Also published on this date: Shelf Awareness for Wednesday, May 22, 2013

Wednesday, May 22, 2013: Maximum Shelf: Five Days at Memorial

Crown: Five Days at Memorial by Sheri Fink

Crown: Five Days at Memorial by Sheri Fink

Crown: Five Days at Memorial by Sheri Fink

Crown: Five Days at Memorial by Sheri Fink

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

by Sheri Fink

It has been almost eight years since Hurricane Katrina bore down on New Orleans, devastating the city and forever altering innumerable lives. In that time, countless stories of the individual tragedies, epic governmental failures, and rippling aftereffects that marked this disaster have been explored across all media--television, film, and hundreds of books. Despite all this coverage, however, new details of the hurricane and its aftermath continue to emerge. In Five Days at Memorial, Pulitzer Prize-winning journalist and physician Sheri Fink presents a meticulously researched examination of one of the most shocking stories to come out of Hurricane Katrina—the bodies of 45 patients found at New Orleans' Memorial Medical Center in the days following the storm; more deaths than at at any other comparable New Orleans hospital. An investigation into those deaths began almost immediately, and one year after the storm, a physician, Anna Pou, and two nurses were arrested and accused of euthanizing several of those patients.

There is no aspect of what happened at Memorial in the days following the storm that can be easily explained. It is a story of such complexity and so many moving parts that even the basic facts require careful examination. It is a credit to Fink's six years of research, which included numerous interviews, that she manages to re-create the increasingly chaotic scene on such a granular level that readers will have a visceral sense of what it might have been like to be there. Especially relevant to the story is the background information Fink provides. Opened as Southern Baptist Hospital in 1926, Memorial had been purchased in 1995 by Tenet Healthcare, a corporation based in Dallas. Like most hospitals in New Orleans, part of Memorial's back-up generator system was located at ground level, making it prone to flooding. Though recommended after Hurricane Ivan, retrofitting the hospital would have been costly and didn't happen. Nor did the hospital have a cohesive, written plan in place that would have determined how patients would be triaged in the event of a disaster. The hospital's helipad was also old, decrepit and difficult to reach. During the evacuation, Memorial staff members were forced to push patients through a hole in a machine room wall, into a parking garage, and up two flights of stairs to get them staged for the helicopters. Finally, the seventh floor of Memorial was leased by LifeCare Hospitals for critically ill or injured patients needing round-the-clock care, essentially creating a "hospital within a hospital" that had its own staff and administrators.

When Katrina hit, there were 2,000 people at Memorial. Roughly 240 of those were patients (52 of whom were LifeCare patients), 600 were staff, and the rest were family members. Some people had brought their pets. Though Memorial weathered the storm and its generators kicked on when the power went out, when the flooding began 24 hours later, it--like so many others in New Orleans--was marooned. The generators failed, knocking out the respirators that many patients relied on. The temperatures rose and patients spiked fevers of up to 105 degrees. Toilets backed up and became unusable, filling the hospital with stench. Patients began dying. Memorial and LifeCare staffers, all of whom were exhausted and operating on very little sleep, frantically begged Tenet for help via e-mail before their computers quit. Tenet wished them luck and told them to wait for FEMA. Evacuations were erratic and slow. Memorial's tenuous helipad route and structure made rescue even more difficult. Doctors began euthanizing pets. Many critical care patients, including neonates, were successfully evacuated, but many remained, their situations becoming increasingly dire. Doctors--and Fink points out that this was not a decision by any one person--came up with a triage system: those who could walk would be evacuated first, next would be those who needed more assistance, and scheduled to be evacuated last were the sickest patients and those who had Do Not Resuscitate (DNR) orders. As the days dragged on and the conditions inside the hospital worsened, the doctors, Anna Pou among them, began discussing "comfort care" in the form of morphine and Versed (a powerful sedative) for the patients they feared would not be evacuated. Ultimately, 18 of the patients who died at Memorial were found to have been injected with one or both of those drugs shortly before death.

