Tuesday, September 20, 2005

154 Patients Died, Many in Intense Heat, as Rescues Lagged

The New York Times

154 Patients Died, Many in Intense Heat, as Rescues Lagged

This article is by David Rohde, Donald G. McNeil Jr., Reed Abelson and Shaila Dewan.

If some of those who died in the aftermath of Hurricane Katrina have been described as stubborn holdouts who ignored an order to evacuate, then these citizens of New Orleans defy that portrait: The 16 whose bodies were wrapped in white sheets in the chapel of Memorial Hospital. The 34 whose corpses were abandoned and floating in St. Rita's Nursing Home. The 15 whose bodies were stored in an operating room turned makeshift morgue at Methodist Hospital.

The count does not stop there. Of the dead collected so far in the New Orleans area, more than a quarter of them, or at least 154, are those of patients, mostly elderly, who died in hospitals or nursing homes, according to interviews with officials from 8 area hospitals and 26 nursing homes. By the scores, people without choice of whether to leave or stay perished in New Orleans, trapped in health care facilities and in many cases abandoned by their would-be government rescuers.

Heroic efforts by doctors and nurses across the city prevented the toll from being vastly higher. Yet the breadth of the collapse of one of society's most basic covenants - to care for the helpless - suggests that the elderly and critically ill plummeted to the bottom of priority lists as calamity engulfed New Orleans.

At least 91 patients died in hospitals and 63 in nursing homes not fully evacuated until five days after the storm, according to the interviews, although those numbers are believed to be incomplete. In the end, withering heat, not floodwaters, proved the deadliest killer, with temperatures soaring to 110 degrees in stifling buildings without enough generator power for air-conditioning.

"The statement that you can judge a society by the way it treats elders and the vulnerable is a good way to look at our society," said Alice Hedt, executive director of the National Citizens' Coalition for Nursing Home Reform. "I hope this is going to be a wake-up call."

Somehow, no one ever imagined that flooding might force the evacuation of all health care facilities in a city that sits below sea level and is virtually surrounded by water.

There were piecemeal plans. Hospitals were required to have enough emergency provisions to operate for two to three days during a disaster. State officials said it was their responsibility to evacuate patients if necessary. Nursing homes were required to have their own evacuation plans, complete with contracts with transportation companies.

But once the city filled with water, and the plans by hospitals and nursing homes became quickly overmatched, neither state nor federal agencies came to the rescue, and in some cases appear to have thwarted efforts to evacuate patients.

Nearly all communication systems collapsed, leaving hospital administrators to guess if help was on the way. One administrator said overwhelmed state officials waited nearly a day before getting word to him that his hospital was essentially on its own. In the end, public hospitals turned to a wealthy, for-profit hospital chain for help.

Yet when private companies dispatched helicopters, trucks and buses to evacuate hospitals and nursing homes, officials from the Federal Emergency Management Agency, or FEMA, commandeered some of them for other uses, hospital and nursing home officials said. The rescue of those who had remained in their homes, or were sheltered in an increasingly chaotic Superdome, became the priority.

Natalie Rule, a spokeswoman for FEMA, denied that the agency confiscated any equipment.

Deep water, power failures and looting forced the evacuation of at least 12 hospitals, 2,200 patients and more than 11,000 staff members and city residents. In all, more than 3,800 residents would be evacuated from 53 nursing homes. In two public hospitals that primarily treat the poor, emergency generators and wiring were located on the ground floor, vulnerable to flooding, because state legislators had repeatedly refused to pay for upgrades. Both washed out in the storm.

For days, individual evacuations by boat and helicopter dragged on, with patients spending up to 12 hours waiting in crowded stairwells and rooftops before being told they would have to wait another day. As military helicopters equipped with seats, not stretchers, ferried healthy adults to safety, patients awaiting evacuation died, hospital staff members said.

State officials acknowledged that hospitals were correct in assuming rescuers would come to their aid.

"You have to have enough supplies so that once the storm passes, you can last until we can get to you," said Dr. Jimmy Guidry, Louisiana's state health officer. But he added that officials never anticipated the magnitude of the storm, and were overwhelmed rescuing people in the floodwaters.

"We were competing for resources," he said, stressing that the state did the best it could under the circumstances.

