Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital (76 page)

Withdrawing care from those who have not given their consent is troubling enough. Doing so by following a protocol that is unlikely even to save more lives would be indefensible. To the extent that bad protocols cover up deficits of evidence and accord, and entrench harmful practices, perhaps no protocol would be better after all.

EXPERTS WHO DEVISE guidelines that involve withdrawing life-saving care in emergencies may have never experienced how difficult it would be to implement them. In January 2010, I traveled to Haiti after the devastating earthquake and “embedded” with US federal disaster medical teams, some of whose members had worked in the nightmarish New Orleans airport after Katrina. I planned to
report on what the teams had learned and how prepared they might be to assist in another American disaster, and to study the way professionals handled triage in a setting where the number of critically injured patients far exceeded the initial capacity of the medical system. While the circumstances in a developing country would pose unique challenges, the actual treatment of patients should be similar at home and abroad.

The American team set up a field hospital housed in tents on a college campus in the capital, Port-au-Prince. They had trouble recording unfamiliar names and instead assigned patients numbers. One woman who arrived at the field hospital the week after the earthquake was identified in medical records merely as Jane Doe 326. Her real name was Nathalie LeBrun. She was thirty-eight years old and dressed in a white nightgown with lacy trim. Through a translator, she told me about her medical problems, which had preceded the earthquake. “She can’t breathe
right,” the translator said, “and her body’s swollen. She’s been like that for a while, but ever since the earthquake, it’s added on to it.”

The US medical team found a tank of oxygen and ran a tube to her nose to help her breathe. Overnight the tank ran out. The oxygen level in LeBrun’s blood plunged dangerously low. In the early morning, a nurse who believed she was watching LeBrun die sat crying with her patient. The nurse had been told there was no more oxygen. Doctors called for help, and the staff found another tank. Again, they hooked up Nathalie LeBrun to oxygen, and her breathing eased.

Still, the supply chain to the US disaster teams was failing, as it had after Katrina. The brother of another Haitian patient finagled a large oxygen tank from elsewhere in the city. Meanwhile, the American team had another idea about how to help LeBrun. They put her on a portable oxygen concentrator, which extracts oxygen from the air, but it kept overheating and shutting down. Moreover, the device runs on electricity, and the fuel needed to run the electric generators was in short supply.

At a morning meeting under a mango tree, a logistician passed that news to his medical colleagues. “We’re at a critical level with our diesel supply. We have one can per generator left. After that everything shuts down. So I’m freaking today. I mean, I am freaking.”

The team found more fuel, but twenty-four hours later, bottled oxygen—Nathalie LeBrun’s backup oxygen source—remained scarce. The field hospital’s liaison officer was a nurse. His job was to manage the flow of patients through the hospital, and he told me he faced a quandary: what to do about Nathalie LeBrun.

Her breathing difficulties were likely caused by a chronic heart problem, and her need for oxygen might continue indefinitely. He reasoned that the limited supply of oxygen would be better used if it were given to those who needed it only temporarily—for instance, people who’d been injured in the quake and needed oxygen during surgery. He made the decision to withdraw the oxygen from Nathalie LeBrun. “Which essentially is a death sentence for this woman,” he told me.

He checked his decision with the head doctor. The doctor agreed it was right. A plan was developed. LeBrun’s oxygen would be turned down slowly, and she would be driven to a partially destroyed Haitian hospital where she’d been treated before, but where, they believed, there was no oxygen at all.

LeBrun was not consulted or informed. She was only told that she would be transferred to the Haitian hospital. That afternoon, she gave me a huge smile and spoke hopefully about her future.

By late afternoon, nobody had started to wean LeBrun from her oxygen concentrator. Staff had stayed busy caring for patients with broken bones, complex wounds, and two women giving birth simultaneously.

Then, shortly after five p.m., a hospital staff member abruptly unplugged LeBrun’s oxygen concentrator when medics from the US Army’s 82nd Airborne Division arrived to transport her. Not knowing the plan, they tried to reassure her: “Just tell her she’ll be taken care of,” they said to the translator, “and she’s going to be going to another place.” Then they hoisted her into the back of a Humvee ambulance. Before the ambulance even started rolling, a military doctor noticed LeBrun was beginning to have trouble breathing. The ambulance had an oxygen tank available, but a nurse from the field hospital’s command staff assured the doctor that LeBrun’s problem was chronic. According to the triage decision, no oxygen was provided for her.

With the doors shut, the back of the ambulance was hot and dark. The ride was rough. I sat beside LeBrun, who leaned against one of the Humvee’s metal sides, coughing and struggling to breathe. Someone at the American field hospital had given her an asthma inhaler, which she assumed contained oxygen. She shot doses of the drug into her mouth again and again. “Oxygene!” she wheezed. “Oxygene!” LeBrun knew exactly what she needed.

Based on utilitarian calculations alone, it had been logical to remove LeBrun’s source of oxygen. But the health professionals involved in the
decision were not willing to face her and tell her about it or be there to implement it. Issuing “a death sentence” is easier than executing it.

