Five Days at Memorial

by Sheri Fink

  The new standards required hospitals to set up an incident command system for emergencies like the one Mulderick was currently heading for Katrina. Hospitals were also expected to coordinate plans with the wider community. Preparing for a flood in isolation did not make sense when there might be citywide power and water failures.

  The 9/11 attacks and the subsequent mailings of anthrax-laced letters to politicians, media organizations, and others, which sickened nearly two dozen people and killed five of them, led to a narrowing of focus on particular types of hospital readiness. By 2005, more than a billion dollars had been made available to the nation’s roughly five thousand hospitals to promote bioterrorism preparedness. Memorial’s most detailed and by far its longest emergency planning scenario was written shortly after the 2001 attacks. This bioterrorism plan ran 101 pages, as opposed to the 11 pages devoted to hurricanes.

  JCAHO had nothing to say about how realistic emergency plans had to be. Like biblical passages, the standards were written in a way that invited a generous range of interpretations. For the most part, surveyors did not check whether a hospital had the resources to do what it said it would do. Still, JCAHO’s new standards far exceeded federal requirements, meaning that hospital leaders looking to avoid meeting the new mandates could seek accreditation from one of JCAHO’s competitors.

  Hospital emergency plans were supposed to be based on a yearly analysis of vulnerability to a variety of potential emergencies or “hazards.” Every year since 2001, Mulderick had convened Memorial’s emergency preparedness committee to go over a three-page form covering some forty-seven events, from volcanic eruptions to nonfunctioning fire alarms and an undefined “VIP situation.” Unlike some other hospitals, Memorial had never hired a consultant for this task. Instead, Mulderick and her committee evaluated their own preparedness at a time they were under pressure from above to save money. The template the committee used could be downloaded for free from the Internet, and other New Orleans hospitals also used it. Mulderick and her committee produced a matrix of scores estimating probability, risk, and preparedness for each event. The latest rendering was rife with multiplication errors.

  Mulderick’s committee had rated the hospital’s preparedness for power outages, generator failure, and floods as “good”—the top ranking on the scale. In designing their plans, committee members would later say they thought more about the constellation of emergencies that had happened rather than the worst things that could happen.

  Whether scoring the “probability,” “risk,” and “preparedness” for volcano eruptions in Louisiana was a true contribution to disaster preparedness could certainly be questioned.

  Years after Katrina, Bob Wise would look critically at Memorial’s twenty separate emergency preparedness plans. “They have nothing to do with each other,” he would say. “Nobody can know this many plans.” Memorial, he felt, had missed the point of JCAHO’s new preparedness standards, putting down on paper what was needed to pass accreditation inspection rather than focusing on cross-cutting “all hazards” preparedness. “It’s not the guts of what you’re supposed to be doing. It’s covering your ass, is what it’s doing.” He found this all too often.

  Memorial was now facing its first real crisis. Despite years of emergency preparedness committee meetings and revisions of the hospital’s disaster plans, in many ways the hospital would have to wing it.

  TO ICU NURSE manager Karen Wynn, the moment Susan Mulderick announced in their hastily organized meeting that floodwaters were headed their way, the atmosphere in the command room shifted from a hospital emergency to a military operation. There was one objective: act quickly before the power failed.

  Nearly two hundred Memorial patients needed to be brought to safety. Mulderick suggested that the sickest, the ones most dependent on life support or mechanical aids, should go out first. That meant around two dozen patients in the ICUs, a similar number in the newborn nursery, high-risk pregnant mothers, and around a half dozen dialysis patients, with more showing up since the storm. There were also two bone marrow transplant patients highly vulnerable to developing infections. It would be difficult to care for them if all power was lost. Others at the command meeting agreed.