Communication between state officials was so confused that it still remains unclear whether the area's nursing homes were even required to follow Mayor C. Ray Nagin's mandatory evacuation order issued a day before the hurricane struck.

Dr. Guidry said it was up to each nursing home to decide what was best for its residents. Even so, the Louisiana attorney general, Charles C. Foti Jr., cited the order in charging the owners of St. Rita's Nursing Home with criminally negligent homicide in the deaths of their residents.

Whatever the requirements, problems immediately arose. Because too many nursing homes had contracted with the same bus companies, or waited too long to leave, there were not enough vehicles. Two homes that were able to get buses fled to a school that ended up being in the storm's path. After the school's power was knocked out, two patients died.

There are clear signs that earlier, better-organized evacuations helped save hundreds of people.

Ten for-profit nursing homes evacuated early, hiring buses, ambulances, and in one case a helicopter, to safely move more than 1,000 patients. One private, for-profit hospital leased planes to safely evacuate all 200 of its patients.

The state pulled off some evacuations successfully as well. A state mental hospital was emptied before the storm. After the hurricane passed, a fleet of buses and hundreds of heavily armed guards safely evacuated New Orleans' prisons and jails. All of the city's 7,600 prisoners made it out safely.

Weathering Previous Storms

Most of the city's hospitals decided to take a calculated gamble.

They had sturdy walls and backup generators. They had weathered storms before, notably Hurricane Betsy in 1965, when winds of 125 miles per hour killed at least 75 people. New Orleans often flooded, but pumps always took the water out.

The hospitals had plans: They assumed that they could hold out for two or three days, that they had backup electricity, that help would arrive.

They did not assume that they would be marooned in a vast lagoon of water so deep that alligators could cross intersections but military trucks could not, that telephones would break down completely, that state and federal officials would dither days away bickering over legalities, that there would be a chaotic competition for helicopters, that the city would get so dangerous that looters would paddle up to a hospital's doors in a hot tub.

By Monday, Aug. 29, most hospital officials were relieved: the storm had passed, and except for some broken windows they were largely intact.

By Tuesday, Aug. 30, with the levees broken and the city underwater, 13 hospitals were facing a daunting task of evacuating patients, staff, family members and people who had taken shelter inside.

As far as can be determined now, more than 90 patients died in hospitals: at least 35 found dead from the storm in Memorial Hospital, 16 in Methodist Hospital, about 19 in Lindy Boggs Medical Center, 13 in Touro Infirmary, 8 in the related Charity and University Hospitals. An unknown number died in transit or at triage centers like those at Louis Armstrong New Orleans International Airport or the Pete Maravich Assembly Center in Baton Rouge.

There is no suggestion that any patients drowned or were abandoned in their beds.

Bodies were found in odd places, but most were shrouded somehow, and lined up carefully in impromptu morgues by the living before they escaped.

Tony Carnes, a journalist with Christianity Today, was with a flotilla of rescue boats on Sept. 5 when they pulled up to regroup on a Memorial Hospital ramp.

The hospital's doors were wide open, he said in a telephone interview, and, curious, he went in. There were no signs of looting, but in the second-floor chapel, guarded by only a handwritten "Keep Out" sign, he found 16 bodies. They lay on gurneys, covered, but with hands and legs and the crowns of heads poking out.

On higher floors, he found several more. "One was draped over a chair like a coat," he said. "They were all wrapped in blankets, or sheets, or that exam table paper."

Autopsies have not been conducted, but many hospitals said patients were elderly, in organ failure or had just had serious surgery. When the power went down, they had to endure days of 110-degree temperatures with high humidity, and the most desperate had to be manually ventilated - air squeezed into their lungs by hand for hours at a time. Some were on heart pumps running on batteries.

The hospitals were not required to follow the evacuation order issued by Mayor Nagin on Sunday, Aug. 28. "Hospitals don't evacuate," said John A. Matessino, president of the Louisiana Hospital Association, a trade association. "Hospitals stay in place."

In each case, administrators took their best guess as to whether it would be safer to keep patients in a strong building, or to risk their dying in a helicopter, or in an ambulance caught in a traffic jam.

Making that calculation harder, the weather reports kept shifting.

"How many times have we heard that storms are going to hit New Orleans, but they veered to the east?" asked Virginia McCall, director of the intensive-care unit at Methodist Hospital. "We got lackadaisical."

