In the aftermath of Hurricane Katrina in 2005, I was deployed to Gulfport, Mississippi for a week to assist with 911 operations. I witnessed firsthand the destruction caused by the storm, and witnessed the great resilience of the Gulf Coast people. Most of the news coverage at the time focused on the flooding of New Orleans. I remember reading subsequently that a doctor and some nurses in a New Orleans hospital were charged with murder in hastening the deaths of some infirm patients who were unable to be evacuated. I remember being outraged by the gall to charge health care providers who were no doubt doing their best under extraordinary circumstances, and I remember being glad to hear the charges were subsequently, dropped.
With this background in mind, I was interested to read a new book Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital, an account of what happened at Memorial Hospital during Hurricane Katrina and its aftermath. The New York Times selected the book as one of the ten best of the year.
I was greatly disturbed by what I read.
First off, let me say, I have always tried to hold to the creed of “You canít judge another paramedic or health care provider unless you were there.Ē So many times I have heard stories that caused me to react one way, but then on hearing the real story, I was able understand a providerís actions. Now that I am an EMS coordinator, responsible with overseeing care, I find myself having at times to judge without being there. I try to get as much firsthand information as possible, and I find myself giving people wide latitude unless the failures are too great.
Thus in this book, we are left in the authorís hands, and the author was not there, but that said, her book is exhaustive, and she spoke at length, it seems, to a great many people who were there.
This is her take on what happened. A hospital was flooded. Electricity was lost. The heat rose. There was fear of marauders in the streets. There was no clear disaster plan. Communications with the outside world were disjointed. The decision was made to evacuate the sickest people last. At some point in time on the fifth day, someone decided rather than putting the sickest through the ordeal of evacuation, they would instead give them lethal doses of morphine and midazolam to ease their suffering. This was done without consultation with them or their families. Quite a large number of patients died within a few hours, on the fifth day when evacuations were still going on and capable of going on for some time. The patients were later found to have excessive amounts of these drugs in their bodies inconsistent with their prior treatment plans. At least one of these patients, an extremely obese paraplegic, had been up until that time alert, oriented, and without a terminal disease.
Some other allegations from the book include: patients were turned away from the hospital while the staff membersí pets were being cared for, there was amble food and water, parts of the building had electricity while in other parts peopleís ventilators were turned off, patients suffered dehydration because when the electricity died , their IV pumps didnít work, and no one thought to use gravity and run drips by hand (eventually someone thought of this on one of the floors, but not throughout the hospital. The hospital stopped being a hospital and went into what they called ďSurvival Mode.Ē
While only one doctor was charged, the author suggests the more than one doctor participated. What is not clear is whose idea it was. Clearly, it was never discussed in an open forum. The authorís conclusion is not only should it not have been done, it was not necessary. Many of these patients, she argues, would have survived. There was food, there was water, and there were means of evacuation.
I believe when an individual provider fails, the error is not just an individual error but a system error. Here individuals failed because the system failed them. And the individuals at Memorial, unlike those at another hospital, were unable to adjust their systems on the fly.
In the aftermath, the fall guys were (as is often typical) the individual providers who the system failed by not providing them with better plans or guidance. Providers were charged with crimes. The people who had botched the disaster preparationsóthe state, city, and hospital administrators– were not. In the end, understandably perhaps, no one had the stomach to prosecute the health care providers and charges, despite the evidence, were dropped.
I found this book disturbing mainly because the decision to euthanize lacked a sound ethical basis. The decisions had a paternalistic arrogance that these deciders knew best and thus they made decisions which were not theirs to make in secret.
In contrast, the author points out, another New Orleans hospital undergoing similar conditions was able to evacuate their sickest patients without the same loss of life, and they never stopped caring for their patients. They insisted their staff rest and work as much on regular schedule as possible. They came up with creative approaches and kept everyone’s morale high.
As a practicing paramedic, a reaffirming lesson for me in this book is when it comes to the life and death decisions we have to make, never hesitate but to act in the patientís best interest, and never be afraid to confer with others. 500 pound patient on the 4th floor in cardiac arrest? Treat them no different than a 100 pound patient in cardiac arrest. If they meet the criteria to continue working, work them as if they are your family member. If the call has reached the point of futility, establish consensus with your fellow providers. Our guidelines require any cessation of termination require the agreement of all paramedics on scene, not just the most senior.
I am all for comfort measures for terminal patients, but lacking proper ethical process, hastening another’s death, is not what we should ever be about.