by Sheri Fink
“We need to have a little bit more of a surgeon’s attitude,” Walsh said. Surgeons were men and women of action. The group of doctors in the suite opted for insubordination over inaction. Rather than await the scheduled morning meeting to discuss options, Walsh left after first light with an anesthesiologist on the plant-operations director’s fishing boat to try to organize a more concerted rescue effort. Another anesthesiologist went to find Drs. Anna Pou and Roy Culotta to see if they would re-triage the patients who remained. The message that day needed to be a positive one: everyone would be getting out.
SOON AFTER SUNRISE, hospital staff gathered on the emergency room ramp. Incident commander Susan Mulderick stepped up on a curb to begin the meeting, with CEO Goux beside her, and medical chairman Deichmann also present. Doctors, nursing managers, maintenance workers, and security staff jostled and shushed one another. It was difficult to hear.
Mulderick went over what remained of food, water, and people at the hospital. Few participants took special note when she mentioned the LifeCare patients who were still on the seventh floor.
The conversation moved in other directions. Food-service employees fretted over the remaining food stocks, having spent days filling Styrofoam cups with grits, sausage, and spaghetti prepared with propane stoves and Sterno, and serving juice, bagels, and mystery meat from a temporary kitchen above the flooded basement.
One doctor asked what was being done to dispose of human waste; the smell in the hospital was bestial. The hospital’s elder statesman, Horace Baltz, formally commended his colleagues for their hard work. He told them to pull together and they would all get out alive. The crowd applauded him.
Memorial’s chief financial officer, Curtis Dosch, returned to the ramp as the meeting started to disperse. He had just used a working cell phone to speak with Tenet official Bob Smith in Dallas and received confirmation that Tenet was dispatching the fleet of privately hired helicopters and a satellite phone that morning. “Everybody shut up for a minute,” someone shouted. “We got an update.” Mulderick asked Dosch to share the good news. Some of the worn, anxious staff members seemed to disbelieve him. They wanted to know exactly when and how they were getting out of the hospital, answers Dosch and Mulderick couldn’t provide. All the leaders could do was reinforce the idea that they were awaiting more boats and helicopters and, somehow, they were going to get everybody out of Memorial that day.
From: Bob Smith [regional senior vice president, Tenet Healthcare]
Sent: Thursday, September 1, 2005, 8:56 AM
To: Captain John Andrews, Navy Second Fleet
Subject: Tenethealth Prioities in NOLA
Since my communication yesterday we have a dire situation at Memorial Hospital in NOLA. This facility is unsecure and we need immediate assistance. We are unable to evacuate our patients and staff due to gun fire in the area. The facility is compromised and there are people dying in the building. There are people with weapons in and/or around the building. We believe lives are in immediate danger. Memorial Medical Center 2700 Napoleon Ave.
Louisiana Bureau of Emergency Medical Services phone call log, Thursday, September 1, 2005, 9:33 AM:
…60 patients that need a move by stretcher are at Memorial Medical Center.
US Coast Guard LTJG Shelley Decker notes on Thursday, September 1, 2005:
Tenant Memorial Hospital-Presidential tasking to evac immediately
IT SMELLED WORSE on the second-floor lobby than Susan Mulderick remembered from having walked through the area on Wednesday. Despite the broken windows, the air stayed stubbornly still near the bathrooms. The fecal stench was intense.
Nobody, she thought, should have to bear such conditions, particularly not fragile patients. Some called for help, looking up from their cots along the hallway, dazed and fearful as people streamed past them.
Mulderick knelt beside an elderly woman. She peeled the pads away from her backside and began to wipe away her feces. The woman cried. The heat and a shortage of diapers and fresh linens had defeated the nursing staff’s efforts to keep patients dry and clean. Her skin was raw. Mulderick found a fresh red sore above her buttocks. It looked as if the skin had broken down as the woman lay sweating into her cot. The slightest touch caused her to yell out in pain, and as Mulderick took in the woman’s misery and extrapolated it to the dozens lying around her, the normally stoic nurse executive was profoundly shaken.