Her hospital, she said, would definitely have evacuated in the face of a Category 5 hurricane. But it was reported to be dropping from a Category 5 to a Category 4 as it neared land. Some predictions said it would miss the city and blow into Mississippi.

After discharging as many patients as possible, the largest hospitals decided that letting their sickest patients stay was safer.

At the Ochsner Clinic, a private hospital housing about 400 patients before the storm, that gamble worked. Built near the edge of a levee in Jefferson Parish, it perches "on the lip of the bowl of New Orleans," said Warner Thomas, president of the foundation that runs it. When the levees broke, water came up to its front steps, but no farther.

The generators, behind high retaining walls, kept running. Winds knocked out a cooling tower, so the air-conditioning was weak, but not off. City water stopped, but Ochsner has its own well.

Incoming calls stopped, but a direct circuit to a sister hospital in Baton Rouge allowed outgoing calls and e-mail.

The Jefferson Parish emergency center sent over National Guard troops when some of the people streaming past the hospital tried to break in, Mr. Thomas said.

Eventually, it decided to remove about 25 patients, including babies in incubators and adults on ventilators. Although ambulances could have driven up, Mr. Thomas said he was doubtful about the roads, so he called in private helicopters, which took patients to Houston and Birmingham, Ala.

"We did not lose one patient," he said.

Other hospitals were not as lucky. Methodist was on the low-lying east side, and smaller hospitals in the area brought their patients there before the storm because it was taller.

Ms. McCall, in an interview from her sister's home in Wichita, Kan., said Methodist tried to evacuate 20 critically ill patients on Aug. 28, just before the storm, but no ambulances were available. "There was no getting out," said Ms. McCall, who runs Methodist's intensive-care unit.

After the levees broke, five feet of water filled Methodist's reception area within 15 minutes. Fires started when the main generator shorted out. But people kept arriving. "We had one woman who was a post-op kidney transplant swim in," she said.

The 827 people inside - 137 of them patients - stayed relatively calm until Wednesday, when food and water ran short and the heat reached 110 degrees. "You get a feeling of, Does anybody know we're here?" Ms. McCall said.

She was told by top officials at Universal Health Services, the company that runs the hospital, that they had rented two trucks with food, water and diesel fuel and sent them on, "but they were confiscated by federal authorities," she said. The company also hired two helicopters, but officials refused to let them fly, she said. Company officials declined to comment.

A police officer who is the husband of a Methodist nurse made his way home to get his boat and Jet Ski, Ms. McCall said. On his way back, she said, federal authorities commandeered the Jet Ski for attic rescues but let him keep the boat, with which he brought food, water and dry clothes.

By the time helicopters and FEMA evacuation trucks arrived Thursday, Sept. 1, people were so frustrated that one man who was not even a patient slipped into a hospital gown, trying to get out, she said.

When it was over, 16 patients had been put in the operating room designated as a morgue.

No Information, No Help

At the far end of the financial spectrum, serving the city's poorest patients, were Charity and University Hospitals.

As public hospitals, they had no money for private helicopters and had to rely on government officials. Like other hospitals they were frustrated at getting no information about when help might be coming.

Dr. Dwayne A. Thomas, chief executive officer for both hospitals, said the Legislature had repeatedly declined to vote $8 million to retrofit them for hurricanes - both have electrical equipment in their basements.

So each June 1, as hurricane season starts, he said, he rents portable generators, stockpiles 36 hours worth of oxygen and enough food and medicine for two weeks. Knowing that his toilets might stop working, he stores 1,000 five-gallon buckets lined with red infectious waste bags and hundreds of gallons of bleach.

After the levees broke, the water eventually rose to eight feet deep around Charity and University Hospitals.

The basement of Charity flooded, ruining much of the food before it could be moved upstairs. The main generators shut down, and the building became stifling hot.

The toilets did stop working, and Dr. Thomas had the buckets handed out, and told people to use the bags, pour in bleach, tie them off and throw them out the window.

"Some people were upset that we were polluting," he said. "But I said: Look, we're a hospital. We can't afford to let infection spread. Besides - look at the water. The sewers have backed up, it's full of oil. At least our bags are tied off."

