A thousand Memorial Hospitals now – What will your number be?

We have often heard the slogan: “A pandemic will be like a thousand Katrinas at the same time”.  But what does this mean? Concretely, it means that there won’t be enough essential services for those who need them. We have already seen some evidence of this with overly restrictive Tamiflu prescription practices and clinics that run out of vaccine before pregnant women, who have been waiting for hours, can get any. Emergency rooms are overflowing in many areas and ICUs are starting to fill up. What can we expect in the future, if we are using Katrina as guide? The worst case scenario is a Memorial Hospital event, or perhaps more properly, a thousand Memorial Hospital type events at the same time.

ProPublica has an outstanding investigative piece on what happened at Memorial Hospital in New Orleans during the Katrina aftermath. I highly recommend reading the whole article. Below, I include some excerpts:

The smell of death was overpowering the moment a relief worker cracked open one of the hospital chapel’s wooden doors. Inside, more than a dozen bodies lay motionless on low cots and on the ground, shrouded in white sheets. Here, a wisp of gray hair peeked out. There, a knee was flung akimbo. A pallid hand reached across a blue gown.

Within days, the grisly tableau became the focus of an investigation into what happened when the floodwaters of Hurricane Katrina marooned Memorial Medical Center in Uptown New Orleans. The hurricane knocked out power and running water and sent the temperatures inside above 100 degrees. Still, investigators were surprised at the number of bodies in the makeshift morgue and were stunned when health care workers charged that a well-regarded doctor and two respected nurses had hastened the deaths of some patients by injecting them with lethal doses of drugs. Mortuary workers eventually carried 45 corpses from Memorial, more than from any comparable-size hospital in the drowned city.

Investigators pored over the evidence, and in July 2006, nearly a year after Katrina, Louisiana Department of Justice agents arrested the doctor and the nurses in connection with the deaths of four patients. The physician, Anna Pou, defended herself on national television, saying her role was to ‘‘help’’ patients ‘‘through their pain,’’ a position she maintains today. After a New Orleans grand jury declined to indict her on second-degree murder charges, the case faded from view.

[snip]

It is now evident that more medical professionals were involved in the decision to inject patients — and far more patients were injected — than was previously understood. When the names on toxicology reports and autopsies are matched with recollections and documentation from the days after Katrina, it appears that at least 17 patients were injected with morphine or the sedative midazolam, or both, after a long-awaited rescue effort was at last emptying the hospital. A number of these patients were extremely ill and might not have survived the evacuation. Several were almost certainly not near death when they were injected, according to medical professionals who treated them at Memorial and an internist’s review of their charts and autopsies that was commissioned by investigators but never made public.

[snip]

The full details of what Pou did, and why, may never be known. But the arguments she is making about disaster preparedness — that medical workers should be virtually immune from prosecution for good-faith work during devastating events and that lifesaving interventions, including evacuation, shouldn’t necessarily go to the sickest first — deserve closer attention. This is particularly important as health officials are now weighing, with little public discussion and insufficient scientific evidence, protocols for making the kind of agonizing decisions that will, no doubt, arise again.

[snip]

…doctors and nurses decided that the more than 100 remaining Memorial and LifeCare patients should be brought downstairs and divided into three groups to help speed the evacuation. Those who were in fairly good health and 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 agreed the day before, those with D.N.R. orders.

Though there was no single doctor officially in charge of categorizing the patients, Pou was energetic and jumped into the center of the action, according to two nurses who worked with her. Throughout the morning, makeshift teams of medical staff and family members carried many of the remaining patients to the second-floor lobby where Pou, the sleeves of her scrubs rolled up, stood ready to receive them.

In the dim light, nurses opened each chart and read the diagnoses; 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 were taken to the emergency-room ramp, where boats were arriving. The 2’s were generally placed along the corridor leading to the hole in the machine-room wall that was a shortcut to the helipad. The 3’s were moved to a corner of the second-floor lobby near an A.T.M. and a planter filled with greenery. Patients awaiting evacuation would continue to be cared for — their diapers would be changed, they would be fanned and given sips of water if they could drink — but most medical interventions like IVs or oxygen were limited.

