Tragic Triage: Five Days at Memorial Life and Death in a Storm-Ravaged Hospital

five daysFive Days at Memorial:  Life and Death in a Storm-Ravaged Hospital

Sheri Fink

Crown Publishers.  2013.  559 pgs including detailed footnotes and index.

Other books I’ve read by Fink:  none.  She received the Pulitzer Prize for journalism for her 2009 article in the New York Times magazine on this same subject.

Fink is a Stanford University-trained doctor and PhD researcher.  She has provided aid and medical relief in combat zones.

This is  one of the most disturbing books I have ever read.  It is also a book that will have to substitute for a criminal trial, since the people accused of ending the lives of helpless hospital patients were never brought to justice.

Hurricane Katrina was one of the worse natural disasters in U.S. history.  Almost 2,000 people lost their lives in the 2005 storm and subsequent flooding.  This book is about the effect of the storm on Memorial Hospital,  located in uptown New Orleans.  When the levies broke, Memorial was completely surrounded by flood waters almost to the second story — trapping patients, staff and visitors and destroying the emergency electrical generators located in the basements.  Plunged into darkness, heat and chaos, the stranded staff endured five days of terror and confusion.  While stories of valor and clear-thinking emerged (the entire NICU was evacuated by helicopter with every baby saved) a darker picture emerged as the flood waters receded.

After all staff and patients had been evacuated, 45 bodies were discovered in the hospital chapel — the highest number of any of the New Orleans hospitals caught in the flood.  Autopsies revealed a deadly level of morphine and other sedatives in the bodies of a number of the deceased, and patient records determined that these drugs had not been prescribed.

What was determined much later, through detailed investigations and even the free admission of several of the doctors — was that seriously ill, fragile patients were euthanized instead of being evacuated, because there seemed to be no way to move them out of the hospital.  Their continued presence and stubborn clinging to life meant the staff could not leave the heat-choked, stinking hospital.  And in the doctors’ minds, they were going to die anyway.

“I gave her medicine so I could get rid of her faster, get the nurses off the floor…There’s no question I hastened her demise.’  — Dr. Ewing Cook, (p. 161).”

Memorial Hospital, New Orleans

Memorial Hospital, 2007. Photo Credit: Infrogmation. Creative Commons license.

The majority of the patients who received the high doses of morphine and midazolam occupied the floor of the hospital set aside for nursing home occupants.  They were primarily elderly and had DNR (“Do not resuscitate”) orders in their charts.  But even a younger, very obese patient was euthanized.  Many patients were alert and cognizant.  Several had family members present who were forced away from their bedsides — either by police who were supervising the evacuation, or by staff members.   Chillingly, they all died the same morning — even while rescue helicopters were landing on Memorial’s roof.

The first half of this book is a compulsive, page turning read depicting the events of the storm and the five days of confusion, terror, and death.  The second half traces the criminal investigation, the bungling of the district attorney, the publicity campaigns on behalf of the accused nurses and doctor and eventually, the grand jury’s failure to indict.  This half of the book is somewhat more difficult to get through, but detailed footnotes and a chart of significant individuals and their affiliations helps keep everyone straight.

There are so many layers to this book.  You can read it as a horrific crime  story — from the point of view of the perpetrators and the victims.  It is a stern warning about the lack of emergency planning.  In a larger sense it is the tragedy of an inept local and federal government who failed to respond to a disaster.  It is  also a study in the ethics of disaster management and triage.

But one questions kept coming back to me:  why did the staff at this hospital react in this deadly way?  For these acts were personal choices carried out by several doctors and nurses — and other staff knew the euthanasia was taking place.  Why did Memorial’s staff choose death as an option, when other approaches were possible?  To me, one of most fascinating and tragic “what-if’s” of this tale relates to the comparison between events at Memorial, and those at Charity, another New Orleans hospital.

Katrina evacuations near Charity Hospital, New Orleans.  Photo Credit:  Frogmation.  Creative Commons License.

Katrina evacuations near Charity Hospital, New Orleans. Photo Credit: Frogmation. Creative Commons License.

Charity had a larger patient census and fewer staff during the storm, and was also flooded and stranded.  But fewer than ten patients died at Charity during the storm and its aftermath.

Why the choice of life over death at Charity?  Why the better outcome?  Fink describes specific choices made by the leadership at Charity that were strikingly dissimilar to Memorial:

  • Charity kept their regular shift schedule and as much as possible, continued normal medical care.   Staff were released to sleep and rest.  In contrast, Memorial went into “survival mode” where normal routine was abandoned.
  • Charity evacuated their sickest patients first; Memorial assigned the sickest patients, and those with DNR orders into a perilous “Category 3” status.  Most of the deaths occurred here.
  • Charity had drilled for a category three hurricane.  Memorial’s plan existed primarily in binders no one consulted.
  • Most interestingly to me, Charity kept a positive, upbeat tone with frequent staff meetings throughout the day that included everyone — from doctors to janitorial staff.  Management also forbade rumor spreading.  A “you can only say it if you see it” policy was enforced.  The staff even put on a talent show by flashlight to support morale.  In contrast, dark rumors ran rampant at Memorial.  Staff thought they were under martial law (they were not) and were convinced the hospital was going to be invaded every moment by rampaging gangs.  Leadership was confused and diffused.  Several c-suite staff from corporate headquarters were actually present at the hospital during the storm, but they had found a refuge in a remote office that through some fluke of electrical circuity still had power and air conditioning.

