Journalism in the Public Interest

The Deadly Choices at Memorial

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A Memorial Medical Center nurse fans a patient, who has the number 3 and D.N.R. written on his gown for triage category 3 and Do Not Resuscitate, waiting in the hospital's parking garage for helicopter transport from New Orleans on Sept. 1, 2005. (Brad Loper/Dallas Morning News/Corbis)

That morning, doctors and nurses decided that the more than 100 remaining Memorial and LifeCare patients should be brought downstairs and divided into three groups to help speed the evacuation. Those who were in fairly good health and could sit up or walk would be categorized ‘‘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 agreed the day before, those with D.N.R. orders.

Though there was no single doctor officially in charge of categorizing the patients, Pou was energetic and jumped into the center of the action, according to two nurses who worked with her. Throughout the morning, makeshift teams of medical staff and family members carried many of the remaining patients to the second-floor lobby where Pou, the sleeves of her scrubs rolled up, stood ready to receive them.

In the dim light, nurses opened each chart and read the diagnoses; Pou and the nurses assigned a category to each patient. A nurse wrote ‘‘1,’’ ‘‘2’’ or ‘‘3’’ on a sheet of paper with a Marks-A-Lot pen and taped it to the clothing over a patient’s chest. (Other patients had numbers written on their hospital gowns.) Many of the 1’s were taken to the emergency-room ramp, where boats were arriving. The 2’s were generally placed along the corridor leading to the hole in the machine-room wall that was a shortcut to the helipad. The 3’s were moved to a corner of the second-floor lobby near an A.T.M. and a planter filled with greenery. Patients awaiting evacuation would continue to be cared for — their diapers would be changed, they would be fanned and given sips of water if they could drink — but most medical interventions like IVs or oxygen were limited.

Pou and her co-workers were performing triage, a word once used by the French in reference to the sorting of coffee beans and applied to the battlefield by Napoleon’s chief surgeon, Baron Dominique-Jean Larrey. Today triage is used in accidents and disasters when the number of injured exceeds available resources. Surprisingly, perhaps, there is no consensus on how best to do this. Typically, medical workers try to divvy up care to achieve the greatest good for the greatest number of people. There is an ongoing debate about how to do this and what the ‘‘greatest good’’ means. Is it the number of lives saved? Years of life saved? Best ‘‘quality’’ years of life saved? Or something else?

At least nine well-recognized triage systems exist. Most call for people with relatively minor injuries to wait while patients in the worst shape are evacuated or treated. Several call for medical workers to sort the injured into another category: patients who are seen as having little chance of survival given the resources on hand. That category is most commonly created during a devastating event like a war-zone truck bombing in which there are far more severely injured victims than ambulances or medics.

Pou and her colleagues had little if any training in triage systems and were not guided by any particular triage protocol. Pou would later say she was trying to do the most good with a limited pool of resources. The decision that certain sicker patients should go last has its risks. Predicting how a patient will fare is inexact and subject to biases. In one study of triage, experienced rescuers were asked to categorize the same patients and came up with widely different answers. And patients’ conditions change; more resources can become available to help those whose situations at first appear hopeless. The importance of reassessing each person is easy to forget once a ranking is assigned.

After several helicopters arrived and rescued some of the LifeCare patients, Air Force One flew over New Orleans while President Bush surveyed the devastation. Few helicopters arrived after that. Pou told me she heard that the Coast Guard was focusing on saving people stranded on rooftops around the city. Meanwhile dozens of patients sweltered on the lower two floors of Memorial and in the parking garage as they waited to leave.

Mark and Sandra LeBlanc at home in New Orleans. They led a flotilla of boats to the hospital to save his mother, among others. (Paolo Pellegrin/Magnum Photos)Many of the doctors and nurses had shifted from caring for patients to carrying them and were loading people onto helicopters and watercraft. Vera LeBlanc, the LifeCare patient whose son arranged the airboat flotilla that had arrived hours earlier, was among the patients massed on the second floor. Her chart read ‘‘Do Not Resuscitate,’’ as it had during several hospital admissions for more than a decade, so that her heart would not be restarted if it were to stop. Mark LeBlanc decided he was going to put his mother on one of the airboats he and his wife had directed to the hospital. When the LeBlancs tried to enter the patient area on the second floor, a staff member blocked them, and several doctors told them they couldn’t leave with Vera. ‘‘The hell we can’t,’’ Sandra said. The couple ignored the doctors, and Vera smiled and chatted as Mark and several others picked her up and carried her onto an airboat.