To say that Five Days at Memorial is an engrossing read is a vast understatement. Throughout this horrifying, fascinating book, Fink maintains the highest journalistic standard. Her reporting is detailed, nuanced and far-reaching, yet it is never biased--a striking accomplishment in a story with this kind of moral complexity. And while the material devoted to the sweltering, desperate days and nights inside Memorial is stunning, the latter part of the book, which Fink devotes to discussing the legal wrangling that followed, is equally compelling. She gives voice to all sides--the doctors, nurses, families and patients themselves--and leaves the conclusions and judgments, none of which can or ever will be easily reached, to the reader. This is a book not to be missed. It is, quite simply, required reading. --Debra Ginsberg

Crown, $26, hardcover, 9780307718969, September 10, 2013

Crown: Five Days at Memorial by Sheri Fink

Sheri Fink: Unraveling a Story with Care

photo: Tony Cenicola/NYT

Dr. Sheri Fink has reported on health, medicine and science in the U.S. and internationally. As a staff reporter at the nonprofit news organization ProPublica, Fink received a Pulitzer Prize in investigative reporting and a National Magazine Award in reporting for her story "The Deadly Choices at Memorial," co-published by ProPublica and the New York Times Magazine in 2009. In September 2013, Crown will publish Five Days at Memorial, an in-depth expansion of her prize-winning story. She received the 2013 Mike Berger Award from Columbia University for her coverage of Hurricanes Sandy and Isaac. In 2010, Fink was the lead reporter and co-editor of "Rationing Health," a radio series on PRI's The World that examined health-care around the world. The series received reporting awards from the Overseas Press Club, the Association of Health Care Journalists and the Global Health Council.

Fink's book War Hospital: A True Story of Surgery and Survival (PublicAffairs, 2003) told about doctors, nurses and patients under siege in Srebrenica, Bosnia-Herzegovina. It won an American Medical Writers Association special book award and was a finalist for the Overseas Press Club and PEN Martha Albrand awards. Fink received her M.D. and Ph.D. from Stanford, and worked with humanitarian aid organizations in more than a half dozen emergencies in the U.S. and overseas. She is a senior fellow at the New America Foundation and at the Harvard Humanitarian Initiative.

What comparisons can you make between what happened at Memorial and war zone situations?

The similarities were that medical professionals were working in an extremely stressful environment, with a failure of critical infrastructure and utilities like power and running water, and where the needs of the patients often outstripped the resources at hand. The process of triage--where patients are sorted and prioritized for evacuation or other forms of care that many need but can't all get at once--was also similar. There was also a level of breakdown in public order--from reports of looting and violence to police leaving their posts. On the other hand, this wasn't a war zone. There weren't bombs falling. And while rescue felt excruciatingly slow, and was sometimes lethally so, it occurred within a few days of the flooding. Still, the vast majority of the doctors and nurses working in disaster-struck New Orleans had never experienced something like this before--they had never had to practice medicine robbed of high-tech, lifesaving tools. There are parts of the world where doctors and nurses and other health workers face these kinds of conditions on a daily basis, but for most in New Orleans it was a huge shock.

The contrasts between what happened at the private Tenet hospitals and the public Charity Hospital are stark. To what do you attribute this?

It was interesting to see that the big, public Charity Hospital in New Orleans lost very few patients, even though it also lost power and was surrounded by water--very similar conditions to Memorial--and had, on its two campuses, about twice as many patients. Of course it's important not to draw any sort of firm conclusions from a single case. What struck me was that people who had worked at Charity for many years were used to improvising in the face of a somewhat resource-limited environment. They were experts at finding ways to take care of patients when they couldn't always rely on the latest, high-tech equipment. They also avoided creating a category of patients designated as "beyond help" or too sick to survive in the disaster. Leaders worked hard to keep up morale and tamp down scary rumors ("only say it if you saw it"). Finally, and importantly, they kept up the organizational routine of modern hospital medicine as best they could in the context of the crisis. Patients stayed in their units and doctors and nurses continued to make rounds on them as would happen in normal times, even after the power went out.

photo: Times-Picayune

The villain here could be seen as Tenet--both during and after the storm. Is that too simplistic?

