Saturday, December 13, 2014

Sheri Fink: Five Days at Memorial

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In 2009, Sheri fink published an amazing article with ProPublica that I believe I read in the New York Times magazine. If you haven't read it, it's worth the read. Either that, or pick up "Five Days at Memorial," the book length story. Hefty, it is a fast read, and a thought-provoker.

You've heard the premise, or at least some of it. In August, 2005, Hurricane Katrina hit New Orleans and the results are now well known. Memorial is a hospital (now operating under a different name) that had been in New Orleans for almost 100 years. A well-established community hospital, residents had been taking shelter there for as long as the building had been around. And, in a familiar story, the hospital was completely unprepared for the storm. Even though a disaster preparedness workshop had taken place a week before, no changes had been made. For example, backup generators were underground- sure to be flooded in a hurricane of any size. How triage decisions would be made had not been made ahead of time. Incident commanders and personnel structure had not been established. A contract company, LifeCare, leased the 7th floor and cared for patients who needed 24/hour care. They had not been included in any disaster preparedness conversations. Although these things are all terrible, it's important to point out that they were not unique to Memorial, or to hospitals: almost EVERYTHING failed during Katrina, from the local level to the federal level. Five Days at Memorial is the story of this particular hospital, however.

Basically, when Katrina hit there were lots of people at the hospital. There were doctors and nurses, some friends and family of these doctors and nurses who were sheltering there with them, hospital patients of varying levels of illness, some friends and family who stayed with their loved ones, LifeCare staff, doctors and nurses, and the LifeCare patients and some friends and family of these patients. The hospital ceased normal function pretty quickly, and the lack of protocol was apparently pretty quickly. The power went out and the generator kicked in, then the generator and backup generators went out. If you stop for a second and think about your life, and even more, the daily operations at a hospital, pretty much everything relies on electricity. And in a time of crisis, you need to be able to communicate with outside- even in (way back!) in 2005, Memorial and LifeCare were trying to communicate via cellphones and email and were quickly thwarted. Even the basic needs of the healthy people in the hospital couldn't be met adequately: it is fucking hot in NoLa in August, and the air conditioning and even air circulation couldn't work without the power, so the hospital was hot and steamy and full of disease-ridden flood water, and the air had nowhere to go. People started smashing through thick windows, but it didn't help circulation. The lights stopped working, obviously. So the huge building was dark. It's hard to practice medicine in the dark. The elevators stopped working, so doctors and nurses had to walk up and down flights of stairs (don't forget that LifeCare was on the 7th floor, and operated independently) to get to patients. And the stairwells were now pitch black, and hot as hell since the power was out. They were also sometimes full of human waste, since the toilets weren't working anymore and people slipped into them to get privacy and go to the bathroom.

Basically, it was a disaster, and many people were trapped in the hospital. Communications with the company that ran Memorial were a mess, and they weren't working that quickly to get people out. They hadn't really planned for this- and it was too late to book helicopter-ambulances. The water quickly rose too fast to get people out by anything but boat or helicopter. Rescue efforts were ad hoc- some people who knew some people got many people out. Sometimes people on the helipad- itself dangerously old, small and unstable- made decisions to send helicopters away. People were queued up, on stretchers in dark hot hallways, waiting to be evacuated, for hours. Eventually, after 5 days, with almost no communication or organization, everyone living got out.

The thing is, not all of the people in the hospital died naturally. This background information is only a taste of how awful things there were, and how chaotic, but they're not meant as an excuse. Fink does an amazing job of telling the story, from all sides of the picture- I'm just attempting to sum it up in not-too-many-words (Fink has written quite a long book). One of the things that happened during the 5 days at memorial is that some of the doctors decided on a triage system- they decided who would be evacuated first. Initially, the system had the sickest patients leaving first. Ultimately, they ended with a system from 1 to 3: 1s for the healthiest patients who could move themselves and the 3s were both very ill and had DNR orders. As Fink rights, "Concepts of triage and medical rationing are a barometer of how those in power in a society value human life." Very little research has been done on triage in the United States- even though there are nine standard triage systems- Fink speculates "perhaps because of the potential for political embarrassment or due to a lack of financial incentives." There are risks and justifications with any system, but in this case "[Dr.] 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."

Finkel tells the amazing story of what happened next in Memorial- how Dr Pou and others (the book focuses mainly on Pou because the subsequent investigation focused only on Pou and two nurses, which I never quite understood), ended up euthanizing several patients- the majority of whom were on the 7th floor- the LifeCare floor. Many of these patients were indeed very very ill, and almost all of them had DNRs. The majority of them- except for an obese paraplegic man who otherwise was awake and coherent, were in and out of consciousness. They needed critical supplies and medicine and electric-powered machines to keep them alive. They were lowest on the doctor-decided triage list for evacuation. And evacuation was coming very very slowly. The thing was, evacuation HAPPENED the day that Dr Pou and two nurses euthanized the final patients (a couple were euthanized earlier). The mercy killings happened without consent of the patients themselves or without the consent of family members- some of whom had been present in the hospital hours before.

Subsequently, the Medicaid Fraud Control Unit investigated the deaths at Memorial and other hospitals. They ended up looking primarily at Memorial. They amassed a huge case against Pou and the two nurses who euthanized the patients with her. Ultimately, however, the case needed to be tried locally, in New Orleans, which has a terrible homicide clearance rate. Coupled with the politics of inter agency cooperation, the local DA wasn't in the mood to make this as big of a deal as the feds, who spent a year focusing on the case. Meanwhile, the medical community had rallied behind the doctors and nurses. Professional associations came out in support of Dr Pou. A well-respected ear-nose-throat doctor, she laid low for awhile then continued to perform intense surgeries. The nurses had a harder time, but found support as well. No one in New Orleans really wanted to open Katrina-related wounds again. It ultimately came down to whether the coroner ruled the deaths homicides or not. So he got something like 5 outside experts to look at the evidence: They all said they felt the deaths were homicides. When the coroner testified in front of the grand jury, however, he said that he couldn't say for sure that the deaths were homicides. The grand jury failed to indict. The case was closed.

The story is a *lot more complicated than this. Fink does an amazing job of telling it, and getting readers to think about all sides of the story. She doesn't moralize about the "right" answer, because ultimately, there isn't really one. Even if the sickest patients had been evacuated the first day, what the doctors didn't know is that they would have been unceremoniously dumped on the interstate, or at the airport, or even in the Superdome. Hospitals were turning away patients. They may have gone to somewhere with even less medical attention. On the other hand, other hospitals in the area had worse conditions and no deaths, let alone euthanasias. At the end of the book, Fink talks about the state of disaster preparedness in other situations, and what could be done. It isn't pretty. Ultimately, the best case scenarios come down to well-laid and executed plans, good communication and keeping doctors and practitioners out of the decision making. Well worth the read.