On a seventh-floor hallway at LifeCare, Angela McManus, a daughter of a patient, panicked when she overheard workers discussing the decision to defer evacuation for D.N.R. patients. She had expected her frail 70-year-old mother, Wilda, would soon be rescued, but her mother had a D.N.R. order. ‘‘I’ve got to rescind that order,’’ Angela begged the LifeCare staff. She says they told her that there were no doctors available to do it.

By Wednesday afternoon, Dr. Ewing Cook was physically and mentally exhausted, filthy and forlorn. A 61-year-old pulmonary specialist, he’d had his semi-automatic Beretta strapped to him since he heard on Monday that a nurse was raped while walking her dog near the hospital (a hospital official denies that this happened). Cook had had two heart attacks and could not help transport patients in the heat.

That afternoon, Cook stood on the emergency-room ramp and caught sight of a mattress floating up Napoleon Avenue. On it lay an emaciated black woman, with several young men propelling her through the fetid water. ‘‘The hospital is closed,’’ someone shouted. ‘‘We’re not accepting anybody.’’

René Goux, the hospital’s chief executive, told me he had decided, for reasons of safety, that people floating up to Memorial should generally be directed to dry ground about nine blocks south. Medical workers finally insisted that the woman and her husband be allowed to enter, but the men who swam in the toxic soup to rescue her were told to leave. When a couple with small children rowed up and were told to ‘‘go away,’’ Bryant King, who was one of Memorial’s few African-American physicians, lost his temper.

‘‘You can’t do this!’’ King shouted at Goux. ‘‘You gotta help people!’’ But the family was turned away.

King was out of touch with reality, Cook told me he thought at the time. Memorial wasn’t so much a hospital anymore but a shelter that was running out of supplies and needed to be emptied. Cook also worried that intruders from the neighborhood might ransack the hospital for drugs and people’s valuables.

Recently retired from clinical practice, Cook became a Memorial administrator a week before Katrina hit, but he had spent many years working on the eighth floor in the I.C.U. That afternoon, he climbed slowly upstairs to check what was happening there. Most of the patients had been evacuated on Tuesday, but a few with D.N.R. orders had not.

‘‘What’s going on here?’’ he asked the four nurses in the unit. ‘‘Whaddya have left?’’ The nurses said they were down to one patient: Jannie Burgess, a 79-year-old woman with advanced uterine cancer and kidney failure. She was being treated for comfort only and had been sedated to the point of unconsciousness with morphine. She was so weighted down by fluid from her diseases that Cook sized her up at 350 pounds.

Cook later told me he believed several things: 1. Given how difficult it had been for him to climb the steps in the heat, there was no way he could make it back to the I.C.U. again. 2. Given how exhausted everyone was and how much this woman weighed, it would be ‘‘impossible to drag her down six flights of stairs.’’ 3. Even in the best of circumstances, the patient probably had a day or so to live. And frankly, the four nurses taking care of her were needed elsewhere.

To Cook, a drug that had been dripping into Burgess’s IV for days provided an answer. Morphine, a powerful narcotic, is frequently used to control severe pain or discomfort. But the drug can also slow breathing, and suddenly introducing much higher doses can lead to death.

Dr. Ewing Cook at his home near Lafayette, La. He says he did the right thing for a very ill woman when he 'hastened her demise.' (Paolo Pellegrin/Magnum Photos)Doctors, nurses and clinical researchers who specialize in treating patients near the ends of their lives say that this ‘‘double effect’’ poses little danger when drugs are administered properly. Cook says it’s not so simple. ‘‘If you don’t think that by giving a person a lot of morphine you’re not prematurely sending them to their grave, then you’re a very naïve doctor,’’ Cook told me when we spoke for the first time, in December 2007. ‘‘We kill ’em.’’

