Medical ethics journalism

Let's write about Sheri Fink's investigative documentary in the best selling Five Days at Memorial.

Echo essay by Amanda Schafer, published in The New Yorker on September 12, 2013, in the Annals of Technology.

Memorial Medical Center in New Orleans was heavily damaged when Hurricane Katrina struck  on August 29, 2005.

A study guide can accompany the reading of this documentary and the link to purchase is at this site here.

In the aftermath of the storm, while the building had no electricity and went through catastrophic flooding after the levees failed, Dr. Anna Pou, along with other doctors and nurses, attempted to continue caring for patients. 

On Wednesday, August 31, United States Health and Human Services Secretary Mike Leavitt reassured the public that 2,500 patients would be evacuated from hospitals in Orleans Parish, although it wasn't clear at first where they would be moved to.

On September 11, 45 bodies were recovered from Memorial Medical Center, about five of whom had died before the disaster (originally thought to be eleven). Out of an estimated 215, bodies found in nursing homes and hospitals in New Orleans, Memorial had the largest number.

In July 2006, a Louisiana judge found probable cause to order the arrest of Dr. Pou and two nurses for second degree murder in the deaths of several of the patients, following a nearly year-long investigation by the office of Louisiana Attorney General Charles Foti.

Nevertheless, a grand jury in Orleans Parish refused to indict Pou on any of the counts. Eventually, the charges were expunged and the State of Louisiana paid Pou's legal fees.

The Moral Dilemmas of Doctors During a Disaster

Before and after Katrina: Memorial Medical Center in New Orleans (Tuscon.com): Parts of the New Orleans Memorial have not yet reopened, post 2005, Hurricane Katrina.

NEW ORLEANS, Louisiana- In the late summer of 2005, the waters loosed in the wake of Hurricane Katrina laid siege to New Orleans. 

At the city's hisoric Memorial Medical Center, the power and then the backup generators failed, creating a silence one doctor described as the “sickest sound” of his life. 

Doctors and nurses, at times in darkness, struggled to take care of patients without life-saving machines, air conditioning, or functioning toilets. After several days of desperation, some allegedly euthanized critically ill patients, even as large-scale evacuations of the hospital began. 

Sheri Fink, a doctor and journalist, published a meticulous investigation of these deaths in the New York Times Magazine and on the Web site of ProPublica, in 2009.

Sheri Fink's work won her a Pulitzer Prize.

In “Five Days at Memorial,” the contours of the Katrinia story remained the same, yet Fink imbued them with far more narrative richness, making the doctors seem both more sympathetic and more culpable. Fink also expanded on the ethical conundrums, which  festered over time and seemed to gain fresh urgency whenever the angry winds of the Katrina hurricane crashed against New Orleans. 

Which patients should receive priority in a disaster? Should doctors abandon the critically ill? What should they do if they believe those patients will suffer? Should they receive legal immunity for decisions made under duress? To a disturbing degree, the best answers seem to run counter to what key players at Memorial did and what at least one of them has advocated for since.

As the waters surged toward Memorial, hospital leaders began by acting with familiar priorities: they chose to evacuate the sickest patients and those who relied on ventilators or other devices first. But then the medical chairman decided that patients with do-not-resuscitate orders should get lowest priority, later saying he thought they had the “least to lose.” As the staff scrambled to move patients down from the upper floors, other factors played a role. One doctor worried that a patient who weighed more than three hundred pounds might slow the evacuation line; he was moved to another area to wait, rather than joining the queue. Some patients on the seventh floor seemed to get even lower priority, in part because their treatment was overseen by LifeCare, a health-care company that leased space within Memorial. As the days passed and doctors soldiered on without electricity, running water, sleep, or outside help, they flipped their moral scale upside down. Now the sickest patients—whom they designated threes on a one-to-three scale—would wait, and the healthiest would go first. This reflected “a sense among the doctors that they would not be able to save everyone,” writes Fink, citing the head-and-neck surgeon Anna Pou.