Dr. Thomas, who was born at Charity Hospital, said the next four days "were as close as I've gotten to the third world. I felt like I was in a war zone."

About 60 flood survivors wandered in, and he gave them a lounge to sleep in and paper scrubs to wear. But after a day, "they started to complain - they got rowdy about the heat, and finally they got threatening, saying they wanted to eat, and wanted to eat before our staff did. They threatened our nurses with physical harm."

Shooting outside became regular and, at one point, he said "four guys went past us in a hot tub, paddling with two-by-fours. They had guns and two floating boxes with their loot."

Dr. Thomas had metal doors taken from inside the hospital and bolted to the glass outside doors.

A decision crucial to the fate of hundreds was made about 3 a.m. Tuesday, when M. L. Lagarde, president of the Delta division of HCA Healthcare, asleep in Tulane University Hospital, was woken up and told the water was rising.

HCA, the country's largest for-profit hospital chain, had leased 20 helicopters the week earlier. But now the helipad at the Superdome, two blocks away, which was normally used by all nearby hospitals, was cut off by the flooded streets.

They cleared cars and light stanchions from the top deck of Tulane's eight-story garage and set up a makeshift helipad.

It became the landing area for a mix of small private ambulance helicopters and big military Chinooks and Blackhawks. Waiting one floor below, out of the wash of the blades, were hundreds of patients and staff members, the walking ones in a line snaking up the stairs, the stretcher patients on a ramp.

Exactly what happened there is now at the center of a dispute between officials of Tulane University Hospital and the nearby public hospitals.

Because Charity and University were getting little help from the government, HCA told Dr. Thomas he could bring his patients over and they would be flown out too.

Dr. Thomas said he first put his neonatal babies in boats with their mothers and some doctors, "but they were turned around at gunpoint by Tulane police officers," he said. "They came back with the babies, with their mothers and fathers crying. Tulane was evacuating its staff first."

He also charged that, when he got 20 to 30 critically ill patients to the garage Thursday night, they lay on the roof for two hours while Tulane staff members were evacuated, and two of them died.

"That is reprehensible," he said, quietly furious. "To load able-bodied staff before you let patients off a roof is reprehensible."

Mr. Lagarde, who was on the roof, denied equally angrily that it happened that way. He said that helicopters came in unpredictably - some troop carriers with 40 seats, some medevacs with racks for two stretchers. He said they tried to load the sickest patients first.

"Turning away sick little babies?" Mr. Lagarde said. "Give me a break. Dwayne is just mistaken. There was no such order."

Charity's critical patients went out Thursday, Sept. 1, after most of the Tulane staff. The babies were taken out the next day, as order was being restored to the city.

In all, Dr. Thomas said, he lost only three patients from Charity and five from University. Another dozen had been in the morgue. HCA said it evacuated as many as 50 critically ill patients from Charity during the disaster.

'There Was No Central Command'

Tenet Healthcare, another for-profit hospital chain, grew increasingly frustrated at its inability to evacuate its two downtown hospitals, Memorial and Lindy Boggs. The Dallas headquarters of Tenet made frantic calls for help to a long list of officials, from the Coast Guard to the New Orleans police.

"There was no central command," said Bob Smith, a senior vice president for operations for the region. "They were clearly overwhelmed."

Early Wednesday, Aug. 31, the Office of Emergency Preparedness strongly suggested that Tenet act on its own. "That to us was the red flag," said Mr. Smith, who said he would have started 12 to 20 hours earlier if he had known.

After both hospitals were evacuated by week's end, the largest number of bodies - 45 - was found at Memorial. Ten had died before the hurricane, another 24 were on a floor for the most seriously ill, run by a company called by LifeCare Holdings.

The heat was unbearable, recalled Denise Danna, Memorial's chief nurse, who said her staff fanned patients by hand for hours.

Thinking help was imminent, they carried patients in wheelchairs to an exit and then waited - one day for 12 hours before giving up. "Those little patients never complained," she said.

As the hurricane gathered strength over the Gulf of Mexico on Aug. 25, Bob Bates made the decision to get his patients out.

The manager of three nursing homes in the New Orleans area, Mr. Bates had signed contracts with two local bus companies to evacuate his 360 patients. He had also made deposits with each transport company to ensure that the buses would be available in a prestorm rush.

But when he called the bus company he was told "they had no drivers," Mr. Bates said.

