Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital (23 page)

Robichaux no longer had, she explained, a way to contact her corporate office to request the ambulances. The LeBlancs, struck by how resigned everyone at the hospital seemed, offered to try to arrange ambulances themselves with their working cell phone. “Of course,” Robichaux said, “any help you can give us, we’ll take.”

The LeBlancs called an ambulance company and put Robichaux on the phone. She described the location of the site by the railroad tracks near Ochsner Medical Center. “We need an exact address,” the person on the line told her. “Without an exact address, I can’t send anybody out.”

“Well, I don’t have an exact address,” Robichaux said.

“Ma’am, we can’t help you. We can’t help you unless you have an exact address.” While Robichaux’s colleagues wrestled with a pile of phone books, looking for some kind of address or at least the name of a cross street, the call with the ambulance company dropped. Robichaux was unable to reconnect.

She reached a LifeCare corporate representative in Shreveport. Speaking quickly, so as not to lose another call, Robichaux asked if LifeCare could divert some of the ambulances that were heading to the staging area they had previously discussed, and send them instead to the boat location near Ochsner. The corporate representative said she would try. She and her colleagues would also try to locate the ventilator patients who had gone out earlier and arrange for their transfer to other LifeCare hospitals.

The LeBlancs headed back downstairs. Mark was upset.
He believed his mother needed an IV to hydrate her and deliver antibiotics for a stubborn urinary infection, but he’d been told the hospital could no longer provide intravenous fluids. Though his mother was a LifeCare patient, Mark complained to a Memorial administrator, who explained that the hospital was in a survival mode now, not a treating mode. “Do you just flip a switch and you’re not a hospital anymore?” Mark asked.

THAT MORNING, after having difficulty locating a sufficient supply of official, color-coded triage armbands, doctors and nurses settled on a new method for categorizing the many more than one hundred remaining Memorial and LifeCare patients as they were brought downstairs. They were divided into three groups to help speed the evacuation. Those in fairly good health who 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 had agreed on Tuesday, those with DNR orders.

Dr. Anna Pou, always one to take on the most difficult tasks, jumped in to help coordinate the mass movement of patients. Every breath she took of the rancid air burned the back of her throat. She considered the unsanitary conditions in the hospital nearly unbearable, the pitch-black interior rooms exceptionally dangerous. She worried that even healthy people were getting sick and having difficulty breathing in the heat.

Pou and other workers scoured the hospital floor by floor for every last cot and stretcher and dragged them down to the second-floor lobby. Throughout the morning, makeshift teams of medical staff and family members carried many of the remaining Memorial and LifeCare patients there. Pou rolled the short sleeves of her scrub shirt up to her shoulders and stood ready to receive them.

In the dim light, a ranking began. Nurses opened each chart and read the diagnoses, using flashlights sparingly to save batteries. 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—roughly three dozen in total from Memorial and LifeCare—were guided down to the emergency room ramp. The airboat flotilla was beginning to make runs to dry ground, and the plan at first was for these patients to go out on them. LifeCare nursing director Gina Isbell and Memorial nurse manager Karen Wynn took charge of the patients’ care while they waited on the ramp.

The 2’s—perhaps seventy in all throughout the day—were generally placed along the corridor on the way to the hole in the machine-room wall that was a shortcut to the parking garage and, ultimately, the helipad. A dozen and a half or so 3’s were moved to a corner of the second-floor lobby near a Hibernia Bank ATM and a planter filled with striped green dieffenbachia. Patients awaiting evacuation would continue to be
cared for—their diapers would be changed, they would be fanned, often by family members of the staff, and given sips of water if they could drink—but once the patients were moved out of their rooms on Wednesday, most other medical interventions were limited. The idea of indicating somebody’s destiny by a number struck at least one passing doctor, neuroradiologist Bill Armington, as expeditious but distasteful.

Pou and her coworkers were performing triage, a word once used by the French in reference to the sorting of coffee beans and later applied to the battlefield by Napoleon Bonaparte’s chief surgeon, Baron Dominique-Jean Larrey. Triage came to be used in accidents and disasters when the number of those injured exceeded available resources. Surprisingly, perhaps, there was no consensus on how best to do this.

Concepts of triage and medical rationing are a barometer of how those in power in a society value human life. During World War II, the British military limited the use of scarce penicillin to pilots and bomber crews. Before lifesaving kidney dialysis became widely available in the United States, some hospital committees secretly factored age, gender, marital status, education, occupation, and “future potential” into treatment decisions to promote the “greatest good” for the community. When this practice attracted broader public attention in the 1960s, academics condemned one Seattle clinic for ruling out “
creative non-conformists … [who] have historically contributed so much to the making of America. The Pacific Northwest is no place for a Henry David Thoreau with bad kidneys.”