Setting the right triage priorities is one thing. But then something darker began to happen. Four days into the ordeal, Dr. Ewing Cook, who’d previously survived two heart attacks, struggled to reach the eighth-floor intensive-care unit, where he examined a patient with advanced cancer. Convinced that she was close to death and that he couldn’t possibly make it up the stairs again, he asked the nurse to raise her dosage of morphine. “There’s no question I hastened her demise,” he later said. 

Workers move patients up the stairs from the parking garage to the helipad to be evacuated from Memorial Medical Center in New Orleans, Thursday, Sept. 1, 2005, in the wake of Hurricane Katrina. (AP Photo/The Dallas Morning News, Brad Loper)

Cook allegedly spoke with Pou about injecting patients with morphine and the sedative Versed, and she wrote prescriptions for substantial amounts of morphine, which, despite the chaos, were filled by the hospital pharmacy. (Whether her intent was to relieve pain or end life remains in dispute.) 

Meanwhile, the pulmonologist John Thiele apparently injected several category-three patients with morphine and Versed. Knowing that he would soon evacuate, he felt he could not “justify hanging a morphine drip and praying it didn’t run out after everyone left and before the patient died,” Fink reports.

There are moments when doctors face genuinely tough calls about whether to let someone live or die: a soldier on a battlefield, say, who begs a doctor not to leave him behind alive. But this isn’t the way Fink describes the scene at Memorial. Some of the patients whose bodies contained high levels of morphine or Versed were apparently not on the verge of death or even in terrible pain, according to details of the investigation. A three-hundred-eighty-pound paraplegic named Emmett Everett had eaten tuna fish, crackers, and relish for breakfast. “I knew he was sick,” one staff member later said, “but, um, you know, he could talk and everything.” In fact, he told one of his nurses, “Cindy, don’t let them leave me behind.” 

Then, a doctor allegedly ended his life—without his consent. Even after the earthquake in Haiti, physicians from a field hospital said they did not amputate survivors’ limbs without consent, regardless of how urgently they thought patients needed the procedure. Ultimately, over twenty of the bodies found at Memorial contained either morphine and Versed or both. Multiple forensic experts determined that eight or nine of these deaths were homicides. Pou was arrested, but a sympathetic grand jury, which for political reasons was not privy to all of the forensic evidence, failed to indict her. No other doctors or nurses were held to be criminally responsible.

The more gritty detail Fink offers, the harder it is not to feel sympathy for the doctors and nurses. Yet much of what they did—especially the euthanasia but also the triage priorities—sets an awful example for future disasters. For starters, a D.N.R. order simply means that “a patient whose heartbeat or breathing had stopped should not be revived,” Fink writes. It reflects that patient’s wishes for the future; it does not necessarily indicate how sick he is now, or how close to death. Using D.N.R. orders in triage also risks penalizing individuals who plan for scenarios that may not occur. 

At Memorial, the early reliance on these orders meant that some patients were never carried down from the seventh floor to the staging area for evacuation. This made it harder to include them later on, even as more helicopters arrived.

A triage plan that puts the most vulnerable last is also troubling. Doctors may reason that the very sick are too fragile or too heavy to transport or don’t have long to live. But they’re the ones who are most likely to die if left in the hospitals as conditions get worse. A system that prioritizes the healthy—or the unhealthy—should also be looked at with humility. Death is unpredictable, and experts aren’t necessarily good at differentiating among critical patients. Indeed, in a small exercise designed to plan for pandemic flu, researchers asked doctors to assess the likely survival of I.C.U. patients with the H1N1 virus who were on ventilators. Their predictions, as Fink notes in her epilogue, were largely wrong.

Some doctors have been criticized for leaving Memorial, even when food, water, and pain medication were still plentiful. But with gunshots in the distance and rumors of violence and martial law, it seems reasonable that some of them chose to evacuate. “They are not the Secret Service,” the bioethicist Arthur Caplan told me. It also makes sense that they would try to lessen their patients’ pain beforehand, even if the drugs they used risked hastening death. If their intent was to end suffering forever, though, this crosses a line, Caplan and others argue. After all, who can know whether some unforeseen rescue might have materialized at the eleventh hour, however unlikely it seemed?

