First, do no harm. Next… ?

Physicians live by the highest code of ethics. Primum non nocere, or first, do no harm, is a principle we all hear in medical school and which follows us throughout our careers. It reflects the importance of physicians, and all clinicians, avoiding actions which are more likely to hurt than to help our patients. On first blush, this seems like an easy precept to live by. In our daily practices, in normal situations, we do our best to only institute treatment programs whose likely benefits exceed their likely risks.

But what happens next? And what about abnormal situations? Or highly abnormal situations? How do we as physicians respond in the face of overwhelming disaster? In situations so extreme we have no prior experience from which to draw? I just finished reading a book which deals with just such a scenario, and it certainly challenged many of my assumptions about medical ethics what it means to do the right thing. This book made me ponder what I would do if I found myself trying to function as a physician during a major tragedy.

The book Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital, was written by Dr. Sheri Fink and published in 2013. It describes in vivid and painful detail what happened at one of New Orleans’ largest hospitals during the five days following Hurricane Katrina in August 2005. The staff on duty were faced with taking care of well over 100 patients, many of whom were critically ill, in a rapidly deteriorating environment. The hospital lost power, then lost its emergency power as the flood waters surrounded the hospital and submerged the back-up generators in the basement. The only way in an out of the building was by boat or helicopter. All machines stopped working, from ventilators to IV machines to refrigerators to air conditioning. There was no functioning plumbing, so there was no clean water and all toilets were quickly rendered non-functional. Conditions inside Memorial went from bad to worse, then to unimaginable. The temperature inside the building rarely dropped below 100 degrees. Ventilator-dependent patients had to be manually bagged. No showers or baths were available for patients or staff. And the toilets… well, to describe them would fall into the TMI category.

Compounding these problems was the absence of any plan by the hospital’s owners or by any government agency to either bring supplies to the hospital or evacuate the patients. Hospital staff, stuck inside the building, did their best to keep patients alive and minimize discomfort. They functioned on several hours sleep per day. There was no change-of-shift. There was no one coming on duty to replace them. They were given mixed messages from the outside world about whether and when evacuations may start. For many, they did not know if their own families outside were alive or dead and had no way to find out. As the days began to pass, with no clear and reliable information about when help might arrive, patients began dying. Others were very clearly suffering. Patients with DNR orders were in pain. Others could not be ventilated effectively and many had labored, agonal breathing for hour after hour. When some evacuations began after a few days, the staff had to decide whether to first evacuate the sickest patients who would probably not survive without evacuation, and might die even if evacuated. Or should they evacuate the moderately sick patients, who had the best shot at survival? And what about those patients with DNRs?

As the narrative unfolded, I could not help but put myself into Memorial Hospital that August. What would I have done? Which patients would I have wanted to save when limited evacuations began? What would I have done for the near-terminal patients whose suffering was bad and getting worse by the hour, with no respite in sight?

Finally, after five long days and longer nights living in the midst of an inferno, the hospital staff received adequate outside help and all remaining patients and staff were evacuated. But left behind were many patients who had not made it. Some had clearly died from their diseases. Others may have died with large doses of morphine in their bodies.

While this was bad, what happened next was appalling.

I don’t think a spoiler alert is required if I tell you that after a long investigation, one physician and two nurses were subsequently charged with murdering patients at Memorial Hospital in those days after Katrina. While the first half of the book describes in gripping detail what it was like inside Memorial during the five days after the hurricane hit, the second half is just as captivating. The author reviews the legal, emotional, and personal sequelae for the medical staff, the families of those who died, the law enforcement officials investigating what happened inside the hospital, and the medical community as a whole. In describing events from these varying viewpoints, Dr. Fink captures the complexities of the situation. After reading the first half of the book, the decisions and ethical judgments made by the medical staff seemed clear cut. Black and white. Yet as I read the second half, my initial beliefs were  challenged, and I began to view events through a filter comprised of many shades of gray. I began to vacillate on what was right, what was wrong, what should have happened. And what I would have done.

While the conditions inside Memorial Hospital were extreme, they are not unfathomable. All of us in earthquake-prone California face the possibility of a similar situation. And that should force us to think about our own moral compass, our own ethical standards. What would we do if faced with patients who are severely suffering, and for whom no evacuation is foreseen? What would we do if we had to decide which two of ten ventilator-dependent patients would be kept on a ventilator if the back-up power could only support two of them?

The book is a bit long at almost 600 pages, and everyone in health care has a very busy schedule. So it may be hard to find the time to read it. But if you do, I wager your ideas on end-of-life planning, comfort care, triage, and how human beings and institutions respond to crises will be challenged. We all know that first, we should do no harm. But what do we do next?

Richard Fleming, MD

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