  The tougher question was how to move them. Susan Mulderick knew the looming catastrophe was bigger than the staff at Memorial could handle alone. A National Guard unit had spent the hurricane at Memorial, and a few Acadian ambulances were parked on the ER ramp. Mulderick asked if Acadian could provide more ambulances and even helicopters. She sent an e-mail to her ex-husband, a buyer at a helicopter-transport company, asking if his firm could help get a helicopter to fly in medications and fly out patients. He wrote back to tell her that the company had already been hired to evacuate people from another private hospital, Tulane. He sent her the phone number of an Air National Guard major with a Baton Rouge exchange who was, he wrote, coordinating all civil and military evacuation efforts.

  Karen Wynn wondered about the feasibility of an evacuation by helicopter. Memorial’s heliport hadn’t been used in years. The last time she could remember going up there was for an emergency drill in 1987, when Pope John Paul II visited New Orleans. She left that for others to contemplate and returned to the ICU to let the staff know that evacuation was imminent and they would need to get the patients’ medical records and medications ready.

  A CALL WENT out over the public address system. “Prayer service… ten thirty a.m.” Everyone at the hospital was invited to attend.

  Father John Marse was the only chaplain present at Memorial during the storm. He had decided to stay after hearing the voice of God calling him to serve. Now the Catholic father carried his sacramentary and lectionary out of the dim Myron C. Madden Chapel, windowless but for the narrow, stained-glass strips that decorated its two wooden doors. He stood with several dozen people in the well-lit hospital entrance lobby. Father Marse, who spoke quickly in a Southern drawl, began reading from Matthew:

  And, behold, there arose a great tempest in the sea, insomuch that the ship was covered with the waves: but he was asleep. And his disciples came to him, and woke him, saying, Lord, save us: we perish. And he saith unto them, Why are ye fearful, O ye of little faith? Then he arose, and rebuked the winds and the sea; and there was a great calm.

  We’re in this storm, Marse said in a brief homily for those gathered before him. And Jesus is with us, no matter what the outcome is.

  Marse couldn’t help noticing that the water outside the windows of the entrance rose halfway up the side of a fire hydrant during the time he spoke.

  Sandra Cordray, a community relations manager who was the designated communications leader for Katrina, asked Marse to attend all future command meetings. Memorial needed help from every possible power.

  Memorial had another power at its disposal by virtue of having been swallowed by a hospital chain. Cordray took charge of communicating with executives at Memorial’s parent company, Tenet Healthcare. With phone connections difficult to make, but e-mail still functioning, she wrote for help, explaining that water was rising in Memorial’s basement and was expected to keep rising for days. The hospital was locked down because of reports of looting in the area, and other hospitals were evacuating. She said that the National Guard was present at the hospital, and she forwarded the phone number of the Air National Guard major identified by Mulderick’s ex-husband in the hopes that someone at headquarters could contact him. She also shared what she was hearing about the increasingly frightening situation in New Orleans.

  From: Cordray, Sandra

  Sent: Tuesday, August 30, 2005 11:00 AM

  Subject: reports

  We are receiving reports that the inmates at the prison near Tulane have taken over.

  From: Cordray, Sandra

  Sent: Tuesday, August 30, 2005 11:07 AM

  Subject: RE: reports

  Break in the 17th street canal levee—200 feet wide flooding New Orleans

  Cordray’s e-mails to Tenet’s Dallas headqua
rters grew more panicked by the minute. Sean Fowler, Memorial’s chief operating officer, pulled his chair up to hers and instructed her as she typed. Memorial needed to evacuate its patients. Memorial needed medicines and blood products. What did Tenet have in terms of supplies, medicines, water, and food? How quickly could the company deliver them? What kind of airlift and ground resources was the corporate office coordinating?

  WE NEED PATIENTS OUT OF HERE NOW!

  Please can you take patients.

  Is anyone out there?

  Michael Arvin, an executive at Tenet headquarters, finally responded. “We have been told getting into the city is not going to happen,” he wrote. “Have you contacted the National Guard?” It was an odd question. Cordray had already informed Arvin that Guard members were at the hospital. That contingent alone could not solve all these problems.