Pou and her co-workers were performing triage, a word once used by the French in reference to the sorting of coffee beans and applied to the battlefield by Napoleon’s chief surgeon, Baron Dominique-Jean Larrey. Today triage is used in accidents and disasters when the number of injured exceeds available resources. Surprisingly, perhaps, there is no consensus on how best to do this. Typically, medical workers try to divvy up care to achieve the greatest good for the greatest number of people. There is an ongoing debate about how to do this and what the ‘‘greatest good’’ means. Is it the number of lives saved? Years of life saved? Best ‘‘quality’’ years of life saved? Or something else?

[snip]

Pou and her colleagues had little if any training in triage systems and were not guided by any particular triage protocol.

[snip]

On a seventh-floor hallway at LifeCare, Angela McManus, a daughter of a patient, panicked when she overheard workers discussing the decision to defer evacuation for D.N.R. patients. She had expected her frail 70-year-old mother, Wilda, would soon be rescued, but her mother had a D.N.R. order. ‘‘I’ve got to rescind that order,’’ Angela begged the LifeCare staff. She says they told her that there were no doctors available to do it.

[snip]

By Wednesday afternoon, Dr. Ewing Cook was physically and mentally exhausted, filthy and forlorn.

[snip]

Morphine, a powerful narcotic, is frequently used to control severe pain or discomfort. But the drug can also slow breathing, and suddenly introducing much higher doses can lead to death.

[snip]

Doctors, nurses and clinical researchers who specialize in treating patients near the ends of their lives say that this ‘‘double effect’’ poses little danger when drugs are administered properly. Cook says it’s not so simple. ‘‘If you don’t think that by giving a person a lot of morphine you’re not prematurely sending them to their grave, then you’re a very naïve doctor,’’ Cook told me when we spoke for the first time, in December 2007. ‘‘We kill ’em.’’

In fact, the distinction between murder and medical care often comes down to the intent of the person administering the drug. Cook walked this line often as a pulmonologist, he told me, and he prided himself as the go-to man for difficult end-of-life situations. When a very sick patient or the patient’s family made the decision to disconnect a ventilator, for example, Cook would prescribe morphine to make sure the patient wasn’t gasping for breath as the machine was withdrawn.

Often Cook found that achieving this level of comfort required enough morphine that the drug markedly suppressed the patient’s breathing. The intent was to provide comfort, but the result was to hasten death, and Cook knew it. To Cook, the difference between something ethical and something illegal ‘‘is so fine as to be imperceivable.’’

[snip]

Cook sat on the emergency-room ramp smoking cigars with another doctor. Help was coming too slowly. There were too many people who needed to leave and weren’t going to make it, Cook said, describing for me his thinking at the time. It was a desperate situation and he saw only two choices: quicken their deaths or abandon them. ‘‘It was actually to the point where you were considering that you couldn’t just leave them; the humane thing would be to put ’em out.’’

[snip]

Despite how miserable the patients looked, Cook said, he felt there was no way, in this crowded room, to do what he had been thinking about. ‘‘We didn’t do it because we had too many witnesses,’’ he told me. ‘‘That’s the honest-to-God truth.’’

[snip]

Cook said he told Pou how to administer a combination of morphine and a benzodiazepine sedative. The effect, he told me, was that patients would ‘‘go to sleep and die.’’ He explained that it ‘‘cuts down your respiration so you gradually stop breathing and go out.’’ He said he believed that Pou understood that he was telling her how to achieve this. He said that he viewed it as a way to ease the patients out of a terrible situation.