In fact, the distinction between murder and medical care often comes down to the intent of the person administering the drug. Cook walked this line often as a pulmonologist, he told me, and he prided himself as the go-to man for difficult end-of-life situations. When a very sick patient or the patient’s family made the decision to disconnect a ventilator, for example, Cook would prescribe morphine to make sure the patient wasn’t gasping for breath as the machine was withdrawn.

Often Cook found that achieving this level of comfort 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. To Cook, the difference between something ethical and something illegal ‘‘is so fine as to be imperceivable.’’

Burgess’s situation was ‘‘a little different,’’ as Cook described it. Being comatose and on painkillers, she wasn’t uncomfortable. But the worst thing Cook could imagine would be for the drugs to wear off and for Burgess to wake up and find herself in her ravaged condition as she was being moved. ‘‘Do you mind just increasing the morphine and giving her enough until she goes?’’ Cook told me he asked Burgess’s nurse.

Cook scribbled ‘‘pronounced dead at’’ in Burgess’s chart, left the time blank and signed the note with a large squiggle. Then he walked back downstairs, believing that he had done the right thing for Burgess. ‘‘To me, it was a no-brainer, and to this day I don’t feel bad about what I did,’’ he told me. ‘‘I gave her medicine so I could get rid of her faster, get the nurses off the floor.’’ He added, ‘‘There’s no question I hastened her demise.’’

The question of what to do with the hospital’s sickest patients was also being raised by others. By the afternoon, with few helicopters landing, these patients were languishing. Susan Mulderick, the ‘‘incident commander’’ who had worked with Cook for decades, shared her own concerns with him. According to Cook, Mulderick told him, ‘‘We gotta do something about this.’’ Mulderick, who declined to be formally interviewed about the days after Katrina, did tell me: ‘‘We were well prepared. We managed that situation well.’’

Cook sat on the emergency-room ramp smoking cigars with another doctor. Help was coming too slowly. There were too many people who needed to leave and weren’t going to make it, Cook said, describing for me his thinking at the time. It was a desperate situation and he saw only two choices: quicken their deaths or abandon them. ‘‘It was actually to the point where you were considering that you couldn’t just leave them; the humane thing would be to put ’em out.’’

Cook went to the staging area on the second floor where Anna Pou and two other doctors were directing care. Cots and stretchers seemed to cover every inch of floor space. Rodney Scott, an obese I.C.U. patient who was recovering from heart problems and several operations, lay motionless on a stretcher, covered in sweat and almost nothing else. A doctor had decided that he should be the last patient to leave the hospital because he weighed more than 300 pounds and might get stuck in the machine-room hole, backing up the evacuation line. Cook thought Scott was dead, and he touched him to make sure. But Scott turned over and looked at him.

‘‘I’m O.K., Doc,’’ Scott said. ‘‘Go take care of somebody else.’’

Despite how miserable the patients looked, Cook said, he felt there was no way, in this crowded room, to do what he had been thinking about. ‘‘We didn’t do it because we had too many witnesses,’’ he told me. ‘‘That’s the honest-to-God truth.’’

Richard Deichmann, Memorial’s medical-department chairman, also remembers being stopped by Mulderick for a quick conversation that afternoon, an episode he wrote about in ‘‘Code Blue,’’ a memoir he published in 2006 about the days after Katrina. He was startled, he wrote, when Mulderick asked him his thoughts about whether it would be ‘‘humane’’ to euthanize the hospital’s D.N.R. patients. ‘‘Euthanasia’s illegal,’’ he said he told her. ‘‘There’s not any need to euthanize anyone. I don’t think we should be doing anything like that.’’ He had figured the D.N.R. patients should go last, but the plan, he told Mulderick, was still to evacuate them eventually. Through her lawyer, Mulderick denied that she discussed euthanasia of patients with Deichmann or anyone else at Memorial.

As darkness fell, rumor spread that evacuations would halt for the night because people were shooting at rescuers. In the adjacent parking garage, Goux distributed guns to security and maintenance staff, who cordoned off the hospital’s entrances. That night, dozens of LifeCare and Memorial patients lay on soiled and sweaty cots in the second-floor lobby. Pou, several doctors and crews of nurses worked in the dim light of a few lamps powered by a portable generator. For the third night in a row, Pou was working with scarcely an hour’s sleep, changing patients’ diapers, giving out water, comforting and praying with nurses.

