by Sheri Fink
The goal of maximizing net good for a population has its roots in the utilitarian philosophy developed by Jeremy Bentham and John Stuart Mill in the eighteenth and nineteenth centuries. More recent philosophers have warned that this approach, if applied to lifesaving medical care in disasters, may require an unacceptable level of sacrifice from those most in need of assistance. These thinkers favor an approach modeled on the principles of justice set out by John Rawls in the late twentieth century (although Rawls himself did not apply them to medical care). The idea is to distribute care based on need. Those in the most imminent danger of dying without care have a bigger claim to the pool of aid, much as French surgeon Larrey articulated, even if that inconveniences a larger number of patients with less urgent conditions who have to wait. This is the approach taken in most American emergency rooms in non-disaster settings.
Other philosophers have gone further afield, arguing that potentially lifesaving resources should be allocated randomly, because everyone deserves an equal chance to survive, and because it is dangerous to endow groups of people with the power to assign who lives and who dies. This argument sparked a debate that played out in the pages of philosophy journals for a decade beginning in the late 1970s. Proponents rejected the popular idea that the number of lives saved should be a central consideration when prioritizing rescues. The writer of an influential paper, John M. Taurek, also argued that suffering is not cumulative between individuals—for example, that it is impossible to add up the suffering of a large number of people with minor headaches to equal the suffering of a single person with a migraine, as a utilitarian might do. This concept was also elegantly expressed many years earlier by the author C. S. Lewis, who wrote:
There is no such thing as a sum of suffering, for no one suffers it. When we have reached the maximum that a single person can suffer, we have, no doubt, reached something very horrible, but we have reached all the suffering there can ever be in the universe. The addition of a million fellow-sufferers adds no more pain.
The quandary of disaster triage had an analogue in everyday American medicine: the allocation of transplant organs. The United Network for Organ Sharing invited both doctors and laypeople to help design allocation schemes as part of an ethics committee. According to medical ethicist Robert M. Veatch, members of the general public typically favored giving organs to those in the direst need, even if these patients were less likely to survive or lived at a greater distance from where organs became available. In contrast, health professionals tended to favor systems aimed at directing available organs to the patients most likely to benefit medically from them. To achieve this, the professionals were more willing to accept that many of the sickest patients would die without transplants, as would patients who had less of a chance of acquiring a well-matched organ because they were members of ethnic groups that had a higher rate of need or a lower rate of donation (a problem mitigated by the development of newer antirejection drugs). The approach could also disadvantage members of groups whose outcomes tended to be poorer, including, in the case of kidney transplants, those of lower socioeconomic status.
Although no allocation method could ever enlist universal agreement, the process of devising a method, at least, can be made more just. In the case of organ transplantation, including both doctors and laypeople in decision making resulted in policies that prioritized a mixture of both justice and efficiency. Who decides how care is allocated is critically important because it is, at its heart, a question of moral priorities.
At Memorial, however, in the disaster’s vise, only medical professionals had a say in how patients would be categorized for evacuation. Once the decisions were made, no system was established to share the information with the people who would be most affected by it.
In some cases it was actively kept from them.
On a fifth-floor hallway in Memorial’s Clara Wing, transporters rolled a bed-bound patient toward the stairwell for evacuation, but after seeing she had a DNR order, they stopped and repeatedly maneuvered other patients around her. Nurses were instructed not to tell the patient’s daughter that this was because her mother had a DNR order. To calm her, they said her mother wasn’t the only patient left on the floor, failing to mention that the only other patient was dead. His son had taken him to Memorial’s emergency room before the storm for a cough, but the ninety-seven-year-old man with Alzheimer’s disease, James Lafayette, was discharged and had spent two days lying on the floor of Memorial’s lobby before being admitted. Hours later, nurse Michelle Pitre-Ryals found him pulseless in his bed. Doctors and nurses appeared from everywhere, lighting his room like a Christmas tree with their flashlights. They ran a Code Blue, but extraordinary measures, after the lack of ordinary measures, failed to revive him. Pitre-Ryals was distraught. In her five years as a professional, no patient had died unexpectedly on her watch.