[snip]

According to statements made to investigators by Steven Harris, the LifeCare pharmacist, Pou brought numerous vials of morphine to the seventh floor. According to investigators, a proffer from Harris’s lawyer said that Harris gave her additional morphine and midazolam — a fast-acting drug used to induce anesthesia before surgery or to sedate patients for medical procedures. Like morphine, midazolam depresses breathing; doctors are warned to be extremely careful when combining the two drugs.

Kristy Johnson, LifeCare’s director of physical medicine, said she saw what happened next. She told Justice Department investigators that she watched Pou and two nurses draw fluid from vials into syringes. Then Johnson guided them to Emmett Everett in Room 7307. Johnson said she had never seen a physician look as nervous as Pou did. As they walked, she told investigators, she heard Pou say that she was going to give him something ‘‘to help him with his dizziness.’’ Pou disappeared into Everett’s room and shut the door.

As they worked their way down the seventh-floor hallway, Johnson held some of the patients’ hands and said a prayer as Pou or a Memorial nurse gave injections. Wilda McManus, whose daughter Angela had tried in vain to rescind her mother’s D.N.R. order, had a serious blood infection. (Earlier, Angela was ordered to leave her mother and go downstairs to evacuate.) ‘‘I am going to give you something to make you feel better,’’ Pou told Wilda, according to Johnson.

[snip]

According to Memorial workers on the second floor, about a dozen patients who were designated as ‘‘3’s’’ remained in the lobby by the A.T.M. Other Memorial patients were being evacuated with help from volunteers and medical staff, including Bryant King. Around noon, King told me, he saw Anna Pou holding a handful of syringes and telling a patient near the A.T.M., ‘‘I’m going to give you something to make you feel better.’’ King remembered an earlier conversation with a colleague who, after speaking with Mulderick and Pou, asked him what he thought of hastening patients’ deaths. That was not a doctor’s job, he replied. Patients were hot and uncomfortable, and a few might be terminally ill, but he didn’t think they were in the kind of pain that calls for sedation, let alone mercy killing. When he saw Pou with the syringes, he assumed she was doing just that and said to anyone within earshot: ‘‘I’m getting out of here. This is crazy!’’ King grabbed his bag and stormed downstairs to get on a boat.

[snip]

The debate among medical professionals about how to handle disasters is intensifying, with Pou and her version of the Memorial narrative often at the center. At a conference for hospital executives and state disaster planners a few months ago in Chicago, she did not mention that she injected patients, saying that helicopters arrived in the afternoon of Thursday, Sept. 1, and ‘‘we were able to evacuate the rest.’’

Pou projected the booking photo from her arrest onto the screen as she argued for laws to shield health workers from civil and criminal liability in disasters.

Before delivering the keynote address, Pou participated in a panel on the ‘‘moral and ethical issues’’ that could arise if standards of care were altered in disasters. At one point, one of the panelists, Father John F. Tuohey, regional director of the Providence Center for Health Care Ethics in Portland, Ore., said that there are dangers whenever rules are set that would deny or remove certain groups of patients from access to lifesaving resources. The implication was that if people outside the medical community don’t know what the rules are or feel excluded from the process of making them or don’t understand why some people receive essential care and some don’t, their confidence in the people who care for them risks being eroded. ‘‘As bad as disasters are,’’ he said, ‘‘even worse is survivors who don’t trust each other.’’

This is a sensitive subject. I understand that some would prefer that it not be discussed. But we are rapidly approaching the point where health care workers will be having to make similar decisions to those made by the staff at Memorial Hospital in New Orleans after Katrina. The National Emergency that was declared on October 24, 2009 lays the legal groundwork for moving patients to “alternative locations”, imo. These sites, hospital tents, hotels or convention centers, are unlikely to have the same level of facilities that regular hospitals do. What will happen to patients who desperately need a ventilator, but none is available for them? What about patients who are “terminally weaned” from a ventilator? How will this be done?

We have heard a lot about the impact of closing the schools on the economy. We have not given as careful consideration to the consequences of allowing the infections to spread unchecked.

A thousand Memorial Hospitals will scar our souls.

Close the schools now!