Kamel Boughrara, a LifeCare nursing director, walked past the A.T.M. area on the second floor where some of the sickest patients — most of whom had been given 3’s — lay. Carrie Hall, a 78-year-old LifeCare patient with long, braided hair whose vast family called her Ma-Dear, managed to grab him and indicate that she needed her tracheostomy cleared. The nurse was surprised at how fiercely Hall was battling to stay alive. He suctioned her with a portable machine and told her to fight hard.

Comfort Care Or Mercy Killing?

Workers move patients up the stairs from the parking garage to the helipad to be evacuated from Memorial Medical Center in New Orleans on Sept. 1, 2005. (Brad Loper/Dallas Morning News/Corbis)Soon after sunrise on Thursday, Sept. 1 — more than 72 hours into the crisis — Memorial’s chief financial officer, Curtis Dosch, delivered good news to hospital staff gathered on the emergency-room ramp. He had reached a Tenet representative in Dallas and was told that Tenet was dispatching a fleet of privately hired helicopters that day. Dosch later said that the dejected staff was skeptical. But soon the hospital’s voice chain began echoing with shouts for women and children to evacuate. Boats were arriving, including fishing vessels that had been parked on trailers in the neighborhood and were now commandeered by hospital workers. Helicopters at last converged on the hospital within a couple of hours of daylight, according to a Memorial nurse from the Air Force Reserve who oversaw helipad operations. The Tenet spokesman and testimony by Mulderick in a 2008 deposition also confirm this. The hospital filled with the cacophony of military and private crafts hovering and landing. Down on the emergency-room ramp that morning, stone-faced State Police officers wielding shotguns barked that everyone had to be out of the hospital by 5 p.m. because of civil unrest in New Orleans; they would not stay later to protect the hospital.

Meanwhile, Cook strapped on his gun again and prepared to leave the hospital by boat to rescue his son, who had been trapped at his house since Tuesday’s flooding. He told me that Mulderick asked him before he left to talk to Pou.

On the second floor, Cook says, he and Pou, both weary, discussed the Category 3 patients, including nine who had never been brought down from the seventh floor. According to Cook, Pou was worried that they wouldn’t be able to get them out. Cook hadn’t been on the seventh floor since Katrina struck, but he told me that he thought LifeCare patients were ‘‘chronically deathbound’’ at the best of times and would have been horribly affected by the heat. Cook couldn’t imagine how the exhausted Memorial staff would carry nine patients down five flights of stairs before the end of the day. Nobody from outside had arrived to help with that task. If there were other ways to evacuate these patients, he didn’t see them.

Cook said he told Pou how to administer a combination of morphine and a benzodiazepine sedative. The effect, he told me, was that patients would ‘‘go to sleep and die.’’ He explained that it ‘‘cuts down your respiration so you gradually stop breathing and go out.’’ He said he believed that Pou understood that he was telling her how to achieve this. He said that he viewed it as a way to ease the patients out of a terrible situation.

In an interview with Newsweek in 2007, Pou acknowledged that after discussions with other doctors, she did inject some Category 3 patients. But she said her intention was only to ‘‘help the patients that were having pain and sedate the patients who were anxious’’ because ‘‘we knew they were going to be there another day, that they would go through at least another day of hell.’’ Beyond that, Pou has not talked about the details of what happened on that Thursday, citing the pending legal cases and sensitivity to patients and their families. What follows is based on the recollections of others, some of which were recounted in interviews with Louisiana Justice Department investigators, as well as in interviews with me.

Therese Mendez, a LifeCare nurse executive, had worked overnight on the first floor, she later told investigators. (She declined to speak with me.) After daybreak, she heard the sound of helicopters and watched the evacuation line begin to move. According to Mendez, she returned at around 8 or 9 a.m. to the seventh floor and walked along a corridor. The patients she saw looked bad. Several were unconscious, frothing at the mouth and breathing in an irregular way that often heralds death. Still, while two patients died on the LifeCare’s seventh floor on Wednesday, the others had lived through the night, with only a few given small doses of morphine or the sedative lorazepam for comfort.

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.

If this article, or this comment, offends you, remember—reading it or subscribing to this service, is an optional activity.

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

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.


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:

Deadly Choices

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

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