Thursday, June 19, 2014

Book Review: Five Days at Memorial: Life and Death at a Storm-Ravaged Hospital

I frequently find myself with good intentions for finishing one book, only to be sidetracked by another book. I eventually finish the first, but if the latter is amazing or absorbing- all bets are off until it is done. So it was this week in preparing for book review time. I have a stack of things that are finished or almost finished and ready for review, when I just happened to check out Five Days at Memorial: Life and Death at a Storm-Ravaged Hospital. Frankly, it’s amazing that I still paid attention to my family, work, and personal hygiene while reading this book. So it passed all other comers for today’s review because it is both an excellent book and because it raises some serious ethical questions that must be considered. 

Sheri Fink (M.D., Ph.D.) is a correspondent for the New York Times on a variety of issues, but especially on medical issues and crises. Five Days at Memorial is six years of painstaking research, interviewing, backtracking, and piecing together what happened at Memorial Medical Center between the actual storm of Hurricane Katrina in 2005 and when all living people were evacuated from the hospital five days later. To be absolutely fair and clear, Sheri Fink was not in the hospital during that harrowing time frame. Neither was I. Most likely, neither were you. What we think we might have done is only speculation. 

The truth is that at least one hospital administrator, at least two doctors, and at least three nurses made the decision to divide patients up according to a survivability prognosis. Patients who were not likely to fare well in transferred to another facility, according to the decision of this small group, were administered heavy doses of morphine and a benzodiazepine sedative (Versed). This cocktail was administered with the intention of hastening death. Those who administered the drugs only know whether that goal was a secondary result of a primary desire to comfort the patients. 

The book details the fears and frustrations in the aftermath of Katrina. The reader is pulled along in the tumult of frantic messages for help, combined with hospital personnel sending empty helicopters away so that they (the personnel) could rest. There was a point during my reading when I said to my husband, “This is the worst train wreck ever and I can’t look away.” Ultimately, though Memorial Medical Center still had plenty of bottled water, food, and medicines, people panicked and a mentality of scarcity took over and ruled the day. 

It was not unusual for people to ride out a hurricane at the hospital and so many staff members were sheltered there, with family members and pets. Under the stress of no air conditioning or lights, frustrations were high. One doctor began to worry about her cat and several people asked for doctors to euthanize their pets, lest they suffer unduly by being left behind in a rescue (if that ever occurred). Once the word had been uttered, some people wondered why there was more consideration for the comfort of the animals that the people. 

Fink captures one doctor’s reflection: 

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 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… She could no longer envision what would happen when life returned to normal… 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 leaders]… (p. 193) 

Fink carefully documents that in the months and years to come, people will differ on what they remember saying and who they remember saying it to and when. Some people will admit to participating in the conversations about euthanasia, about who should die and how. Other people were adamantly against it at the time and continued to be later. Others were ambivalent at the time, but would regret their actions, one way or another, in time to come. Regardless, people were killed in the hospital, by those who had been entrusted with their care, just as rescue was imminent. Almost all those who were injected with the drug cocktail died on Thursday, September 2nd. The hospital was emptied of its live occupants by that evening. 

As the book goes on, the reader learns that the Cancer Center at Memorial hospital continued to have some working generators. The upper administrators of the hospital stayed in office suites and comfortable waiting areas there. For stress relief, some nurses in the main hospital used oxygen masks to blow on their faces, cooling them and, temporarily, making the situation more bearable. Outside the hospital, chaos reigned. The local, state, and federal government scrambled and discovered the true gaps in their disaster preparedness, including and especially the lack of interoperable communications. The main doctor in the story, Anna Pou, later reflected that New Orleans during and after Katrina was “not America”. 

The first part of the book details the activity in the hospital. The second part details the legal investigations in the aftermath. It also contains the grief of the families of the patients who died, plus the struggles of the doctors and nurses who had been in Memorial. Memorial Medical Center was not the only hospital or nursing facility to have patients die in unexpected numbers, under suspicious circumstances. 

The interesting part of the book comes during the epilogue. Fink was present at a hospital in New York during Hurricane Sandy. Despite being years after Katrina, many of the same plant issues remained- electrical grids on the ground level floor or in the basement (at risk in flooding), inadequate generator fuel supplies for more than a couple days, lack of clear chain of command. Most disturbingly, Sandy revealed that the hospitals had worked on a plan to ration access to ventilators and, possibly, other life-saving equipment. 

The conversation for this plan (pre-disaster) happened within and among doctors and nurses. Patients and their families were not consulted about their wishes in creating the plan or during the disaster. While the situations that came out of Katrina mostly managed to be avoided with Sandy, some of the flotsam left behind these storms is the need to have these conversations in our community. 

Do you know the natural disasters (and/or manmade events) that are most likely in your area? 

Do you and, if applicable, your family have a clear plan and/or resources for this situation? 

Are you aware of community conversations regarding evacuating nursing homes, mental institutions, prisons, or other community living spaces? 

Do you know the protocol in your local hospital for providing care, triage, and/or rationing medicine? 

Fink writes, “Emergencies are crucibles that contain and reveal the daily, slower-burning problems of medicine and beyond- our vulnerabilities; our trouble grappling with uncertainty, how we die, how we prioritize and divide what is most precious and vital and limited, even our biases and blindness.” (p. 462) 

The thing that sticks with me about this book is that perhaps all the patients who were killed would have died soon anyway- during transport, awaiting care in another facility, in the chaos of the other locations to which people were transported. Perhaps they would have been hot, in pain, disoriented, alone. Was the death that came better? Ultimately, we must leave that question unanswered to pursue what truly matters- preventing that situation from occurring again in New Orleans, in your town, in mine, in the world. 

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