Using the Katrina clusterfuck to shine a flashlight into one dark corner of our health care clusterfuck
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.
In the four years since Katrina, Pou has helped write and pass three laws in Louisiana that offer immunity to health care professionals from most civil lawsuits — though not in cases of willful misconduct — for their work in future disasters, from hurricanes to terrorist attacks to pandemic influenza. The laws also encourage prosecutors to await the findings of a medical panel before deciding whether to prosecute medical professionals. Pou has also been advising state and national medical organizations on disaster preparedness and legal reform; she has lectured on medicine and ethics at national conferences and addressed military medical trainees. In her advocacy, she argues for changing the standards of medical care in emergencies. She has said that informed consent is impossible during disasters and that doctors need to be able to evacuate the sickest or most severely injured patients last — along with those who have Do Not Resuscitate orders — an approach that she and her colleagues used as conditions worsened after Katrina.
New Orleans, as everybody now knows, is just a bowl waiting to be filled with water. Memorial Medical Center, like all hospitals, had a backup power system, and what better place to stick something you're unlikely to use than in the basement? It's not like Memorial was alone in this decision:
As at many American hospitals in flood zones, Memorial’s main emergency-power transfer switches were located only a few feet above ground level, leaving the electrical system vulnerable. ‘‘It won’t take much water in height to disable the majority of the medical center,’’ facilities personnel had warned after Hurricane Ivan in 2004. Fixing the problem would be costly; a few less-expensive improvements were made.
A few less-expensive improvements were made. Remember that.
And so, as anybody could have predicted, the hurricane knocked out the main power and the rising floodwaters knocked out the emergency power. And like many other hospitals, Memorial had patients whose lives depended on that power, patients who needed machines to filter their blood for them, patients who needed machines to breathe for them.
The hospital staff exhausted themselves over the next couple of days while waiting for rescue, trying to do by hand what normally electrically-powered machines do instead. As it became clear that people power was insufficient, and that sick people were going to die miserable deaths, the decision was made to overdose some of them with morphine and other painkillers. Euthanasia, to be blunt, but why not? We do no less for our beloved pets.
In this interview about her article, Dr Fink [she has an MD degree and a PhD degree too] talks about working in extreme cases.
[keeping in mind that i am not a transcriptionist] Dr Fink:
Now there's a field of humanitarian assistance where we look at those really extreme situations and we say How can we do better? How can we ensure that as many people survive as possible? How can we do our jobs in the best possible way? Human beings deserve that.
The real relevance here, from a journalistic standpoint, is to look at the fact that America is going to face future disasters. We're going to have more hurricanes. We have threats of pandemic diseases, including influenza this season. There are going to be times where resources are limited. There are going to be times, unfortunately, where government fails as government failed these people and health workers and patients get trapped in very difficult situations.
The whole reason to go back and look at this is to say What can we learn? What is it that this story teaches us?
I haven't been able to bring myself to finish reading the article or to watch the interview beyond the brief excerpt above, but to begin to address Dr Fink's question What can we learn? here's a comparison with another hospital in the same city, in the same dire straits, Charity Hospital.
Charity Hospital was founded on May 10, 1736, by a grant from the French sailor and shipbuilder Jean Louis, who died in New Orleans the year before. His last will and testament was to finance a hospital for the indigent in the colony of New Orleans from his estate. His hospital has served the poor in New Orleans for over 250 years.
Charity Hospital's patients were evacuated on basically the same timeline as Memorial's, and might possibly have waited even longer had CNN and Sanjay Gupta not taken up their cause and broadcast their plight on national television.
First, some quotes from this article about Charity as they grappled with the problem of keeping as many very sick people alive as possible under extreme conditions:
DeBoisBlanc, better known as Dr. Ben, ran the intensive care unit at Charity Hospital and Dr. Peter Deblieux ran the emergency room and helped teach emergency medicine.
The hospital doesn't just represent top-notch medical care, it means something more to the community. "That hospital stands for a lot of things, and it mostly stands for taking care of all patients regardless of their ability to pay," said DeBoisBlanc.
"Seventy percent of the doctors that practice within the state of Louisiana came through the halls of Charity Hospital. Seventy percent. We're committed to the care of our patients. It's the mission of the hospital," Deblieux added.
