ a LifeCare representative outside the hospital wrote to Robichaux. ‘‘Will eventually be to our patients. Maybe in the morning.’’
Fateful Triage Decisions
At about 2 a.m. on Wednesday, Aug. 31 — nearly 48 hours after Katrina made landfall near New Orleans — Memorial’s backup generators sputtered and stopped. Ewing Cook later described the sudden silence as the ‘‘sickest sound’’ of his life. In LifeCare on the seventh floor, critically ill patients began suffering the consequences. Alarm bells clanged as life-support monitors and ventilators switched to brief battery reserves while continuing to force air into the lungs of seven patients. In about a half-hour, the batteries failed and the regular hiss of mechanical breaths ceased. A Memorial nurse appeared and announced that the Coast Guard could evacuate some critical patients if they were brought to the helipad immediately. Volunteers began carrying the LifeCare patients who relied on ventilators down five flights of stairs in the dark.
A LifeCare nurse navigated the staircase alongside an 80-year-old man on a stretcher, manually squeezing air into his lungs with an Ambu bag. As he waited for evacuation on the second floor, she bagged him for nearly an hour. Finally a physician stopped by the stretcher and told her that there was no oxygen for the patient and that he was already too far gone. She hugged the man and stroked his hair as he died.
Anna Pou began bagging another patient on the second floor to relieve a nurse whose hands were growing tired. That patient, along with two other LifeCare patients who relied on ventilators, also died early that morning, but the others were evacuated by helicopter. The hospital chaplain opened a double door with stained-glass windows down the hallway, and the staff began wheeling bodies into the chapel. Distraught nurses cried, and the chaplain held them and prayed with them.
The sun rose and with it the sultry New Orleans temperature, which was on its way to the mid-90s. The hospital was stifling, its walls sweating. Water had stopped flowing from taps, toilets were backed up and the stench of sewage mixed with the odor of hundreds of unwashed bodies.
Visitors who had come to the hospital for safety felt so desperate that they cheered when two airboats driven by volunteers from the Louisiana swamplands roared up to the flooded emergency-room ramp. The flotilla’s organizers, Mark and Sandra LeBlanc, had a special reason to come to Memorial: Vera LeBlanc, Mark’s 82-year-old mother, was at LifeCare, recovering from colon-cancer surgery. Sandra, an E.M.T., knew that her mother-in-law couldn’t swallow, so she was surprised when she saw that Vera and other patients who needed IVs to keep hydrated were no longer getting them. When her husband asked a Memorial administrator why, the administrator told him that the hospital was in survival mode, not treating mode. Furious, Mark LeBlanc asked, ‘‘Do you just flip a switch and you’re not a hospital anymore?’’
In the tragedy of Katrina, one hospital faced choices with the gravest of consequences.
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