Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital (9 page)

Intensive care grew to become a major specialty at Memorial and across the country. With it came new ethical challenges and a changing definition of what constituted “extraordinary measures” in medicine. When should life support be instituted? Critical care, transplant surgery, and other new practices were expensive. On the heels of their invention came the second big change: cost consciousness and the rise of for-profit medicine. By the early 1980s, health care was a medical marketplace.
“Many of us have trouble accepting the business motive in medicine rather than the professional ethic,” Baltz told a Baptist Hospital newsletter writer in the mid-1980s. Baptist was still nonprofit and faith-based, but it had to compete in an increasingly commercialized environment. Its doctors, and many across the country, feared being told by accountants and other nonclinicians what tests and treatments they could give to which patients.

As doctors began to rely more on machines and focus more on business,
Baltz worked to remind his Baptist Hospital colleagues of the ethical tenets of their profession. As medical staff president, he urged them to stay compassionate and be selective about adopting new technologies. Baltz encouraged the establishment of an ethics group at the hospital and participated in a discussion of groundbreaking cases, including that of fifty-eight-year-old
Clarence Herbert, a comatose patient whose doctors were tried for murder in Los Angeles after they withdrew his life support and IV fluids. The investigation followed from a nurse’s complaints, an indication that difficult end-of-life decisions could create fissures between doctors and nurses. Family members also alleged that doctors had misrepresented Herbert’s chances of recovery so they would agree to withdraw life support. The charges against the doctors were ultimately dismissed.
“The ways and means of dying must be carefully considered,” Baltz commented in the newsletter.

Over the years, Baltz continued the dialogue with colleagues. LifeCare leased the seventh floor of the main building in 1997, establishing the long-term acute care hospital within the main hospital. A Medicare payment change created incentives for these types of business arrangements, and they proliferated at hospitals around the country. Baltz engaged in spirited debates over coffee with colleagues who believed excessive resources were being poured into LifeCare’s typically elderly, infirm patient population. “We spend too much on these turkeys,” one of them said. “We ought to let them go.”

“You have no right to decide who lives and who dies,” Baltz would answer. Through these conversations, he learned that some of his fellow doctors adhered to what Baltz thought of as the “Governor Lamm philosophy.” In 1984, at a time of growing budget deficits and ballooning medical costs, Colorado governor Richard Lamm criticized the use of expensive, high-tech medicine to keep some patients alive almost indefinitely, regardless of their age or prognosis. At a meeting of the Colorado Health Lawyers Association, Lamm bolstered his argument by citing a recent critique of antiaging research penned by the prominent University
of Chicago bioethicist Dr. Leon R. Kass. “
We’ve got a duty to die,” Lamm said, “and get out of the way with all of our machines and artificial hearts and everything else like that and let the other society, our kids, build a reasonable life.”

Lamm’s words were picked up by an attentive
Denver Post
reporter and caused a nationwide furor.
With the appearance of crash carts and the expansion of intensive care medicine in the 1960s and ’70s, hospitals had become adept at keeping sick people alive longer. Medicare covered the new technologies regardless of cost, and by the 1980s some policymakers worried about the projected growth in medical spending. Lamm’s comments awakened the public to the problem and demonstrated the tension between the “business motive” and medicine’s burgeoning end-of-life dilemmas.

Lamm’s rationing directive rankled for many reasons. To limit life-saving care would be to deny the human impulse to rescue individuals in extremis. To handicap the race for new treatments that might prolong life would be to call off the eternal search for the elixir of immortality.

Plus it would be bad for capitalism. At the time, the US-Soviet war urge was sublimated into battles for technological innovation. We were going to the moon. Why not also cure cancer or raise the dead?

Also the relatively recent eugenic and Nazi subversions of science and medicine—their conceptions of “lives not worth living” and the sick logic of ridding society of certain of its members to enhance the perceived health of the larger body—had ingrained in Americans an aversion to assigning lower values to certain lives.

On the other side, with drug and device developers figuring out how each organ that threatened to quit could be repaired or replaced, the practice of life support surged ahead of the practice of relieving pain, both physical and existential. Patients weren’t given much of a say in how much of this new medicine they really wanted if they became critically ill and unable to speak for themselves.

And there were deeper, more unsettling questions. How now to
define death? When was it permissible, even right, to withhold or, more wrenchingly, withdraw life-sustaining care? For a few weeks after a reporter cast Lamm’s remarks before them, regular Americans looked these questions in the eye.

They quickly looked away.

BALTZ LEARNED of Anna Pou soon after her arrival at Memorial in the fall of 2004. One of his patients had developed a pouch in the esophagus that trapped food and caused problems eating and swallowing. It was Pou’s turn to do ear, nose, and throat consultations, and Baltz asked some of the nurses about her. Who was she? What was she like? They raised their eyebrows. From what little they volunteered, Baltz guessed that they considered Pou a loose cannon, someone to avoid.