Pou and her team have argued that we should not second-guess doctors and should instead grant them broad legal immunity for their work during disasters. But this is neither necessary nor wise. Doctors are already judged according to the resources available and the circumstances, as George Annas of Boston University told me. The standard of care is what “a reasonable physician would do in that disaster, not in a fully equipped O.R. in New York.” And the last message we should want crisis workers to receive is that anything goes.

Terrified, weary doctors should not abandon ethical standards; they should cling to the norms of medicine, beyond when it feels reasonable to do so. This means talking to patients and respecting their autonomy, even under awful conditions. It also means making every effort to evacuate the sickest and most dependent patients first. The original—deeply reasonable—triage plan at Memorial prioritized babies, I.C.U. patients, those who required dialysis, and those who had received bone-marrow transplants (and therefore had compromised immune systems). If hospital leaders had been forced to choose some of these patients over others, it would have been reasonable to send babies over the elderly, since infants arguably have the most life ahead of them. (Alternatively, some ethicists propose simply drawing straws.)

But the grim hypotheticals risk obscuring another issue: medical workers under siege can easily lose perspective.

Although it is startling, medical workers can start to make decisions based on their own dark fears rather than the changing facts on the ground. “For heavens sake,” one of the forensic experts cited by Fink said, “Memorial wasn’t on a goddamn battlefield with enemy shells coming in. This was New Orleans, and there were helicopters and boats. And really, were they saying they couldn’t get patients off the seventh floor?”

In any disaster, medical teams must re-evaluate patients’ conditions and the available resources frequently, as Fink argues, “maintaining the ability to ‘see’ in the midst of a crisis.” This, along with better backup generators, is what may ultimately save the most lives.

Amanda Schaffer is a science and medical columnist for Slate and a freelance science writer.

Above: The former Memorial Medical Center, parts of which have not reopened since Hurricane Katrina, in 2009. Photograph by

Learning to cook for the not so culinary inclined

Maine Writer- When I was managing a company with young employees, I was stunned to learn how little most of them understood about cooking. Many, literally, did not know how to boil water! One young nurse who reported to me said that in her family, on Easter Sunday, they sent out for Chinese food because no restaurants were open. She couldn't prepare a ham! (The easiest cut of meats to cook!) Perhaps, this extraordinary pandemic experience will encourage young people to want to learn how to cook! I found this article published in the Dallas Morning News and enjoyed reading this descriptive writing:

Published in the Dallas Morning News:

https://www.dallasnews.com/food/cooking/2020/05/04/8-essential-cooking-skills-to-learn-while-still-stuck-at-home/

By Rebecca White

Many are still dining in. But even if you’re not a skilled or well-equipped cook, you can still turn out good meals. Knowing some basic cooking skills will make cooking easier and more enjoyable.

There’s no time better than the present to acquire confidence in the kitchen. Below are a few areas in which you might need a refresher course. Also, don’t feel ashamed if you know none of the steps below. We all start somewhere, so start today.

While some of these techniques may not be James Beard-approved, they work.

Feel free to alter these steps to best fit your kitchen rhythm.

How to properly salt: Knowing how and when to salt food is fundamental to cooking. From the beginning, middle and end of the cooking process, salt plays a critical role in the overall outcome of the final dish. When cooking,  salt meats 30 minutes to an hour before cooking. 

If salt is added at the beginning of the cooking process, it has the time to penetrate the food.

When distributing salt, be sure to sprinkle the salt from a good height. America’s Test Kitchen suggests 12 inches to achieve the most even distribution.

To make chicken with skin more flavorful, be sure to peel back the skin and salt underneath. Salt steak anywhere from 1-8 hours before cooking to achieve great flavor. This time frame is based on how thick of a cut of steak you are working with.

How to cook eggs

Boiled: There are two methods. Try each and see which one works best for you and your cooktop. (Maine Writer note- I purchased an egg timer that works by putting it into the pan with the water.)

(This is a Julie photo- the egg timer works just like the directions describe.)