This book made me angry.  Not only the levies collapsed in New Orleans, but at Memorial — standards of ethics, morality, and even human decency collapsed as well.  There are many lessons from this tragic crime.  One of the simplest is that there is always a place for strong, sensible and clear leadership in every crisis.  If only the leaders (if they existed) at Memorial could have stepped up — then some sane choices would have been made and those who depended on the quality of others’ choices would have survived the five days.

Making a list…checking it twice…

Checklist Manifesto coverThe Checklist Manifesto

Atul Gawande

Picador.  2011.  240 pgs.

I’ve read two other wonderful books by Gawande:  Better, about a surgeon’s search for improved performance and Complications (reviewed on this blog) about what can go wrong in medicine.  His newest book, The Checklist Manifesto, is his best yet, because its lessons are applicable to all fields of work.

In it, Gawande describes his quest for a solution to the common failures of surgery:  infection, bleeding, unsafe anesthesia and a fourth amorphous but deadly factor he simply calls “the unexpected.”  This investigation will take Gawande to such disparate settings as operating theaters, jumbo jet cockpits, building worksites, investment firms and restaurant kitchens:  anywhere where it is no longer appropriate for mere humans to rely on focus, daring, wits and the ability to improvise.  Gawande demonstrates that many work settings where we attempt to function are too complex and risky for professionals to rely on those afore-mentioned traits, despite our zeal, hours of work and training.

What is the answer?  Gawande proposes the humble checklist — a short, succinct list of questions that can be run through before and during any high-stakes endeavor — whether slicing open someone’s chest or taking 200-300 human souls up to 30,000 feet.  This isn’t Gawande’s original idea: he traces the history of successful checklist-based work from the early days of aviation to the present, and describes how the ” miracle on the Hudson” — Capt. “Sully” Sullenberger’s successful landing of U.S. Airways flight 1549 — was actually due to calm and professional work from a checklist for engine failure and water-based landings.  Gawande describes how the use of complex checklists, with the addition of required communications and cross checks between teams, are what enable the construction of skyscrapers.  He interviews successful financial investors who shared their use of pre-investment checklists, ensuring that every financial report is plumbed for the signs of risk — particularly in the areas of debt leverage —  in order to avoid what one financier described as a “cocaine brain” rush to invest in the next sure thing.

Of course, Gawande writes primarily about his own field, surgery, and he describes his work with the World Health Organization to come up with the Safe Surgery Checklist — a two-minute check of vital pre- and post-surgical factors directly linked to the common failures of surgery.  One of the most interesting aspects of the checklist was the incorporation of communication:  having the entire surgical team introduce themselves to each other and formally, but quickly, share any concerns about the patient.  Gawande describes how the introductions and rapid but effective team bonding empower all team members to speak out, particularly nursing staff who may observe risks before surgeons do.  In fact, nursing staff can read off the checklist and in some cases, will prevent a surgeon from picking up a scalpel if a key checklist component has been missed.  The Safe Surgery Checklist was tested in eight hospitals around the world, and was featured in an early release article in the January 2009 issue of the New England Journal of Medicine.  It has been linked to significant, statistical improvements in care — and Gawande bravely and humbly describes how the checklist prevented a death in his own operating room.

One of the signs of a great book is that it changes you for the better.  One of my personal quests is to become a better manager.  The Checklist Manifesto made me ask the question:  what are the common failures of management?  I thought of two:  failure to communicate a vision and lack of connections between staff and manager.  Would a checklist help me try to avoid these pitfalls more consistently despite the complexity, shifting priorities and general madness of each day?  I hold weekly status meetings with each staffperson and I started to wonder, since I already prep before meeting with staff, would a checklist help?  Here is my proposed pre-meeting checklist for my regular meetings:

Do we need to meet?  Did we meet informally earlier in the week and could our time be better spent without the meeting?

Review notes and assignments from last meeting.  What needs to be followed up on?

Review emails from and to the employee over the past week.  What has happened?  Did something unexpected come up?  Is there a new priority on the horizon?

Are there outstanding questions I need to address?

What role is the employee playing with any long-term organizational goal?  Where are they on that?

What are my concerns about this employee?  Should I bring them up?  What might theirs be — I’ll be sure to ask.

The Checklist Manifesto teaches us that it is not a weakness to lean on a humble tool when stakes are high and risks are many.  As usual, Gawande presents a clear and compelling vision and this time his lesson is that we need all the help we can get to be fully human and fully successful in the increasing complexity we live in.

Atul Gawande

When medicine doesn’t work….it’s complicated

Complications by Atul Gawande

Complications

Atul Gawande

Picador.  2003.  269 pgs.

I’ve pretty much decided that I would read a telephone directory if this man wrote it.  I didn’t think there could be a, well, better book than his previous work, Better, but I think this tops it.  Complications is about the imperfections in medicine — the unexplained mysteries, the screw ups and the inconsistencies in decision-making.  Reading this book is almost like being faced with a terrifying medical decision for a loved one, but while you face it Gawande has his hand on your shoulder.  His compassion and wonder at what we don’t understand about the human condition — both of patients and of doctors —  is on full view — but in such a way that you feel hopeful and brave.  The chapters about morbidly obese patients, and also the one about doctors who have “gone wrong” are written with respect and almost tenderness that is as touching as it is illuminating and clear-eyed.