He was not alone. Across New Orleans that weekend, state-mandated nursing home evacuation plans "fell spectacularly apart," said Linda Sadden, a government-financed nursing home advocate. On paper, the state required nursing homes to have signed agreements with bus companies to evacuate patients, and have identified inland nursing homes to accept them. But no one had noticed that many homes had contracted with the same companies. "They were never ever going to be able to meet the need," Ms. Sadden said.

In the end, only 40 percent of the 53 nursing homes that evacuated did so before the storm, according to the State Department of Health.

Mr. Bates, meanwhile, was desperate to get his people out of the city. His staff called the Louisiana State Nursing Home Association, which promised eight buses Sunday morning, a full day before the hurricane was expected to make landfall.

That morning, three buses arrived. Five others had been diverted to another home. With less than 24 hours to go before the storm made landfall, Mr. Bates and his administrators decided to evacuate the nursing home that faced the most potential danger from winds and flooding, and hunker down in the other two.

After the storm cleared Monday afternoon, Mr. Bates said he thought his homes had survived the storm. But when flooding knocked out power in the city late that afternoon, another problem arose. Emergency generators lacked enough power to run air-conditioning, and temperatures within the homes quickly rose.

Nurses began forcing patients to drink as much water as possible and used what generator power was left for fans and ice-making machines.

Mr. Bates finally reached a private bus company in Dallas. After making a 10-hour drive, the buses took the remaining patients from the other two homes on Thursday and Friday. But for some patients, Mr. Bates said, it was too late.

"We had some deaths in the facilities, which is not an abnormal occurrence," he said, declining to give a number.

Threats Beyond the Weather

Across town in the French Quarter, Andrew Sandler, the administrator of the Maison Hospitaliere nursing home, was dealing with similar problems. Initially, he said he decided it would be too dangerous to evacuate his 50 to 60 patients on short notice. Mr. Sandler, a Michigan native, was terrified of hurricanes, but reasoned that his nursing home sat on high ground and that elderly residents had died during past evacuations.

"People die on bus rides sitting in traffic for 15 hours," he said.

But by Tuesday, after he lost air-conditioning and all running water, he said he realized patients needed to leave and began calling for help.

Then another threat arose. On Wednesday, his staff woke him in a panic. "They said, 'Dr. Sandler get the pistol, there is someone in the courtyard,' " he said.

His staff nailed plywood over windows and doors. They placed a shotgun at the nursing home's front desk to deter ne'er-do-wells.

By Thursday, no buses had arrived and patients began to die in the heat. Bus managers told Mr. Sandler over the phone that FEMA officials had told drivers it was too dangerous to enter and that buses were needed at the Superdome.

On Friday, a convoy of buses escorted by police cars finally arrived. All told, four of his patients perished in the aftermath of the storm, including one who died during the evacuation to Houston.

"I feel like two or three of them, it might have been related to them not having air-conditioning," said the administrator, who praised the heroism of his staff and defended his original decision to stay put. "It could have been a lot worse."

In St. Bernard Parish, just outside New Orleans, Salvatore and Mable Mangano, the operators of St. Rita's, made the fatal decision to wait out the storm. Local officials called the couple and offered to send two buses. The Manganos declined.

Last Tuesday, the state attorney general, Mr. Foti, indicted the couple on 34 counts of negligent homicide in the drowning deaths. So far, no other nursing home operators have been charged.

In East New Orleans, the eight nuns who run the Lafon Nursing Home made the same decision not to evacuate. What exactly happened at the home, though, remains a mystery. The home's operators declined to be interviewed. Instead, they issued a statement this week saying its staff moved patients to the second floor and cared for them at all times. Fourteen Lafon residents died.

On the brick outside the home's front entrance this week were spray-painted X's left by recovery workers. On the right side, dated 9-9, were the words "14 dead." On the doors leading to the cafeteria are taped signs that read "Morgue." The gurneys were lined up inside. Brown stains on white tablecloths revealed how high the water reached in the room - about three and a half feet.

In one ground-floor sitting room, a Bible sat open to Psalms 34, which reads in part: "I will bless the Lord at all times; praise shall be always in my mouth."

Michael Luo, Jennifer Steinhauer and Paul von Zielbauer contributed reporting for this article.