Katrina: les choix mortels des médécins (2)

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

Dr. Anna Pou poses for a photograph at her home in New Orleans on July 22, 2006. (Alex Brandon/AP Photo)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.''

 

Doctors wait to pass patients through the machine-room hatch into the parking garage on their way to the helipad. (Photo Courtesy of Dr. Paul Primeaux)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.


An airboat pulls up to the Memorial Medical Center in New Orleans on Aug. 31, 2005. (Bill Haber/AP Photo)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?''


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.


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.


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.

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