* Place eggs into saucepan. Pour room temperature water over the eggs. Place onto the cooktop and bring the pan of water to almost boiling. Cover and remove from heat. Set timer to 10 minutes. Quickly pour out the hot water and fill with ice water to stop the cooking process. Seven minutes for soft-cooked; 9 minutes for squishy yolk; and 12 minutes for hard-cooked yolk.

* Bring pan of water to boil. Gently place eggs into the water. Boil until desired doneness is achieved. Quickly pour out the hot water and fill with ice water to stop the cooking process.

Scrambled: Crack the desired number of eggs into a bowl. With a whisk, scramble the eggs until frothy. To achieve the frothiest (which yields the fluffiest of scrambled eggs) eggs, use a blender or Vitamix to blitz the eggs. Place a ceramic (or nonstick) skillet onto the cooktop. Place a small pat of unsalted butter into the skillet. Melt over medium-low heat. Once the butter is melted, swirl the butter to coat the pan. Pour the frothy eggs into the skillet and stir with a rubber spatula. Continue to stir the eggs for a few minutes. Once the eggs have warmed through, season to taste with just a pinch or two of salt (a small amount goes a long way with eggs). At this point, add any cheese or greens desired. Continue to stir, and once the eggs begin to look firm but still wet, remove from the heat. Continue to stir once off the heat. Serve warm.

Fried and Runny: Place a skillet onto the cooktop and warm a splash of olive oil or unsalted butter over medium-low heat, about 3 minutes. Crack an egg into a small bowl. Once the skillet is evenly heated, gently pour the egg into the skillet. Cook until the white is cooked through and the yolk runny, about 2 1/2 to 3 minutes. Remove from heat and let sit for 30 seconds. Carefully remove from the pan with a spatula and serve with toast.

Poached: Bring a pan of water to boil. While the water is coming to a boil, crack eggs into individual bowls (be sure to not break the yolk). Once the water is boiling, add a splash of white wine vinegar to the water. With a spoon, make a whirlpool in the water by stirring the water in a quick, fluid circular motion. Gently slide the egg into the whirlpool. Cook for 5 minutes. Gently remove with a slotted spoon. Serve immediately.

How to chop vegetables

Onion: Slice the paper tail off. Place this end facing down onto a cutting board, with the root end up (the hairy end). Slice in half. Peel off the papery outer pieces. Take one half of the onion and place flat onto a cutting board. With a knife, slice horizontally through the middle of the onion, stop right before slicing all the way through the root end. Starting from the side closest to you, make half inch horizontal slices all the way through the onion, working your way across. Once the onion has been halved and then sliced, start at the open end of the onion and cut vertical slices from the cut end of the onion, all the way to the root end of the onion. Save the ends of the onion for stock.

Carrot: Using a vegetable peeler, remove the browned outer layer of carrot. Wash the carrots. Slice the carrot vertically in half from top to bottom (think hot-dog style). Place the carrots on the flat side. Make quarter- to half-inch slices. Continue to slice until you reach the top of the carrot head. Save the top for stock and the leafy greens for salads, soups and roasted vegetables.

Celery: Slice off the leafy greens and save to use in salads, frittatas, soups and roasted vegetables. Slice the celery in half vertically (think hot-dog style), slice these two halves in half one more time vertically. Place the flat side down on a cutting board. Make quarter-inch horizontal slices.

Bell pepper: Remove a small slice from the bottom of the bell pepper to secure a flat bottom. Place the flat bottom onto a cutting board. Slice one side of the bell pepper from the top all the way down to the bottom. Now that one side is completely open, place this open side flat onto the surface of the cutting board. Slice the next side from top end to the bottom end. Rotate this open side to the flat surface of the cutting board. Repeat the step until all side are complete removed. The top of the bell pepper should remain intact with the core all the way to the bottom of the pepper. Place the bell pepper sides onto their flat, inside surface onto the cutting board. Cut into thin strips and then, if wanting to dice, cut the strips into desired sizes.

