One of the most compelling stories to emerge from the devastation in New Orleans after Hurricane Katrina involved the death of several patients at the city’s Memorial Medical Center, which had lost power during the storm. Authorities investigated whether some of those patients, who were found to have elevated levels of morphine, had been euthanized by desperate and exhausted doctors. Sheri Fink won a Pulitzer Prize for her coverage of the events at Memorial in a 2009 joint assignment for ProPublica and The New York Times Magazine. In “Five Days at Memorial,†Ms. Fink greatly expands the story, reconstructing the crisis at the hospital and the complicated legal and ethical questions that followed in its wake. In his review for The Times, Jason Berry called the book “social reporting of the first rank.†In a recent e-mail interview, s. Fink discussed the chaos at Memorial, how she pieced her story together, whether we’re better prepared for the next disaster and more. Below are edited excerpts from the conversation:
Q.
When did you know you wanted to write this story on this scale?
A.
When we were finishing the magazine article, I kept finding out new facts and trying to fit them into the story because they seemed essential, and one of my editors, Ilena Silverman at The New York Times Magazine, started saying, “Save it for the book. Save it for the book.†She said there was already enough material for two volumes.
Q.
You write that Memorial doctors “had established an exception to the protocol of prioritizing the sickest patients,†and patients “in fairly good health who could sit up or walk†were evacuated first. In reading, I never understood the logic of this. Why did they do that?
A.
There was an element of trying to match needs with resources, in that they decided early on to get sicker patients out by medevac helicopters and send out healthier ones, who could sit up, on high water trucks or boats. At some point helicopters came less often than boats. But from the moment it looked like the hospital would need to be evacuated, patients with Do Not Rescuscitate orders, assumed to be chronically ill or closer to the ends of their lives, were assigned to go last â€" as one doctor described it, he saw them as having “the least to lose†compared with other patients. These decision-makers were thinking in a utilitarian mode about maximizing the number of relatively healthy lives they could save, although there is little if any research to suggest these types of triage decisions improve overall survival.
Q.
It’s true that “thousands of people in the city needed help,†but why weren’t air resources devoted first to patients in hospitals rather than, say, healthy people stranded in water?
A.
That would be assuming that there was an organized system of prioritizing rescues, but there really wasn’t. So many people needed help and communications were so problematic that Coast Guard air crews, for example, sometimes simply rescued them as they saw them. Healthy people stranded on rooftops in hot weather with no access to water and food are arguably in an equally precarious situation as patients at a well-stocked but powerless hospital. In fact, in the earliest hours of the disaster, medical air ambulance companies did attempt to prioritize rescuing the very sickest patients from hospitals. Incredibly, Coast Guard pilots were waved away from Memorial the night after the floodwaters rose. Some people in charge at the hospital thought it was too dangerous to carry patients up to the helipad in the dark, or judged some patients too sick to be saved given the circumstances, or were worried about where the patients would be taken.
Q.
You weren’t at Memorial during and after Katrina, but you recreate those days in an almost minute-by-minute way. What mixture of original reporting and researching other sources allowed you to do that?
A.
I spoke with hundreds of people, including those who were at the hospital, law enforcement officials, families of the dead, and experts. I collected materials created during the disaster and subsequent investigation â€" photographs, videotapes, e-mails, notes, diaries and interview transcripts. Some fantastic news stories, reports and books by others were also helpful, as were products like weather reports, architectural floor plans, and electrical diagrams of the hospital, and of course I visited the sites where the events took place.
Q.
Did people involved resist reliving this in order to help you piece things together?
A.
Some people were eager to talk about their experiences â€" including family members of those who died as well as patients who survived and some staff members. However certain doctors and nurses were initially unwilling to talk about their ordeal. Ironically there probably never would have been a book if that weren’t the case. My original idea was to interview Anna Pou, the doctor who had then recently been arrested on accusations of second-degree murder, and write an article about her â€" but she wasn’t willing to speak openly about the events, understandably, on the advice of her lawyer.
Jen Dessinger Sheri FinkQ.
Which part of the book was hardest to write, either for technical or emotional reasons?
A.
Chapter seven, I think, which is the first detailed recounting of the medical workers’ decision to inject what investigators later believed were about twenty patients with morphine and Versed, a fast-acting sedative, and the deaths of those patients. I had so much information from so many sources, and it required deciding whose points of view to depict at what points in the book. It was also very complex in terms of who was involved and what each of their intentions might have been.