  Arvin, in Texas, had no background in emergency management. His normal job was to direct business development for Tenet in the Gulf Coast region, which he referred to as “the market.” It was amazing how quickly his duties had changed. Two days earlier, Arvin had interrupted a tennis match with his kids at a Dallas country club to join a conference call with the CEOs of Tenet hospitals in the Gulf region as Katrina took aim at the coastline. Now, three of Tenet’s six hurricane-affected hospitals needed to evacuate.

  Tenet did not have preexisting contracts with medical transport companies. The corporate headquarters did not have an incident command system in place for emergencies. One of its executives had served in the National Guard and knew something about crisis management, but he was on vacation and offered tips by cell phone from a secluded beach retreat in Oregon.

  Arvin let Cordray know that the company was working on securing medicines and blood for Memorial, but he was not sure how to get anything to her. Again he mentioned the National Guard, explaining that Memorial’s sister hospital, Tenet’s Lindy Boggs Medical Center, the former Catholic hospital Mercy, was waiting for troops to arrive.

  We suggest you do the same. If you are beginning your plans to evacuate it is our understanding the National Guard is coordinating. Good luck.

  Cordray wrote back, incredulous:

  Are you telling us we are on our own and you cannot help?

  AT 12:28 P.M., Memorial’s director of case management took matters into her own hands. She typed “HELP!!!!” in the subject line of an e-mail and sent it to colleagues at other Tenet hospitals outside New Orleans. She told them the hospital was expecting fifteen feet of water and it needed to find places for its current census of 187 patients. Hospitals that might accept them should contact Arvin at Tenet headquarters.

  Arvin was quickly inundated with responses. Many hospitals offered space and at least one offered to send relief staff. But Arvin, too, had been busy trying to line up assistance, contacting Tenet hospitals in Houston and Nacogdoches. His message back to the Memorial administrator who sounded the alarm was brusque:

  please route any requests through to me and Bob Smith. We are getting overwhelmed with your MAY DAY to the entire company!!

  Among the hospitals that responded was Atlanta Medical Center. Like Memorial, Atlanta was a former Baptist hospital founded in the early 1900s and now owned by Tenet. By e-mail and phone, its hospital executives offered support, including aeromedical helicopters to help evacuate Memorial’s patients.

  Michael Arvin reined them in, saying that the National Guard was coordinating all relief efforts. The Atlanta CEO understood.

  Michael, per our conversation, we will “sit tight” unless we hear from you or someone at the Dallas office regarding the need for assistance in the evacuation of patients.

  AT MEMORIAL, word spread that all available doctors and nurse managers should report to the ER ambulance ramp, which overlooked Clara Street. Anna Pou walked out of the hot hospital into a bright, slightly breezy day. In a small parking lot across the street, water was rising up the wheel wells of the cars.

  Dr. Richard Deichmann, the head of the internal medicine department, told the doctors that the hospital was going to be evacuated. They needed to work on getting patients transferred, the sickest first.

  Deichmann took stock of who was present and reassigned two physicians to cover each of the fifteen patient wards. At the suggestion of Dr. Horace Baltz, to avoid duplicating work, doctors would no longer visit their own private patients unless they were on the designated ward. The doctors were to categorize every patient and to prepare a count by four p.m. Patients would be marked down for transfer to one of several types of care settings: an ICU, a general hospital ward, a rehabilitation facility, or a nursing home. Patients ready to be discharged could be given a week’s worth of medications and sent on to an evacuation center. The medical staff should get the patients packed up and work on transfer orders.

  Pou paired up with a thirty-five-year-old internist, Kathleen Fournier, and went to the fourth floor, where Pou had several surgical patients. She knew the nurses well, and one confided in her that many of the staff and patients were frightened and worried about their homes and their loved ones outside the hospital. Pou met with the nurses and offered what reassurance she could.

  Pou and Fournier walked from patient to patient, evaluating and classifying them. There were around two dozen, a full complement. Many had been put in wheelchairs and pushed to a central nursing station to sit with fans blowing on them.

  Nurses began photocopying charts and readying a few of the sicker patients to go out first. Throughout the day, Pou shuttled back and forth to the fourth floor, bringing the nurses whatever news she heard.