Now a man with a walkie-talkie appeared and told staff members they had to leave the floor. “What are you talking about?” Pitre-Ryals asked. Nobody had come for the DNR patient. The hot, exhausted nurse couldn’t believe she and her colleagues were being told to abandon her and they refused. Pitre-Ryals informed the woman’s daughter of her right to request that the DNR order be discontinued, just as she had approved it after her oxygen-dependent mother was admitted for the storm. “If she goes into cardiac arrest, let her go,” the daughter had said, reasoning it wouldn’t make sense for her mother to be resuscitated at age ninety-three. This situation struck the daughter as entirely different. “I didn’t mean for her to be left up here,” she told Pitre-Ryals. “When I made my mother a DNR, I did not know it meant ‘do not rescue.’”
The daughter asked for the DNR order to be canceled. She even appealed to the self-interest of the nurses who insisted on staying with her despite being ordered to leave. “You people have to get out, and we’re keeping you.” Someone went to find a doctor to remove the DNR order, and the patient was moved downstairs and out into the parking garage on the way to the helipad and rescue, surviving her immediate ordeal.
On a seventh-floor hallway at LifeCare, Angela McManus, another patient’s daughter, panicked when she overheard workers discussing the decision to defer evacuation for DNR patients. She had expected that her frail seventy-year-old mother, Wilda, would soon be rescued, but her mother, too, had a DNR order. “I’ve got to rescind that order,” Angela begged the LifeCare staff. They told her that there were no doctors available to do it.
Wilda McManus stayed upstairs in LifeCare. The doctors in the second-floor staging area told LifeCare staff to stop sending down patients. There was, they said, no more room.
CHAPTER 6
WEDNESDAY, AUGUST 31, 2005—AFTERNOON
IN A PRIVATE PATIENT room on the fourth floor of the Clara Wing at Memorial, Karen Lagasse watched four men take hold of the corners of her mother’s hospital bed sheet and lift her. The men carried Merle Lagasse toward the staircase. Karen and a nurse followed, holding an oxygen cylinder and the single bag Karen had stuffed with belongings.
Merle was, until recent months, a vivacious seventy-six-year-old. She had volunteered in the schools and worked reception at a beauty salon, and was a lover, rescuer, and collector of feral cats.
Dr. Ewing Cook had treated Merle for emphysema until his recent retirement. Merle adored him. She would dress up for appointments at his office. She had an Elizabeth Taylor aura, her brows arched, a corona of mascara radiating around her richly lined eyes, her lipstick bright. Cook would greet her with a huge smile. “Merle,” he’d say, “you’re gonna make a beautiful corpse.” The comment irked her daughter, Karen. But Merle heard only “beautiful.”
The tall, balding doctor had been sober with them from the beginning. Merle had emphysema. There was not much to be done. Cook prescribed a home oxygen machine and Merle opted for the longest cord so she could walk freely through the house. She went out sometimes with a portable tank. But she was weak. Karen wished Cook would be more proactive. Could physical therapy help?
<
br /> More recently Merle had learned she had lung cancer—not the curable kind. A little more than a week before Katrina, her new doctor, Roy Culotta, had admitted her to Memorial after she had a bad reaction to a pain medicine patch.
During Merle’s hospital stay, Culotta had worked to relieve her pain, her shortness of breath, and the existential anxiety that grips patients whose hunger for air goes chronically unsatisfied. Before the hurricane, he had prescribed treatment with a Vapotherm machine that directed a high flow of oxygen from the supply in Memorial’s walls into Merle’s nose.
Culotta had another idea he said would help Merle breathe easier. Fluid on the left side of her chest cavity was constricting a lung. He could tap the fluid in her thorax using a sterile needle and a flexible tube, allowing the lung to expand again. This thoracentesis procedure promised temporary relief, perhaps for days or weeks, until the fluid built up again.