I see Five Days at Memorial as a book about how we act and make decisions in the midst of crisis, and the degree to which the organizations and infrastructure on which we all rely are or are not prepared. This is not a book that divides the world into heroes and villains. It is very easy to find fault with the ways that most organizations--governmental or private--responded to Katrina and weren't prepared to deal with its consequences. Tenet Healthcare Corporation faced a class-action lawsuit brought by people at Memorial Medical Center after the disaster. It was settled for $25 million in 2011 with no admission of wrongdoing on the part of the company.

Memorial was its own world-in-miniature during the disaster, surrounded by water and largely cut off as similar dramas played out around it. If there's one thing I've learned from every disaster and crisis situation where I've worked, it's that in the critical first moments, people pretty much are on their own and assistance always seems to come too slowly. Often life and death hinge on your own actions and decisions and those of the people around you who are caught in a situation they didn't choose. That's why it's so important to understand individual decision-making and for each of us to be better prepared to make difficult choices under stressful, exhausting conditions--choices we can justify to ourselves when the storm passes.

Racism (e.g., a doctor who considered "the enemy" to be crazy oppressed black people capable of dismembering whites) is a subtext in the book.

At times of crisis, people often turn to their closest, most familiar communities for comfort and assistance. Sometimes fears of other, less familiar groups are heightened. Disasters can bring societal fault lines to the surface. Rumors of looting and violence in New Orleans were rampant during the Katrina disaster, and later many were found to be exaggerated. The same rumors circulated in the hospital, where many believed them to be true.

Memorial was told to turn away sick people after the hurricane. That turns our assumptions about health care, mutual responsibility and community on their head. At what point does a hospital ethically become not a hospital, or can it?

That is the exact question one person in the book, Mark LeBlanc, asks. He was the son of one of the patients, and he and his wife brought a convoy of boats to the hospital to help rescue people there. As an outsider walking into this world on its fourth day in crisis, it upset him to see that his fragile mother wasn't getting life-sustaining treatments. It shocked him when an administrator told him the hospital was in a "survival mode," not a "treating mode." LeBlanc asked, "Do you just flip a switch and you're not a hospital anymore?" A version of the same question was asked by doctors when they saw administrators turn away people who waded or floated up to the hospital's emergency room ramp for help. There were still supplies, medicines, doctors and nurses at that point inside the hospital. The people inside felt they still had something to offer. But the administrators had their own, not unreasonable, view of things. They felt that the hospital itself--having lost electrical power, air conditioning, running water and sewage services--had become a lethally hot, dysfunctional, dangerous place, and the main priority was to get everyone out of it as quickly as possible. I think the larger point to take away from this scenario is the tremendous cost we all pay when our critical infrastructure, which is needed more than ever in a crisis, can't function at precisely the moment that we need it the most.

Have you seen or become aware of changes that would prevent this situation from occurring again?

Unfortunately Hurricane Sandy demonstrated again how extraordinarily vulnerable America's medical infrastructure is to the effects of natural hazards. Again we saw patients being carried down multiple flights of stairs in the dark to be rescued from a hospital without power or running water--this time, unlike Hurricane Katrina, right in the midst of an ongoing hurricane. We saw hundreds of nursing home patients stuck for hours in damp, dark, frightening conditions awaiting assistance, then scattered where their loved ones couldn't locate them, in some cases for weeks. On the positive side, though, many health-care professionals, hospitals and government agencies have begun thinking about how resources can be better marshaled to help patients in disasters. The problem is these discussions are taking place outside of the public eye. It's time for all of us to think about investments in preparedness and the difficult question of who gets prioritized for care and rescue when those resources aren't immediately sufficient. These are questions of values--much larger than just medical questions.

What difficulties did you encounter in researching and writing this story?

As you can imagine, with a respected doctor and two well-regarded nurses having been arrested and accused of killing their patients, many people caught up in the disaster at Memorial Medical Center were initially quite shy about talking about it. It took many years to unravel what occurred there, and there were many mysteries that took a lot of time to unspool. I also felt a great deal of responsibility in writing about the lives of real people caught up in something so traumatic through no fault of their own, and wanted to be as accurate and fair as possible. This all takes time, let alone shaping and writing a readable story. I've been blessed with an enormously patient, understanding and talented editor in Vanessa Mobley and a tremendously supportive publisher in Crown. Without the help and hard work of so many people there, this story could not have been told. --Marilyn Dahl

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