Perhaps informing LeBrun and dispatching her gently in a cloud of morphine would not, however, have been the better option. When we pulled up to the destroyed Haitian hospital, Dr. Paul Auerbach—an emergency physician and one of my former medical school professors—happened to be volunteering there. He found a tank with a bit of oxygen left and treated her aggressively that night with low-cost diuretics to remove some of the fluid from her lungs, stabilizing her to the point that she didn’t, at least for a time, need the oxygen.

WHETHER IN HAITI or the United States, disasters present the same challenge: how and whether to inform and involve viable, aware patients or the family members of patients when potentially lifesaving resources are being denied. Little guidance exists. In normal times, it is easier to avoid acknowledging that some patients don’t get access to needed care and refrain from engaging in an inclusive search for solutions. Disasters foist a recognition of rationing. Years after the earthquake, as Superstorm Sandy intensified outside Bellevue Hospital, Dr. Laura Evans, the critical care medical director, faced a version of the same conundrum. She brought news of the expected power outage back to her ICU staff. Choices had to be made about which patients would have access to the six power outlets that might keep working even if every other outlet died. Evans had studied the New York state guidelines on how to allocate ventilators in a severe respiratory pandemic using a scoring system that estimates how severely ill someone is. Desperate for a procedure to help guide the decision making, she voluntarily repurposed these untested plans that had been inspired by Katrina.

Evans pulled together an ad hoc committee to make the choices. “This isn’t a role for one person,” Evans told hospital leaders. Her committee
was composed of professionals who had no patients under consideration. In this way, direct providers would be free to do what their ethical duty required. “If you’re the primary doctor,” Evans later explained to me, “it’s your job to advocate for your patient.” The committee, by contrast, could take a wider range of factors into account and choose fairly according to clearly defined scoring guidelines. The committee included not only doctors but also ethicists and nurses. It did not, however, include representatives of patients or their families.

The decisions about which patients would be connected to the six power outlets and the reasons were communicated to the other staff members. Some challenged the choices, but they accepted them. All of this was accomplished—a list of patients, moving them between beds and outlets—within about two hours.

As she prepared the plan, Evans also thought about how she would feel the next day if it had to be implemented. She wanted, she said, to “have a process that we can describe, that is transparent,” that was applied to all patients the same way, “as fair and equitable as it can be.” She knew the story of Dr. Pou and Hurricane Katrina. She wanted to look back and be able to justify the decisions she and her colleagues were making, to maintain the trust of the larger society that might examine them. She even imagined what word the infamous tabloid headline writers at the
New York Post
would find to rhyme with her last name if patients died (“heavens,” of course, goes with “Evans”).

That night, as Evans and her colleagues were completing their list, the lights flickered out. City utility power had failed. It took about seven terrifying seconds for power from the backup generators to kick in and get things functioning again. Soon after, Evans received a call from the hospital’s command center. They predicted that, except for those six outlets, all power would be lost in the next sixty to ninety minutes. Millions of gallons of floodwater were filling the basement of the twenty-five-story hospital. Water gushed into elevator pits with enough force to remove elevator doors from their moorings.

Evans and her colleagues stationed two health professionals at the bedsides of all patients who relied on ventilators, preparing to squeeze oxygen into their lungs manually with flexible Ambu-bags. Bright-orange extension cords connected to the backup generator system snaked through patient corridors. Nurses counted drops on IV pumps so that if everything failed they could go “old school” and give vasopressors by drops per minute.

Communicating the triage decisions to patients and their family members was the most challenging aspect of that night, Evans said. She and her colleagues could not imagine how to inform those who would not get power outlets and they feared doing so, so they put off the task. Looking back, Evans feels the families had a right to know. Also, the staff did not think about asking whether any of the selected patients or their families might wish to volunteer to give up a power outlet so that it could be provided to someone else. “It wasn’t even on my radar,” Evans says.

At
Connecticut Hospice in Branford, which evacuated in haste as Sandy approached, the staff did consult with patients and their families. They discovered something surprising. Hospice leaders had planned to move the sickest patients first. But those patients and their families chose to allow the healthier patients to go first.

Involving patients and their families in these decisions is all too rare. Triage is typically seen as the preserve of medical professionals. The ventilator rationing protocols that have been developed around the country have not been publicized, perhaps out of fears of how the public will react; even many medical professionals aren’t aware that their states or hospitals have them in place.

Reluctance to draw public attention to the plans is understandable. They outline the creation of what could, in all fairness, be called death panels: groups of doctors who would decide which patients are given a higher chance to survive. Similar fears surround health-care reform in the United States—when insurance coverage is expanded to more people,
what services, to which people, will be cut? Whether the disaster protocols reflect the values of the larger public simply isn’t known. In an age of extreme sensitivity over health-care rationing, almost no one has dared to find out.

When New York officials first released the ventilator plan that Laura Evans later repurposed for Sandy, they referred to public review as “
an important component in fulfilling the ethical obligation to promote transparency and just guidelines.” They envisaged the use of focus groups to solicit comment from “a range of community members, including parents, older adults, people with disabilities, and communities of color.” Those focus groups were never held. The plans had not been changed.