When Mulderick stood up from her work, Dr. Kathleen Fournier approached her, looking equally upset. She was worried about her cat, she told Mulderick. It was sick and suffering, no longer eating or drinking. She took Mulderick to see “Tabby.” Fournier was torn up by the prospect of putting her pet down. What did Mulderick think?
Mulderick wanted to slap her. How could the doctor express more concern for a cat than for the patients all around her? Pets were everywhere—everywhere!—in spite of Mulderick’s exhortations to keep them out of the hospital. Staff members simply ignored the rules, walking their dogs through the areas where patients were lying and telling her they wouldn’t leave their pets behind. For Christ’s sake! Where’s your damn common sense? she wanted to ask. It angered her to see them attending to pets around the corner from where the sickest patients lay.
A short time later, Mulderick shared these frustrations with a radiologist on the ER ramp. “We are talking about euthanizing the animals,” she said, “but not about what we can do to help the patients.” Mulderick asked him to communicate her concerns to the medical chief, Dr. Richard Deichmann, who was holding daily meetings with the doctors.
She would later recall that her idea was to rid the patients of their pain and dull their senses to the point they would no longer care that they were smelling the feces they were lying in, that panting dogs were weaving past and licking their hands. But the radiologist seemed to interpret her intentions differently. A physician colleague heard him ask Deichmann if they could convene a meeting to discuss euthanasia, because some of the staff were concerned about the patients and wanted to consider it. The radiologist thought it would be best to get the discussion out in the open and not have the decision made by a few people in a dark corner. Deichmann said no. The idea shouldn’t even be considered.
The physician colleague watching the interaction figured that staff inside the hospital didn’t want to see patients suffering and were at a loss for what to do; while medicine had, of late, been overtaken by a fad of standardization, no guidelines existed for this situation. The idea of euthanizing patients, however, struck him as dangerous, and he shared his opinion with the radiologist. “I can’t imagine getting through all this—with all we’ve been through and all we’ve done—and having a physician go to jail because they were trying to help a patient and did something illegal.”
What would stick with Dr. Richard Deichmann years later would be not this conversation, but another one: He and Mulderick speaking in a quiet hallway alone; she asking him whether it would be “humane” to euthanize the hospital’s DNR patients (a word and an idea Mulderick would deny, through her attorney, ever having spoken of with Deichmann or anyone else at Memorial); and Deichmann replying, “Euthanasia’s illegal.” Throughout the disaster, he and Mulderick had expressed minor differences about how the evacuation should proceed, which sometimes frustrated the employees, who were confused about whose direction they should follow. But this question, if Deichmann understood it correctly, represented a major difference. “There’s not any need to euthanize anyone,” he would recall telling Mulderick. “I don’t think we should be doing anything like that.” He had figured the DNR patients should go last, but the plan, he told Mulderick, was still to evacuate them, eventually.
One of the emergency medicine doctors, Karen Cockerham, interpreted Mulderick’s words the same way as Richard Deichmann did and as the radiologist did. However, Cockerham agreed with the idea of euthanizing patients, which was what she was sure was being proposed when she listened to Mulderick on the ER ramp. When is somebody going to sa
y it? she’d been thinking. It’s the thing nobody wants to say. The ER doctor looked around and saw others nod and noticed that nobody was objecting. This is the United States, she thought, and was surprised at what was being said so frankly, out in the open, with maybe a couple dozen people around. She wondered how smart that was, but she thought that euthanasia needed to be considered. It was obvious to her, although she couldn’t, in her normal life, have imagined it being a viable option. Now it seemed, while not the only option, perhaps the only humane one. She felt confident it was the right thing even before this conversation, and no doubt, she thought, others were thinking it, too.