Culotta ordered a thoracentesis kit to be placed at Merle’s bedside, but he had not yet come to perform the procedure. On Monday afternoon, after the intermittent bands of wind and rain from Katrina had abated, Karen saw him in the parking garage. He told her he was on his way home to take a shower. She had not encountered him since then. The kit sat at Merle’s bedside still wrapped in plastic as it had been since the day before the hurricane.
After the air-conditioning cut out on Monday, Karen had lifted a box fan to the bedside table and pointed it at her mother. She covered her in ice packs. She ran downstairs to pray in the dark, empty chapel for her mother and their cats, whom she had left at her mother’s house with food and water. She feared they might have drowned.
Overnight on Tuesday, the alarm on the high-flow oxygen machine began ringing. The respiratory therapist had stopped making visits. To Karen, it seemed to take the nurses on the fourth floor a remarkably long time to figure out the reason for the alarm—the power loss.
They took away the failing Vapotherm machine and replaced it with a less-effective alternative—a mask that connected to the hospital’s bulk oxygen supply, still flowing miraculously from the wall. Karen felt anxious. Her mother’s breathing seemed more effortful. Karen tried to cool her by fanning her with a piece of cardboard printed with the hospital company logo that a hospital worker had distributed.
The nurses said Merle would be one of the first patients to leave Memorial because she relied on equipment to help her breathe. Then a doctor came to ask whether Merle could sit in a wheelchair. Karen didn’t think so. Karen realized the plan for her mother had changed when the patients who could walk or sit in wheelchairs began leaving the floor first.
When it was finally Merle’s turn, a nurse detached the oxygen tubing from a nozzle on the wall and slid it onto a regulator atop a green metal gas cylinder. Karen noticed that the kit for removing the fluid around her mother’s lungs was still sitting at the bedside. She asked the nurse whether to take it along. “Oh, they’re not going to do that now,” she replied.
Several volunteers gripped the sides of Merle’s bed sheets, lifted her, and carried her to a stairwell. They began their descent with Merle facing headfirst. Realizing the peril of this approach, they backed up and turned her feet-forward before continuing.
When they emerged from the stairwell two flights below, they laid her down in a line of patients leading to the machine room on the second floor. Lying flat made it even harder for Merle to breathe. A nurse whom Karen recognized came to check on Merle. “She’s got to go now!” the nurse said, and twisted the knob on the regulator to maximize the flow of oxygen.
No kidding, Karen thought. Staff members descended on Merle to begin moving her to the heliport, and Karen was told she had to leave the area. She started to walk away, but heard her mother’s voice. “Karen,” Merle gulped, “I can’t breathe.” Karen turned around and saw the oxygen tank had been disconnected and her mother was about to be passed through the narrow opening in the wall leading to the parking garage.
“She can’t breathe without the oxygen!” Karen yelled at a woman in scrubs who looked like a doctor and seemed to be in charge. “You have to put it back on her!”
“You don’t know what’s going on,” the woman said. Others stood and stared. Karen argued with the woman, even as she was reassured that her mother would receive oxygen on the other side of the hole in the parking garage. Karen was told she needed to leave the area. She was so hot and angry she felt ready to kill the woman speaking to her so insensitively. She knew she had to get out of there and her mother did too. She turned and rushed down to the ER ramp to try to get on a boat so she could begin searching for wherever her mother might be taken. She did not want her to be alone.
ON THE OTHER side of the wall, on the helipad above the parking garage, a fortunate few were being helped aboard helicopters. Among the first to lift off were a pregnant ICU nurse and several patients with kidney failure who needed dialysis. In the bright sunlight on the open pad, hospital volunteers mopped their brows with small white towels that they wore on their heads or tucked around the necks of their scrub shirts. In the helipad’s shadow, wheelchair-bound patients were staged on the gravel-covered roof of the parking garage so that volunteers could bring them to helicopters quickly.