Without power in the intensive care unit, monitors and ventilators failed, and nurses and doctors kept patients alive by hand.
"We were trusted with the lives of these people that we weren't sure were going to pull through ... we didn't have the resources to protect their interests. And so we were very worried that several of them would die," said DeBoisBlanc.
Just as the staff's fears and frustrations reached an extreme, there was a break. They learned they were going to be evacuated.
The doctors worked quickly to get their patients ready for evacuation, but to their shock, help didn't come. "It didn't come Tuesday morning. It didn't come Tuesday afternoon. It didn't come Wednesday, and we started hearing reports that we had already been evacuated," DeBoisBlanc said.
"It continues to amaze me that a major medical center, a level one trauma center could just disappear off the radar screen for five days. It's unbelievable," he added.
For the hospital staff, this was a breaking point. There were tears and anger -- but there was also unbelievable stamina and unwavering courage.
"I would go to the nurses and I would go to the residents and go to the patients and say, 'I promise you. You're going to leave this hospital before I do,'" said Deblieux.
The staff was exhausted, their hope was fading, and the hallways and stairwells had become an open sewer. They had to get out, but they lacked transportation and the water was still too high.
DeBoisBlanc and his staff had brought some 50 critical care patients to the roof of a nearby parking garage. The move took hours and they now struggled to keep the patients alive by hand-squeezing air into their patients' lungs for hours.
"I saw so many individual acts of compassion in a time when it was out of context, didn't seem to make sense. I would have thought that those expressions of humanism from one person to another, that compassion would have been reserved for a kinder, gentler time. But it was everywhere," DeBoisBlanc said.
But DeBoisBlanc and his team did something that seems almost superhuman. They worked tirelessly for five days and nights in the dark without the use of basic critical care equipment -- pushed to the limits to keep their patients alive. Of the nearly 50 critically ill patients in their care, they lost only two.
For another view of what it was like working as a doctor in Charity Hospital those 5 days, there's this NEJM article. A couple of quotes:
On Sunday, August 28, I was assigned as teaching physician for the infectious diseases unit on the ninth floor of the hospital. There were 18 patients in the unit, of whom 4 had active tuberculosis and 13 had opportunistic infections related to HIV infection and AIDS. We also had a boarder from surgery with a complicated gunshot wound and vascular access problems.
The most critical necessity is a team of professionals who care about their patients and one another. All 18 members of our team (black, white, rich, poor, gay, or straight) had chosen to care for the disenfranchised, the tuberculous, and the HIV-infected. We might not have been able to control what was happening to us, but we could control how we treated one another. I repeatedly declined the option of fleeing to the Tulane helipad across the street, where my son waited with another family. Our group received an offer of special rescue, which we did not accept until each and every one of our patients had been evacuated.
Meanwhile, at Memorial:
That morning, 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.
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?
At least nine well-recognized triage systems exist. Most call for people with relatively minor injuries to wait while patients in the worst shape are evacuated or treated. Several call for medical workers to sort the injured into another category: patients who are seen as having little chance of survival given the resources on hand. That category is most commonly created during a devastating event like a war-zone truck bombing in which there are far more severely injured victims than ambulances or medics.
Pou and her colleagues had little if any training in triage systems and were not guided by any particular triage protocol. Pou would later say she was trying to do the most good with a limited pool of resources. The decision that certain sicker patients should go last has its risks. Predicting how a patient will fare is inexact and subject to biases. In one study of triage, experienced rescuers were asked to categorize the same patients and came up with widely different answers. And patients’ conditions change; more resources can become available to help those whose situations at first appear hopeless. The importance of reassessing each person is easy to forget once a ranking is assigned.
One thing that stands out is that the staff of Charity Hospital, true to its 250-year heritage of helping everybody who needs it no matter their station in life, decided to try to save everybody [and they very nearly succeeded], while the staff at Memorial, true to its heritage, decided to save only some of their patients, and apparently made these life and death decisions without any formal training.
And what would Memorial's heritage be? I don't know anything about its previous life as Southern Baptist, but Memorial was purchased in 1995 by the for-profit hospital chain Tenet. Yes, that Tenet, the one that paid $900 million in settlement after defrauding Medicare, Medicaid, and TRICARE, which seems to have been a tradition of Tenet's former incarnation, National Medical Enterprises, as well.