Why? Because time had come to feel magnified. She was no longer able to envision what would happen when life returned to normal; many people seemed to be wondering whether that would ever happen. Having an end would give them a reference point for their options. Yes, she had heard they would all get out that day, but she couldn’t see it, couldn’t believe it, wasn’t convinced by the CEO or by Susan.
Conditions seemed increasingly unstable. The doctor felt not only unsafe, but also vulnerable. She had fleeting thoughts that at any moment prior to being saved something even more catastrophic would occur—perhaps some sudden, secondary natural consequence of the disaster. This building could explode, she thought, or somebody could come in and hold us up and take everything we have and decide to shoot us. Her two-year-old was safe with her husband out of town, and she worried increasingly about putting herself in harm’s way when she had a responsibility to return to them. She’d heard gunshots outside the hospital, which she knew was turning away neighbors seeking rescue, and she envisioned racial tensions rising. She was sure these existed because once she—a pale blonde student craving a late night biscuit—had stopped at a chicken restaurant a half-mile from the hospital near the Magnolia public housing project, and a lady warned her, honey, to get on out of here.
In the second-floor lobby, where she stopped several times to help, the temperature felt like more than a hundred degrees. Even breaking windows in the glass oven had not improved air circulation that much. This is awful. She saw skinny patients lying almost naked, which was so that the people tending to them could keep them cooler and could more quickly clean up their waste. Some of the patients looked like the cadavers she recalled from gross anatomy in medical school. She was sure they had no idea what was going on, and that they had bedsores from lying in place without a good mattress and someone regularly shifting their bodies from side to side.
She knew what she would want in their place, she would say. “If I were one of those little bitty, skinny, debilitated, confused poor little ladies, I mean let me go to heaven. Don’t do that to me. I’ve lived my life, I’m not going to be watching TV or reading a book or even carrying on a conversation. I got to look forward to being in bed anyway, please don’t do that to me.”
Somebody had already made that choice for the dogs. Why should we treat the dogs better than we treat the people?
She thought it almost criminal what they were doing to these people, putting them through a torturous process of suffering. And these were people, she would later explain, “who in the best-case scenario might be able to nod or something, but not people who can look forward to going through this horrible ordeal and enjoying anything or being aware of life.” They were the type of people she thought shouldn’t be resuscitated anyway, “people who have no quality of life in the best case scenario, even if they make it through this horrible ordeal.” Didn’t military guys take a cyanide capsule to war, to have an option to avoid torture? And those, she reflected, would be people who would have hope for a meaningful life after their horrible torture. The people she saw on the second floor would, she thought, “have horrible torture and no meaningful life.” She knew it was torture, because the heat was hard enough on her, too, that, when she took breaks from working, she sought refuge in her air-conditioned car, grateful for having topped off her gas tank before the storm.
The ER doctor said something to Susan Mulderick, but Mulderick told her it was being taken care of.
MULDERICK’S IDEA to medicate the patients found a champion in Dr. Anna Pou.
The two had met for the first time only the previous day when Pou informed Mulderick that the chapel had been converted into a morgue for the LifeCare ventilator-dependent patients who died after staff put an end to the Coast Guard evacuation. Like Mulderick, Pou had also been pressed for advice by a distraught animal owner deciding whether or not to put down his pet. Mulderick had seen Pou directing patient care on the second floor.
Mulderick shared her feelings with Pou now and repeated her statement. They were talking about euthanizing the animals, but not about what they could do to help the patients. She would later remember Pou saying the men and women lying before her were much like many of her cancer patients—at some point there was nothing else to do for them but try to make them comfortable. Pou said she would use pain medications to do that, though she wasn’t sure what to give the patients.
What to give them? Dr. Ewing Cook would know. Mulderick had worked with Cook for two decades, going back to her time as head nurse in the ICU. She knew he believed that certain drugs exist to relieve suffering. Unlike many doctors, he didn’t shy away from ordering them. For years as a pulmonologist he had helped patients who were taken off life support die without pain and anxiety. Cook believed in making dying patients comfortable.