Garlic: Peel off pieces of garlic from the garlic bulb. Using a flat wooden spoon or the side of a large knife, crush the garlic. Remove the outer papery peel. If there are green roots inside the garlic, feel free to ignore or remove. Make vertical slices from the top of the garlic to its bottom. Two to three slices should do the trick. Then chop the garlic into desired size. A quick rough chop is sufficient.

How to brown (sear) meat

Many recipes require meats to be “browned” or “seared” before moving to the next step of cooking. To achieve a nice sear, a proper skillet (cast-iron or heavy-bottom), high heat and a splash of fat is all that is needed.

Thirty minutes before cooking, remove the meat from the fridge and season with salt, seasonings of choice, and a bit of oil (canola or olive). When ready to cook, add another splash of high-heat tolerant fat to the skillet (canola, vegetable or olive) and warm over high heat. Add the meat to the skillet (2-3 pieces at a time, this depends on the size of the skillet) and cook for 2-3 minutes per side, depending on thickness and specific type of meat. Do not push the meat around and move it all over the surface of the skillet. The meat must stay still in order to properly brown. Resist the urge to move the meat. Once browned, remove the meat and place it onto a rimmed plate (I like to use a glass pie pan) and cover. Continue this process until all meat is browned.

Please note: If the drippings in the pan begin to burn, remove the pan from the heat and add a splash of water and scrape up the brown bits. Slightly turn the heat down and place the skillet back onto the burner with a splash more of cooking fat. Continue the cooking process.

How to thicken soups and sauces

Soups, casseroles and sauces sometimes call for thickening agents. There are several different ways to do this. If you have, unfortunatel,y added too much liquid to a dish, these methods can also help fix the problem.

Roux: Add unsalted butter to a skillet or pan and melt over medium-low heat. Add flour to the melted butter and whisk. Continue to whisk as the flour cooks. The goal is to cook the flour, which yields a dark golden color. Once golden, pour in warmed liquid (like chicken stock). Increase heat to medium and continue to whisk and cook while bringing the liquid to a boil. Let cook for 1-3 minutes to thicken.

Adding warm milk will turn the roux to a béchamel, which when combined with white cheese and nutmeg makes for a delicious sauce for pasta. A good ratio for roux is 3 parts flour to 2 parts fat.

Corn starch: Add 1/4-1/2 cup of cooking liquid (make sure it’s warm) to a tablespoon of cornstarch and whisk until smooth. Slowly pour the “slurry” back into the cooking liquid. Stir to combine and continue to simmer until thickened.

Flour and water: Combine cooking liquid and flour into a sealable container. Let the liquid cool for a few minutes. Seal and shake until mostly smooth. Whisk back into the cooking liquid. Continue to simmer until thickened. Stir and smush any visible flour pockets.

How to roast

Vegetables: Heat the oven to 400 to 450 F. Place the vegetables into a bowl. Add a splash or two of olive oil (or your favorite oil) and toss with salt.

Place the vegetables in a single layer on a rimmed sheet pan. Roast for 15-30 minutes or until the vegetable is browned to preference. A few roasting hacks:

* Steam and then roast: For heartier vegetables like Brussels spouts, broccoli and cauliflower, tightly cover the sheet pan with foil and roast at 500 F for 5-10 minutes. This will steam the veggies to soften them, and then the roasting process will add the flavor. Remove the foil cover, reduce the temperature to 400-450, and then continue to roast until desired color and texture achieved.

* At the end of the roasting time, remove the vegetables from the oven and add fresh lemon juice and zest to brighten the flavor. Once out of the oven, cover with a sprinkling of fresh herbs.

Meat: The key to a good roasted piece of meat is 1.) season properly before roasting; 2.) create a proper sear on the piece of meat before putting into the oven (see above); and 3.) use a digital kitchen thermometer.

Heat the oven to 400 F. Sear meat and place onto a lined baking sheet. Place the instant read thermometer into the thickest part of the meat. Place sheet pan into the oven and cook until thermometer indicates that the meat is cooked all the way through.

