by Sheri Fink
For the vast majority of people camped on the freeway interchange, she could do nothing. Many, Sandra learned, had experienced a terrifying day and night on their rooftops and urgently needed shelter, food, and water. When one approached with a polite request, “Please give me a bottle for my mom over there,” Sandra said no. The medical teams had hidden their own food and water in supply trailers for fear of being overrun. “If I give you a bottle, then I have to give everybody a bottle, and then we won’t have water to take care of you people,” Sandra told the petitioner. She felt horrible. It was crazy. Why wasn’t there water for the people?
As she worked, Sandra combed the crowds for someone who could tell her about rescue plans for the city’s hospitals. Early that afternoon, officials had called on the radio for anyone who had a boat to bring it to a nearby Sam’s Club in a suburb of New Orleans. “We desperately need these boats, we’ve got deputies that need to be rescued,” Aaron Broussard, the president of neighboring Jefferson Parish, had told a radio host. Hospitals, too, could be evacuated by water. But as evening fell and light drained away from the disaster zone, Sandra LeBlanc saw boats lined up on the interstate, on trailers.
While Sandra worked on Tuesday evening, five hundred miles away, in Dallas, Tenet’s regional business director, Michael Arvin, phoned the EMS bureau in Baton Rouge and left a message for its director. He reported that floodwater was rising quickly around Memorial and another of the company’s hospitals, Lindy Boggs Medical Center. One of the hospitals had lost electricity, he said, and he asked the state for help. Within an hour, at 8:30 p.m. on Tuesday, a worker had noted in the state EMS logs that the two hospitals would become a high priority to evacuate: “Mission 1.”
Twenty minutes later the EMS bureau dispatched a volunteer, Carl Cramer, from Baton Rouge toward New Orleans. His mission was to meet up with fifty-five boats and evacuate the two hospitals. He checked in with the bureau after midnight on Wednesday morning, and his update was dutifully recorded in the logs in Baton Rouge. “Never did hook up with the boats. Was told they stopped the boats because of snipers and darkness.” Instead, Cramer joined the other EMS workers at the cloverleaf on Causeway Boulevard.
When Vera LeBlanc’s sitter called Sandra LeBlanc in the middle of the night from Memorial, Sandra carried the phone out of the trailer and saw Cramer. She knew him from his work with the state’s EMS program. “Can you get the command center on the radio?” she asked. If EMS officials could hear the sitter’s desperation, she thought, they might focus harder on rescuing people at the hospital. Sandra’s plea was recorded in the EMS logs at 4:45 a.m. on Wednesday: “Frantic call from her mother in law—the nurses are starting to panic—they are in Memorial Hospital on Napoleon.”
LeBlanc was told, inexplicably, that the hospital was now considered second priority. Its best hope of rescue, it seemed, lay with her, an EMT teacher who wasn’t even on contract with the state anymore. The person on the other side of the radio said Sandra should go with the boats at sunrise, find the best place to launch them, and do what she could to help empty the hospital.
At daylight on Wednesday, the LeBlancs drove six miles south on Causeway Boulevard to the Sam’s Club parking lot near where the floodwaters started. The lot was filled with people and boats. The LeBlancs struck up a conversation with two men. The blunted vowels and head-spinning pace of their patois marked them as Louisiana Cajuns, descendants of the French via Nova Scotia and centuries-long residents of southern Acadiana, a land of marshes and languid bayous that tilted along the Gulf Coast and was best traversed by boat.
“We’re here to rescue people out of the hospitals. That’s what we’re going to do,” one said. Each man had an airboat and was looking for someone to tell him where to go. The LeBlancs told them about Mark’s mother and the horrible conditions the sitter had described at Memorial. The men said they thought Memorial might be one of the hospitals where volunteers would be sent. One of them went to look for information. He returned and said, “They’re fixing to make an announcement.”
The boat pilots in the parking lot gathered around a woman who climbed up on a tailgate to speak to them. She announced that she needed volunteers to scout out routes to an initial set of destinations. She shouted out the names of several hospitals—other hospitals, not Memorial.
When the woman finished, the LeBlancs raised their hands and asked, what about Memorial, what about Baptist? The woman said it was being prioritized last among the hospitals. Why, she didn’t know.
The LeBlancs couldn’t understand it. Didn’t officials realize that Memorial had lost power and that people there were panicking, getting desperate, even dying? Were the other hospitals in New Orleans somehow worse off? Who was in charge? Where were the answers?
One of the two Cajun men asked the LeBlancs if they knew how to get to the hospital. “Well, sure,” Mark said. He had been born there when it was known as Baptist. It was the hospital where his family always went for care. He had visited his mother there just the other day. The two men said they would pilot their airboats to Memorial if the LeBlancs could show them the way.