Mulderick said she would ask Dr. Cook to speak with Pou about what to give the patients. Mulderick found Cook readying his gun. He was preparing to leave the hospital by boat to rescue his son, the doctor who had gone home after the storm and been trapped since Tuesday’s flooding. She asked Cook to talk to Pou before he left.
Cook spoke with Pou on the second floor. He had interacted with her during the year she worked at Memorial and thought highly of her. The weary doctors discussed the category 3 patients. These included some of the patients from Memorial and LifeCare who remained in the staging areas, and nine patients who had never been brought down from LifeCare. To Cook, Pou seemed worried that they wouldn’t be able to get them out. Cook hadn’t been to LifeCare since Katrina struck, and that was on purpose. He had not been asked to go there, had no patients there, and knew that any doctor brave enough to venture upstairs would face difficult, gut-wrenching decisions. He considered LifeCare patients to be “chronically deathbound” at the best of times and knew they would have been horribly affected by the heat. Plenty of staff and volunteers remained at Memorial, but they were exhausted, and Cook couldn’t imagine how they would carry nine patients down five flights of stairs before the end of the day. Nobody from outside had arrived to help with that task. If there were other ways to evacuate these patients, other ways to care for them, Cook wasn’t seeing them.
Cook told Pou how to administer a combination of morphine and a benzodiazepine sedative. He later said he believed that Pou understood that he was telling her how to help the patients “go to sleep and die.” That was different from what she and her colleagues on the second floor already knew how to do and were doing: treat patients for comfort. Over the previous hours, nurses had alerted Pou, Fournier, or King when a patient in the staging area appeared to be in pain or anxious, and the doctors prescribed doses of medicine. Pharmacists had dispensed Ambien, Ativan, diphenhydramine, Geodon, and Restoril to help patients relax and sleep; and morphine, OxyContin, and Vicodin for pain.
What Cook was describing to Pou was something else entirely. The drug combination “cuts down your respiration so you gradually stop breathing and go out,” he would say. He viewed it as a way to ease the patients out of a terrible situation.
Pou wrote out large prescriptions for morphine for three of the patients lying in the second-floor lobby. She ordered nine vials each of a concentrated form of IV morphine, totaling 90 mg for each patient. The highest dose Pou had prescribed for pain in the last two days for her colleague’s patient, the one with cancer who was already on morphine and tole
rant to its effects, had been 10 mg of morphine—nine times less than what she was prescribing for each patient now. In terms of how the drug would be given, Pou wrote only: “as directed.” At the bottom of the prescriptions, she filled in her Drug Enforcement Agency number, as required, which authorized her to prescribe legally controlled substances.
One of Pou’s prescriptions was for LifeCare patient Wilmer Cooley, an eighty-two-year-old former truck driver with heart problems and a serious infection, who required dialysis and had a Do Not Resuscitate order. Another was for Carrie Hall—“Ma’Dear”—the LifeCare patient with a tracheostomy who had so impressed a nurse the previous night with her will to survive. The third was for Memorial patient Donna Cotham, the forty-one-year-old mother of four with liver disease. The day after the hurricane, her condition had worsened, and doctors planned to transfer her to the intensive care unit. But the unit had been evacuating, and she hadn’t gone. She wasn’t expected to survive. She had looked particularly bad overnight to the nurses fanning her on the second-floor lobby.
Two female doctors approached the pharmacist on duty across the hall. He took the three pieces of paper and filled Pou’s prescriptions.
DR. KATHLEEN FOURNIER had been present, listening, when Susan Mulderick spoke with Anna Pou about giving the patients medication.
“I just disagree with this,” Fournier had said.
“OK, don’t order it,” Mulderick responded. “Don’t give it. I’m just asking. If you don’t want to give it, don’t worry about it.”