• Chicken: 165 F

• Pork: 145 F (medium), 150-155 (medium-well), 160-165 (well-done)

• Beef: 130-135 F (medium-rare), 135-140 (medium), 145-150 (medium-well), 155 (well-done)

How to cook dried beans

Beans are one of the most versatile, nutritious and inexpensive ingredients to keep in the pantry. Before cooking, pour out the dried beans and pick through them to remove any bad beans or rocks.

There are two opinions on when to salt beans, at the beginning or at the end of cooking. I add salt at the beginning and then salt to taste at the end. Additionally, I like to add a splash of red wine vinegar to my beans to add a layer of flavor.

There are two methods to prepare and cook beans:

Soak: This method requires a brief moment of foresight. Place the beans into a large bowl and cover with water. Make sure an inch or two of water tops the beans. Let the beans soak for 6-8 hours. Strain the beans from the water and rinse. Place the beans into a large pan and cover with water and again, leave an inch or two of water above the top of the beans. Add any aromatics you desire (halved onions and bell peppers, crushed garlic, herbs like bay leaves and rosemary). Bring the water to a boil, add salt and reduce to a simmer. Partially cover and cook until beans are tender, about 1 hour.

No-Soak: There are a couple of ways to cook beans without soaking.

* Pressure Cook: Combine 1 pound of beans, 7-8 cups of water, 2 teaspoons kosher salt and 1 bay leaf torn in half in a pressure cooker (like an Instant Pot). Cook on high pressure for 30-35 minutes. Natural pressure release for 20 minutes.

* Cooktop: Place 1 pound of beans into a large pan. Cover the beans with enough water to cover by 2 inches. Bring to a quick boil over high heat. Boil rapidly for 2 minutes. Remove from the heat and cover for one hour. After one hour, strain and rinse the beans. Place back into the pan, cover with water (and add any aromatics at this point). Once simmering, add salt and simmer for one hour or until cooked through.

How to quick-pickle

Almost any vegetable can be pickled ― cucumbers, carrots, fennel, green beans. The life of produce can easily be extended by pickling. A quick internet search will yield a variety of pickle brine recipes, but a few of my favorites come from Cooks Illustrated and Bon Appetit.

* Create a brine (2 cups water + 1 cup vinegar + 1 1/2 tablespoons salt + 1 teaspoon sugar, heat until salt and sugar dissolve).

* Prepare vegetables (thin or thick slice, it is up to you!)

* Place vegetables and aromatics into a sealable container (1 teaspoon mustard seeds, 1 teaspoon red pepper flakes, 1/4 cup diced onions, 3 crushed garlic cloves, pinch red pepper flakes). I prefer big glass jars, but any sealable container will work just fine.

* Pour hot liquid over vegetables and aromatics in the container. Let cool and store in the fridge. Pickles will be ready to eat within 2 to 3 hours.

Letter tribute to an American Hero - nicely nuanced

An echo tribute published in The Dallas Morning News. 

An overdue recognition with a patriotic and sensitive point of view.

Another hero among us- from Dallas

This letter to the editor was written in response to "An American hero may be next door — Or at the service station, like Hiroshi 'Hershey' Miyamura,", a report by Mike Tharp

LETTER- In February 1955, I returned to Gallup, New Mexico, after two years of military duty in Japan. 

I returned to my job with the federal government. One day, I met Eddie Shibata, owner of Tom's Variety Store, in downtown Gallup and a Japanese American. For several years, I stopped at least once a week to buy a newspaper or magazine. We became good friends.

I learned that Shibata had fought in Italy with the 442nd Regimental Combat Team. I continually asked him about his exploits. I asked him how rough it was. He replied "a lot especially when we had to knock out the German pillboxes on top of mountains. They rained bullets down on us. We lost many soldiers."

I asked him why he joined the Army and he replied, "because it was my duty as an American." He said he joined in early 1942 right after Pearl Harbor was bombed. Shibata seemed to be more interested in my stories of Japan where I had made many Japanese friends. His wife Keiko told me that Shibata was wounded but returned to duty after healing. She added sometimes he had bad dreams.

Several others of Japanese descent from Gallup were also in the Army. It's also the home of Hiroshi "Hershey" Miyamura, a Medal of Honor winner.

Carlos J. Romero, Dallas