“We don’t need much water to launch,” one of the airboat captains said. They piled into pickup trucks and explored one potential route to the flood zone, then looped back and hit water on Jefferson Highway just east of Ochsner Medical Center, near a set of railroad tracks and the Orleans Parish line. The LeBlancs explained that from there it was a straight shot to Memorial along the highway, which turned into Claiborne Avenue. It was the route, in reverse, that the LeBlancs had used to evacuate the city days earlier. The men backed their trailers into the water and launched the boats from there.
The giant fans at the back of the boats stirred the air with a roar and propelled them. As they floated over the highway, Mark LeBlanc imagined cars, from clunkers to the fanciest Jaguars and Mercedes-Benzes, parked in the medians, now drowned. The deeper they ventured into the city, the more intense and frantic the scene. They saw people wading through water up to their necks who turned to look and gesture at the airboats loudening the midmorning. The LeBlancs had only advice to dispense. “There’s dry land that way! We can’t stop. We’re on our way to the hospital.”
Two small aluminum boats joined them as they went. When they arrived at Memorial, Mark borrowed a flashlight from a nurse and bounded up seven flights of stairs to LifeCare. What hit him first was the heat, then the stillness. Nursing assistants loitered at a desk, looking worn, not tending to patients. Some of them registered shock when they saw him, knowing he had not stayed at Memorial for the storm. The patients he passed were almost naked. He found his eighty-two-year-old mother covered in sweat, lying on a wet bed. She greeted him with a smile and told him she was thirsty. She was, she said calmly, “in a mess.”
The sight infuriated Mark, and he left to get Sandra. They comforted his mother and then went to find out what the hell was happening. Diane Robichaux, the visibly pregnant senior leader on the floor, met with them in her office and said she didn’t have much information. The LeBlancs told her they had brought airboats to Memorial and planned to round up more. They explained the location of the launch site where patients could be dropped. “You’re going to have to have ambulances to pick them up there,” Sandra said.
Robichaux no longer had, she explained, a way to contact her corporate office to request the ambulances. The LeBlancs, struck by how resigned everyone at the hospital seemed, offered to try to arrange ambulances themselves with their working cell phone. “Of course,” Robichaux said, “any help you can give us, we’ll take.”
The LeBlancs called an ambulance company and put Robichaux on the phone. She described the location of the site by the railroad tracks near Ochsner Medical Center. “We need an exact address,” the person on the line told her. “Without an exact address, I can’t send anybody out.”
“Well, I don’t have an exact address,” Robichaux said.
“Ma’am, we can’t help you. We can’t help you unless you have an ex
act address.” While Robichaux’s colleagues wrestled with a pile of phone books, looking for some kind of address or at least the name of a cross street, the call with the ambulance company dropped. Robichaux was unable to reconnect.
She reached a LifeCare corporate representative in Shreveport. Speaking quickly, so as not to lose another call, Robichaux asked if LifeCare could divert some of the ambulances that were heading to the staging area they had previously discussed, and send them instead to the boat location near Ochsner. The corporate representative said she would try. She and her colleagues would also try to locate the ventilator patients who had gone out earlier and arrange for their transfer to other LifeCare hospitals.
The LeBlancs headed back downstairs. Mark was upset. He believed his mother needed an IV to hydrate her and deliver antibiotics for a stubborn urinary infection, but he’d been told the hospital could no longer provide intravenous fluids. Though his mother was a LifeCare patient, Mark complained to a Memorial administrator, who explained that the hospital was in a survival mode now, not a treating mode. “Do you just flip a switch and you’re not a hospital anymore?” Mark asked.
THAT MORNING, after having difficulty locating a sufficient supply of official, color-coded triage armbands, doctors and nurses settled on a new method for categorizing the many more than one hundred remaining Memorial and LifeCare patients as they were brought downstairs. They were divided into three groups to help speed the evacuation. Those in fairly good health who 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 had agreed on Tuesday, those with DNR orders.
Dr. Anna Pou, always one to take on the most difficult tasks, jumped in to help coordinate the mass movement of patients. Every breath she took of the rancid air burned the back of her throat. She considered the unsanitary conditions in the hospital nearly unbearable, the pitch-black interior rooms exceptionally dangerous. She worried that even healthy people were getting sick and having difficulty breathing in the heat.
Pou and other workers scoured the hospital floor by floor for every last cot and stretcher and dragged them down to the second-floor lobby. Throughout the morning, makeshift teams of medical staff and family members carried many of the remaining Memorial and LifeCare patients there. Pou rolled the short sleeves of her scrub shirt up to her shoulders and stood ready to receive them.
In the dim light, a ranking began. Nurses opened each chart and read the diagnoses, using flashlights sparingly to save batteries. 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—roughly three dozen in total from Memorial and LifeCare—were guided down to the emergency room ramp. The airboat flotilla was beginning to make runs to dry ground, and the plan at first was for these patients to go out on them. LifeCare nursing director Gina Isbell and Memorial nurse manager Karen Wynn took charge of the patients’ care while they waited on the ramp.