  One of Memorial’s veteran critical care doctors was Ewing Cook, a pulmonologist who was Dr. John Thiele’s former partner. Cook took responsibility for another section of the fourth floor, replacing his son, also a doctor, who had gone home the previous night and was prevented from returning by the flooding. To ease the load on nurses, Cook decided all but the most essential treatments and care should be discontinued. Bryant King, a thirty-five-year-old internist who had recently joined Memorial as part of its new inpatient hospitalist program, which offered care for other doctors’ patients during their hospital stays, came to check on one of his patients there. Bucking the directive to see only patients in assigned wards, he still planned to submit billing claims on his existing patients as usual. He canceled the senior doctor’s order to turn off his patient’s heart monitor. Cook found out and was furious. He thought that the junior doctor did not understand the circumstances, and he directed the nurse to reinstate his instructions. “I’m in charge of this floor,” he told the nurse in front of King. “I told you what to do; I don’t care what any other doctor says. Do it.”

  Outside on the ER ramp, maintenance workers watched a fuel truck approach to top off the generator tanks. The shiny chrome truck inched toward the hospital along the wrong side of Napoleon Avenue in the lane where the water was shallower. As the tanker turned the corner onto Magnolia Street a hundred yards away from the hospital it stopped, backed up, and left. “Oh jeez,” an electrician said, disheartened. The driver seemed to have judged he couldn’t make it the rest of the way without flooding his vehicle.

  Workers paddled one of the small, flat-bottomed boats kept for minor street flooding to the ER and carried it to the top of the ambulance ramp, which was dry. With dark humor, Susan Mulderick jumped in with chief financial officer Curtis Dosch and hammed for the maintenance chief’s camera, pretending to row. Behind them, Clara Street was a rising lake, calm enough to bear an image of the dappled blue sky, to double the stature of twisty-limbed oaks along Napoleon and add two reflected floors to the cancer institute across the street while now engulfing the cars in its parking lot to their door handles.

  Downstairs in the basement, puddles expanded on the floor. Maintenance staff shut off some lighting and electrical panels to try to prevent a fire. An electrician heard the sound of a waterfall pouring through the breached seals of a ground-level window. Two carpenters raced to buttress the loading
dock against flooding with custom-built plywood walls. They layered duct tape around a vulnerable set of doors, but water sought its level, spurting through cracks ten feet into the hospital shop.

  The supplies that Mulderick and the maintenance crew had moved out of the basement during the storm had been restored shortly after it. Now teams of volunteers rushed to remove them again as water flowed up the drains, a reprise of 1926.

  The pets, too, had been moved back down and were now being taken up to the parking garage facing Magnolia Street. Dr. Ewing Cook and his wife, Minnie, joined a procession bearing creatures and cages. The Cooks and their children and pets always stayed for hurricanes. Recently, not long after his son graduated from medical school, Ewing had retired from clinical practice. He now served as chief medical officer after working at the hospital for a quarter century. Minnie was one of several Baptist nurses who gave birth to daughters who grew up, studied nursing, and replaced them. Her daughter now worked in one of the ICUs with another second-generation RN, Lori Budo, whose mother had once been nursing director there.

  The Cook entourage included their daughter’s three cats and Rolfie, her giant, furry Newfoundland. Minnie walked ahead with one of the cats and Rolfie on the leash, while Ewing followed dragging the dog’s four-foot-long, folded metal cage.

  At the top of the staircase, Minnie turned and waited for Ewing, but he and the cage didn’t appear. “Dr. Cook’s down in the security office,” someone came up and told her. “You might want to go see about him.”

  The sixty-one-year-old doctor had nearly passed out in the heat on his way upstairs lugging the forty-pound cage. A security guard had grabbed him and brought him to his office by the stairwell.

  Minnie thought Ewing was having another heart attack. He’d had two, the most recent one only months earlier when he’d borne the pain like a stoic, continuing to load floor tiles into his car at Home Depot until she noticed he was gray and insisted he go to the hospital.