Lest you think that Tenet is an aberration, Columbia/HCA paid an even larger settlement for defrauding the government.
The excess payments for care in private for-profit institutions were substantial: 19%. This figure implies that the US$37 billion that Americans paid for care at investor-owned acute care hospitals in 20013would have cost only US$31 billion at not-for-profit hospitals — a waste of US$6 billion. But higher acute care (and rehabilitation) hospital payments are not the whole story on investor-owned care. For-profit hospitals and dialysis clinics have high death rates. Investor-owned nursing homes are more frequently cited for quality deficiencies and provide less nursing care, and investor-owned hospices provide less care to the dying, than non-for-profit facilities.
Why does investor ownership increase costs? Investor-owned hospitals are profit maximizers, not cost minimizers. Strategies that bolster profitability often worsen efficiency and drive up costs.
Not to mention the possibility of competition causing not lowered prices and better quality, but that of non-profits having to act more like for-profits or die.
Getting back to Katrina and lessons learned, it would appear that a culture of maximizing profits does not lend itself to maximizing lives saved in times of emergency. Whether or not you believe that converting all our hospitals to non-profit status would be better for us in the next Spanish flu epidemic, doing so will certainly save us enough money that we could apply it to some worthy public health expenditure [stocking up on Tamiflu, or developing better flu vaccines, perhaps] instead of lining the pockets of corporate fatcats.
HR 676 contains just such a provision btw:
SEC. 103. QUALIFICATION OF PARTICIPATING PROVIDERS.
(a) Requirement To Be Public or Non-Profit-
(1) IN GENERAL- No institution may be a participating provider unless it is a public or not-for-profit institution. Private physicians, private clinics, and private health care providers shall continue to operate as private entities, but are prohibited from being investor owned.
(2) CONVERSION OF INVESTOR-OWNED PROVIDERS- For-profit providers of care opting to participate shall be required to convert to not-for-profit status.
(3) PRIVATE DELIVERY OF CARE REQUIREMENT- For-profit providers of care that convert to non-profit status shall remain privately owned and operated entities.
(4) COMPENSATION FOR CONVERSION- The owners of such for-profit providers shall be compensated for reasonable financial losses incurred as a result of the conversion from for-profit to non-profit status.
(5) FUNDING- There are authorized to be appropriated from the Treasury such sums as are necessary to compensate investor-owned providers as provided for under paragraph (3).
(6) REQUIREMENTS- The payments to owners of converting for-profit providers shall occur during a 15-year period, through the sale of U.S. Treasury Bonds. Payment for conversions under paragraph (3) shall not be made for loss of business profits.
(7) MECHANISM FOR CONVERSION PROCESS- The Secretary shall promulgate a rule to provide a mechanism to further the timely, efficient, and feasible conversion of for-profit providers of care.
(b) Quality Standards-
(1) IN GENERAL- Health care delivery facilities must meet State quality and licensing guidelines as a condition of participation under such program, including guidelines regarding safe staffing and quality of care.
(2) LICENSURE REQUIREMENTS- Participating clinicians must be licensed in their State of practice and meet the quality standards for their area of care. No clinician whose license is under suspension or who is under disciplinary action in any State may be a participating provider.
(c) Participation of Health Maintenance Organizations-
(1) IN GENERAL- Non-profit health maintenance organizations that deliver care in their own facilities and employ clinicians on a salaried basis may participate in the program and receive global budgets or capitation payments as specified in section 202.
(2) EXCLUSION OF CERTAIN HEALTH MAINTENANCE ORGANIZATIONS- Other health maintenance organizations, including those which principally contract to pay for services delivered by non-employees, shall be classified as insurance plans. Such organizations shall not be participating providers, and are subject to the regulations promulgated by reason of section 104(a) (relating to prohibition against duplicating coverage).
(d) Freedom of Choice- Patients shall have free choice of participating physicians and other clinicians, hospitals, and inpatient care facilities.
One more reason to reject HR 3200 and its cousins. There's no mention in any of them about turning all the hospitals into non-profits.