Q.
Was there one source or discovery that surprised you and provided a crucial piece of help?
A.
At a time when some of the medical and nursing professionals were observing a code of silence about what had happened at Memorial or suggesting that the alleged acts never happened, several were brave and honest enough to say that they had ordered or injected the drugs found in some of the patients who died. Two doctors told me that they had intentionally hastened the deaths of their patients and explained why they did that. It was shocking, even as evidence had pointed that way. Their explanations allow the reader to understand how that could have occurred. We can’t learn from what happened until we know what happened.
Q.
Once the levees failed, with so many patients left in the city, how much of the emergency at Memorial do you think was preventable?
A.
A coordinated and well-rehearsed rescue effort on the part of government agencies, private transportation companies, and hospital owners might have brought patients to safety more quickly. The hospital could have invested more in protecting its backup power system from flooding and providing for running water in the event of a municipal outage, both of which its current owners are now putting into place. It might have helped to have a flexible and transparent plan to guide the distribution of potentially life-saving resources, like evacuation helicopter slots, informed in advance by the wider community’s values, not just those of exhausted, front-line professionals making these decisions on the fly. And finally disaster management training, improved communications and leadership structures within the hospital, and the enforcement of staff sleep schedules might have enabled healthcare workers and administrators to make different decisions during the crisis.
Q.
In an epilogue, you report on conditions during Hurricane Sandy, when it seems like hospitals were still unprepared for what to do in the face of a complete loss of electrical power. Why haven’t hospitals addressed these issues? Are there any formal efforts under way industrywide to do so?
A.
Hospitals haven’t addressed these issues because they’re expensive to address and because nobody has made them do it. For example, the Centers for Medicare and Medicaid Services has still not issued a proposed rule on emergency preparedness, which was proposed years ago “in response to concern about the ability of healthcare providers across the United States to plan for and respond to emergencies.†The long-belated rule, inspired in part by the failures of preparedness after Hurricane Katrina, would make it a requirement for health care facilities, including hospitals, to meet certain preparedness standards in order to participate in Medicare and Medicaid. The “systemic gaps†in healthcare preparedness cited by the agency remained unfilled to this day, more than eight years after Katrina.
Q.
The epigraphs to each of the book’s sections are all from the novel “Blindness†by Jose Saramago. Can you tell me why?
A.
I read Saramago’s novel when I was writing “Five Days at Memorial,†and I appreciated the metaphor of blindness for what often happens in a disaster, which is that we lose the ability to see the larger context of the events, something disaster nerds call “situational awareness.†And yet it is so important to remember that the level of resources can change, that there is a tomorrow after a disaster and the choices we make at the most critical moments have the potential to affect us and those around us for a lifetime. In “Blindness,†Saramago also imagines both the inhumanity and humanity individuals might exhibit in the crucible of a disaster â€" the horrible things people do when they are fearful, when resources appear to be scarce, and also the heroism that emerges.
Q.
Some of what you wrote near the end of the book led me to believe that you felt Anna Pou should not have gone completely unpunished for her actions during the emergency. Is that accurate?
A.
That is a question for the justice system and those affected by her actions to answer, not me. Certainly some people in the book expressed the opinion that she should have spent time in jail or lost her medical license, and others in the book supported Dr. Pou and saw her as a hero or at least someone who tried hard to help others at a very difficult time and who was punished by the very fact of being arrested and sued by patients’ families (a grand jury refused to indict her on criminal charges, and all of the civil cases against her, which included other parties, have since been settled).
What I think you’re picking up on toward the end of the book is that Dr. Pou became a campaigner for changing the standards of medical care during disasters and for laws that would immunize doctors and nurses against civil lawsuits for their work during disasters. She has lectured to large groups of doctors on “disaster ethics†and triage, showing her mug shot on screen and calling for protections against criminalizing medical judgment, but leaving out why she was arrested, or any mention that patients at Memorial died after healthcare workers injected them with powerful drugs, or what her involvement was with that. How can we be asked to learn lessons, make policy choices, and craft new laws based on what she has referred to as the personal tragedy of her arrest without the full and true story of what happened?