A Coast Guard lieutenant reached Susan Mulderick by phone. His colleagues had been trying to put Memorial staff in touch with state emergency officials but had difficulty reaching anyone at the hospital. The overnight rescue operation had come in for some official criticism. At least one Coast Guard commander said the local sector and its junior grade lieutenants had stepped on toes by responding directly to Memorial, taking initiative when they received no response from higher officials or those stationed at the state Emergency Operations Center.
The lieutenant on the phone asked Mulderick whether the hospital had water and food. When she told him it did, he said he needed to pull helicopters away for a period of time to rescue people stranded on rooftops, something that had been more difficult to do overnight in the dark. Coast Guard pilots, entering New Orleans airspace at night on the way to Memorial, had seen what appeared to be a sea of light through their night vision goggles. With no streetlights or headlights, every source of those lights likely represented a person with a candle, flashlight, or lighter, signaling for help. Additional search-and-rescue assets were being sought from around the nation. The number in the area was inadequate to the need. Pilots nearing Memorial could see people desperately waving their arms and flapping sheets and towels out of the windows of a nearby apartment building and from the back of a flooded pickup truck. Near the intersection of Claiborne and Napoleon Avenues, some people attempted to wade through rainbow-sheened water nearly up to their necks, pushing tires and coolers ahead of them as flotation devices.
Private air ambulance companies now had to request special permission to enter the New Orleans airspace, and those present were focusing on critical patients at other hospitals. Even as the number of aircraft operating over the city grew, the limited or absent air traffic control radar and air-to-ground communications, and the presence of aboveground power and phone lines, made flying extremely dangerous. Only a few private and military choppers arrived at Memorial on Wednesday morning after daylight. Some of the pilots seemed to be under the mistaken impression that only a handful of patients remained. Several National Guard pilots landed to drop off patients at Memorial.
At least the Coast Guard emergency radio proved helpful. To conserve its batteries, every hour, at a quarter to the hour, the nurse who was also an Air Force Reserve captain asked someone to find the CEO and Susan Mulderick and see if the hospital needed anything. She then turned on the radio, checked in with emergency officials, and made requests for supplies, which helicopters dropped on the pad. Later, someone took the radio and gave Memorial two satellite phones to use instead, but nobody could make them work. Reliable communications with the world outside were lost.
Overhead, the sky pulsed with a war-zone soundtrack of low-flying aircraft. During the day Presi
dent George W. Bush, too, cutting short his Crawford, Texas, ranch vacation two days after the storm, overflew the devastation in Air Force One on his way back to the White House.
Inside the plane, photographers Jim Watson and Mannie Garcia captured the president in profile as he leaned toward a window. Daylight sharpened the maze of creases on his face and illuminated the frown on his lips. Another photographer, Susan Walsh, caught the president from a different angle, behind a shoulder of his monogrammed blue flight jacket as he rested on crossed forearms, gazing out at a body of water, hands balled into fists.
Some would later accuse the president’s peregrination of grounding rescue flights. Exceptions to presidential airspace restrictions were, however, typically granted for lifesaving medical flights. Whatever its causes, the slowdown in the arrival of rescue helicopters compared with the previous day frustrated the staff and volunteers on Memorial’s helipad, who were now organized, eager to work, and surrounded by patients awaiting transport. A doctor on the helipad aimed his Treo cell phone skyward and snapped a picture of what appeared to be the Boeing 747 body silhouetted against bright clouds as it glided overhead, less than half a mile above the hospital.
GREEN VINES SPILLED over the side of a smoking balcony, where several people watched as evacuees were helped down from the top of the emergency room ramp onto the bow of an airboat. Other onlookers took to hospital windows, and still others watched suspended from a double-deck bridge over flooded Clara Street.
Each of the two airboats fit three or four people in addition to its pilot. Several adult patients whose breathing relied on a tracheostomy—a surgical hole in the neck—or who had cancer went aboard, including the two relatively young people who had recently received bone marrow transplants and whom Memorial staff had hoped to transfer out on Tuesday. They were highly susceptible to infections but were able-bodied enough to wade through shallow water at the drop-off point. They and the other passengers put on earmuffs or stuffed their ears with gauze to protect against the din of the airboat propellers.