The 2’s—perhaps seventy in all throughout the day—were generally placed along the corridor on the way to the hole in the machine-room wall that was a shortcut to the parking garage and, ultimately, the helipad. A dozen and a half or so 3’s were moved to a corner of the second-floor lobby near a Hibernia Bank ATM and a planter filled with striped green dieffenbachia. Patients awaiting evacuation would continue to be cared for—their diapers would be changed, they would be fanned, often by family members of the staff, and given sips of water if they could drink—but once the patients were moved out of their rooms on Wednesday, most other medical interventions were limited. The idea of indicating somebody’s destiny by a number struck at least one passing doctor, neuroradiologist Bill Armington, as expeditious but distasteful.
Pou and her coworkers were performing triage, a word once used by the French in reference to the sorting of coffee beans and later applied to the battlefield by Napoleon Bonaparte’s chief surgeon, Baron Dominique-Jean Larrey. Triage came to be used in accidents and disasters when the number of those injured exceeded available resources. Surprisingly, perhaps, there was no consensus on how best to do this.
Concepts of triage and medical rationing are a barometer of how those in power in a society value human life. During World War II, the British military limited the use of scarce penicillin to pilots and bomber crews. Before lifesaving kidney dialysis became widely available in the United States, some hospital committees secretly factored age, gender, marital status, education, occupation, and “future potential” into treatment decisions to promote the “greatest good” for the community. When this practice attracted broader public attention in the 1960s, academics condemned one Seattle clinic for ruling out “creative non-conformists… [who] have historically contributed so much to the making of America. The Pacific Northwest is no place for a Henry David Thoreau with bad kidneys.”
A story in LIFE magazine by Shana Alexander exposed the practices and led to public outcry. Lawmakers created a system in which Americans who needed dialysis would be entitled to it, typically at the government’s expense. However, in countries such as South Africa, dialysis rationing persisted for patients receiving care in public hospitals. With the number of those who could benefit far exceeding the number of treatment slots, doctors struggled at weekly meetings to choose who lived and who died. Would it be ethical to weigh “social-worth criteria” like a person’s job, parental status, or drug-abuse history alongside medical criteria? Should patients be informed of the decisions and given the opportunity to appeal? After years of decisions that favored white South Africans, how could the process itself be made more just? Eventually doctors sought input from patients themselves in constructing a more standardized rationing system; the dreadful process of selecting patients was made more accountable as advocates campaigned to expand dialysis programs for low-income South Africans and to prevent kidney disease.
In the United States at the time of Katrina, at least nine well-recognized triage systems existed to prioritize patients in the case of mass casualties. Because of the difficulty of investigating outcomes, including deaths, in emergencies—and perhaps because of the potential for political embarrassment or due to a lack of financial incentives—almost no research had been done to see whether any of the commonly used triage systems achieved their intended goals or even that they didn’t paradoxically worsen overall survival. Most systems called for people with relatively minor injuries to wait while medical personnel attended to patients in the worst shape. This was Baron Larrey’s original concept of triage as described in his memoirs of an October 1806 battle in Jena, Prussia, between Napoleon’s forces and the Fourth Coalition. “They who are injured in a less degree may wait until their brethren in arms, who are badly mutilated, have been operated on and dressed,” he wrote. “Those who are dangerously wounded should receive the first attention, without regard to rank or distinction,” an idea in keeping with the French Revolutionary concept of égalité.
British naval surgeon John Wilson introduced another triage tier several decades later in 1846 when he decided to withhold surgery from patients for whom it would likely be unsuccessful. In 2005, a few triage systems incorporated this idea, calling for medical workers to forgo treating or evacuating injured patients who were seen as having little chance of survival given the resources at hand. That category was intended for use during a devastating event such as a war-zone truck bombing in which there were far more severely injured victims than ambulances or medics.
Consigning certain sicker patients to go last has its risks, however. Predicting how a patient will fare is inexact and subject to biases. In one very small study of triage, experienced rescuers were asked to categorize
the same patients and came up with widely different lists. Many patients who could have survived were mistakenly deemed unsalvageable by some rescuers. And patients’ conditions can 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.
Designating a category of patients as beyond help creates the tragic possibility that a patient with a chance of survival will be miscategorized and left to die. To avoid this, some experts have concluded that patients seen to have little chance of survival must still be treated or evacuated—after those with severe injuries who need immediate attention to survive, but before those with significant injuries who can wait.
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.
POU WOULD LATER SAY that the goal in a disaster must be to do “the greatest good for the greatest number of people,” the same phrase used by public servants, including New Orleans Sewerage and Water Board superintendent George G. Earl when he decided which parts of New Orleans to protect from flooding with his limited budget in the 1920s.
But what does the “greatest good” mean when it comes to medicine? Is it the number of lives saved? Years of life saved? Best “quality” years of life saved? Or something else?