A story in
LIFE
magazine by Shana Alexander exposed the practices and led to public outcry. Lawmakers created a system in which Americans who needed dialysis would be entitled to it, typically at the government’s expense.
However, in countries such as South Africa, dialysis rationing persisted for patients receiving care in public hospitals. With the number of those who could benefit far exceeding the number of treatment slots, doctors struggled at weekly meetings to choose who lived and who died. Would it be ethical to weigh “social-worth criteria”
like a person’s job, parental status, or drug-abuse history alongside medical criteria? Should patients be informed of the decisions and given the opportunity to appeal? After years of decisions that favored white South Africans, how could the process itself be made more just? Eventually doctors sought input from patients themselves in constructing a more standardized rationing system; the dreadful process of selecting patients was made more accountable as advocates campaigned to expand dialysis programs for low-income South Africans and to prevent kidney disease.

In the United States at the time of Katrina,
at least nine well-recognized triage systems existed to prioritize patients in the case of mass casualties. Because of the difficulty of investigating outcomes, including deaths, in emergencies—and perhaps because of the potential for political embarrassment or due to a lack of financial incentives—almost no research had been done to see whether any of the commonly used triage systems achieved their intended goals or even that they didn’t paradoxically worsen overall survival. Most systems called for people with relatively minor injuries to wait while medical personnel attended to patients in the worst shape. This was Baron Larrey’s original concept of triage as described
in his memoirs of an October 1806 battle in Jena, Prussia, between Napoleon’s forces and the Fourth Coalition. “They who are injured in a less degree may wait until their brethren in arms, who are badly mutilated, have been operated on and dressed,” he wrote. “Those who are dangerously wounded should receive the first attention, without regard to rank or distinction,” an idea in keeping with the French Revolutionary concept of
égalité
.

British naval surgeon John Wilson introduced another triage tier several decades later in 1846 when he decided to withhold surgery from patients for whom it would likely be unsuccessful. In 2005, a few triage systems incorporated this idea, calling for medical workers to forgo treating or evacuating injured patients who were seen as having little chance of survival given the resources at hand. That category was intended
for use during a devastating event such as a war-zone truck bombing in which there were far more severely injured victims than ambulances or medics.

Consigning certain sicker patients to go last has its risks, however. Predicting how a patient will fare is inexact and subject to biases.
In one very small study of triage, experienced rescuers were asked to categorize the same patients and came up with widely different lists. Many patients who could have survived were mistakenly deemed unsalvageable by some rescuers. And patients’ conditions can 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.

Designating a category of patients as beyond help creates the tragic possibility that a patient with a chance of survival will be miscategorized and left to die. To avoid this, some experts have concluded that patients seen to have little chance of survival must still be treated or evacuated—after those with severe injuries who need immediate attention to survive, but before those with significant injuries who can wait.

Pou and her colleagues had little if any training in triage systems and were not guided by any particular protocol. Pou viewed the sorting system they developed as heart-wrenching. To her, changing the evacuation order from sickest first to sickest last resulted from a sense among the doctors that they would not be able to save everyone.

POU WOULD LATER SAY that the goal in a disaster must be to do “the greatest good for the greatest number of people,” the same phrase used by public servants, including New Orleans Sewerage and Water Board superintendent George G. Earl when he decided which parts of New Orleans to protect from flooding with his limited budget in the 1920s.

But what does the “greatest good” mean when it comes to medicine? Is it the number of lives saved? Years of life saved? Best “quality” years of life saved? Or something else?

The goal of maximizing net good for a population has its roots in the utilitarian philosophy developed by Jeremy Bentham and John Stuart Mill in the eighteenth and nineteenth centuries. More recent philosophers have warned that this approach, if applied to lifesaving medical care in disasters, may require an unacceptable level of sacrifice from those most in need of assistance. These thinkers favor an approach modeled on the principles of justice
set out by John Rawls in the late twentieth century (although Rawls himself did not apply them to medical care). The idea is to distribute care based on need. Those in the most imminent danger of dying without care have a bigger claim to the pool of aid, much as French surgeon Larrey articulated, even if that inconveniences a larger number of patients with less urgent conditions who have to wait. This is the approach taken in most American emergency rooms in non-disaster settings.

Other philosophers have gone further afield, arguing that potentially lifesaving resources should be allocated randomly, because everyone deserves an equal chance to survive, and because it is dangerous to endow groups of people with the power to assign who lives and who dies. This argument
sparked a debate that played out in the pages of philosophy journals for a decade beginning in the late 1970s. Proponents rejected the popular idea that the number of lives saved should be a central consideration when prioritizing rescues. The writer of an influential paper, John M. Taurek, also argued that suffering is not cumulative between individuals—for example, that it is impossible to add up the suffering of a large number of people with minor headaches to equal the suffering of a single person with a migraine, as a utilitarian might do. This concept was also elegantly expressed many years earlier by the author C. S. Lewis, who wrote: