In 2008, Hurricane Katrina barreled across Florida and the Gulf of Mexico with New Orleans directly in its sights, prompting a mass evacuation of the city. Those who were able fled the path of the storm, while many poor and elderly Louisianans and those too ill to travel were left behind. The storm ravaged the city in mere hours, producing few casualties. But after the storm had passed, the city’s levee system failed catastrophically, putting approximately 80% of New Orleans under several stories of water. The death toll quickly soared to nearly 2000 as trapped survivors faced the heat, lack of power, shortages of food and drinkable water, and roaming gangs of looters.
Hospitals became lifeboats to seriously ill patients and their family members and to many courageous medical staffers who stayed behind to care for them. Most lost power, medical supplies were cutoff, and evacuation efforts suffered from almost no oversight or interagency coordination. Organization of medical care and rescue efforts fell to managers with little or no experience or training.
As the city struggled to right itself, stories emerged of hellish conditions experienced in some nursing homes and hospitals as doctors and nurses struggled to provide medical care while supplies ran low; the heat soared, and fatigue and desperation exacted its toll on the boundaries of human behavior. Rumors circulated that in at least one hospital doctors had systematically euthanized patients only hours before rescue would arrive.
Five Days at Memorial tells the story of what happened at one New Orleans hospital, Memorial Medical Center. Written by Pulitzer Prize winner Sheri Fink, a physician, the book is a maelstrom of story threads—of patients and families, nurses and physicians, and of the breakdown of the rules governing medical decision-making in a time of chaos. The book takes the reader from the hours just preceding the hurricane all the way through the investigation of the nurses and physicians who were accused of carrying out a plan to “leave no living patient behind.”
What happened in the aftermath is as compelling as the story of the storm itself. There was passionate debate over whether doctors and nurses trapped at Memorial were morally justified when they systematically injected large doses of morphine and midazolam and other drugs into patients they felt had little chance of evacuation or survival, even though some of those patients were beyond the ability to suffer, and others were not even near death. This tale poses the question of whether normal ethics are irrelevant under extreme circumstances or whether in the words of Dr. Lachlan Forrow “we should almost always see exceptional moral situations as opportunities for us to show exceptionally deep commitment to our deepest moral values.” Ultimately, the story is a remarkable one of a community’s response to the knowledge that doctors among them may well have killed as a means to provide comfort—outrage, blindness, denial, and, ultimately, a kind of forgiveness for those who were forced to act with little support on the front lines of disaster.
Despite having a riveting story to tell, however, Five Days at Memorial is a mess of a book. The large cast of characters is difficult to keep straight through the meandering narrative. Digressions into the history of levies and other subjects distract from the main story without adding substance. Fink’s mostly flat and dispassionate style makes this book a difficult read, and her treatment of Dr. Pou, one of the accused physicians, appears less than objective. Discussions of the moral dimensions of the disaster are very superficial.
Fink’s book hints at but fails to meaningfully address many key questions. Other hospitals in New Orleans faced similar conditions, and yet widespread instances of euthanasia were not reported in most other institutions. What kept doctors from such tragic actions elsewhere while those at Memorial sank into chaotic and flawed decision-making? Should doctors have evacuated the vulnerable ahead of the healthy and able-bodied? Do patients with “do not resuscitate” orders abdicate their place in line for rescue under extreme circumstances even though the do-not-resuscitate order was executed under completely different conditions? Is it ever acceptable to euthanize patients when neither they nor their loved ones have requested it? Should medical personnel be held criminally liable for difficult if flawed decisions that they make in good faith when they have few resources and little support? How can we be sure better decisions will be made the next time disaster strikes?
Fink’s report is sobering. New civilian disaster triage plans created in the wake of Katrina may not lead to better outcomes. Studies suggest that patients whom doctors would classify as likely to die in an emergency and be triaged to have care withdrawn under such plans would probably survive if given appropriate care. Other studies show that even with clear guidelines, triage officers often disagree with and deviate from established triage rules. Experts admit that traditional methods of triage may be ineffective and require rethinking, but this has yet to be done.
Despite its flaws, Five Days at Memorial is a compelling modern-day story teaching us that human judgment, however well-intentioned, is fragile and flawed when the normal rules of civilization break down. When it comes to managing medicine in the wake of a disaster, we have only just begun to address some of the hard questions that Five Days At Memorial begs us to face.