When Pou came to see Baltz’s patient, she didn’t merely offer her opinions. From Baltz’s perspective, she took over like a commander and failed to discuss important aspects of his patient’s care with him. Baltz judged her competent, but lacking in finesse. After the incident, he took it upon himself to give her some constructive criticism. He made it a practice to improve the work of those around him, especially younger, newer doctors. Pou seemed to listen to him.

After having spent seven years in Galveston, it would have been a challenge adjusting to the culture, etiquette, tools, and systems of any new hospital. When Pou was passionate about something, whether or not she was right, she stated her beliefs as unequivocally as a partisan talk-show host. Projecting surety was a defensive skill some doctors developed during their training, when attendings “pimped” them, barraging them with tough questions before their peers during rounds. Often, too, patients and families wanted clear answers when there weren’t clear answers to give.

One day, Pou cornered the nurse in charge of her postsurgical patients
at Memorial. “We can’t have this!” she said. The previous night, one of her patients had become confused after surgery. Nurses caught him trying to get out of bed and pulling at the breathing tube in his neck. A nurse had paged the medical resident on duty to order a set of soft, loose cuffs with long straps. The nurses tied the straps to the bed and placed the soft cuffs on the man’s wrists. This would limit his movements and keep him safe until he was less agitated. When Pou arrived the next morning and saw her patient restrained, she was unhappy. She told the head nurse to ask a hospital risk manager for workers who would sit at the patient’s bedside twenty-four hours a day and watch him to make sure he was safe without the restraints. It was an unusual request. It earned Pou respect from the nurse in charge. To her, it meant that Pou had compassion for her patients.

Unlike many surgeons who manifest their authority by getting ugly or impatient in the operating theater, Pou was methodical and explained things carefully to residents and nurses. She had a way of speaking like a schoolteacher, enunciating her words to draw out each syllable and nodding her head for emphasis.

Perhaps more than anything it was the type of patients Pou cared for that impressed those around her. These patients were dealing not only with cancer, but also the way it deformed their faces. Some coughed and sputtered and had a hard time speaking. Pou split her time between several hospitals. At Charity, she created a clinic for low-income patients with head and neck cancers to receive advanced treatments and reconstructive surgery. She convinced an array of doctors and therapists to provide these services without receiving additional pay.

On January 15, 2005, Pou attended an annual banquet at the RitzCarlton in New Orleans to celebrate the installation of Memorial Medical Center’s elected medical staff leaders. The festivities took place under crystal chandeliers. The Blackened Blues Band belted out rock, blues, and soul music. Giant trays of oysters and shrimp balanced on the banquet table beside bouquets bursting with lilies, birds-of-paradise, and
irises. Dessert tables adorned with Mardi Gras beads, masks, and candles held trays laden with tarts.

Pou wore a short-sleeved pantsuit with a double strand of pearls and pearl drop earrings and a sleek, chin-length hairstyle. She spent the evening socializing with other members of the medical staff and their spouses, flashing her broad, toothy smile for the event photographer.

The doctors’ lavish party contrasted with the troubled state of Memorial’s parent company, Tenet Healthcare, which owed hundreds of millions of dollars in fees and settlements for allegations of fraud and unnecessary surgeries at other hospitals. Tenet faced falling stock prices, multibillion-dollar operating losses, a federal lawsuit for overbilling Medicare to inflate revenues, and a class-action lawsuit by shareholders for allegedly having misled investors. As part of an aggressive shift away from this troubled history, Tenet had moved its corporate headquarters from California to the Gulf South in Dallas, and
was in the process of selling twenty-seven hospitals that weren’t meeting financial goals.

The doctors affiliated with Memorial followed the news, but they still had
much to celebrate. Only three years after the hospital’s new surgery center opened, executives had recently cut the ribbon on a new, $18 million cancer institute across the street from the main hospital. They had also completed a $5 million renovation of the labor and delivery center. Memorial had passed a midterm hospital accreditation survey, and it boasted some of the highest employee satisfaction rankings of any of Tenet’s dozens of hospitals in several states. For the staff at Memorial, the year 2005 looked bright.

POU HAPPENED TO BE on duty for her department when Katrina threatened, meaning she was expected to stay for the hurricane. Dr. Dan Nuss, the department chairman, called her, concerned. “I think this is the real thing,” he said. None of their postsurgical patients, spread
over several area hospitals, were terribly sick. Nuss urged Pou to sign out the patients’ care to other doctors. Pou’s husband agreed. Two resident physicians were on call with Pou that weekend. She dismissed them so they could be with their families. “Leave town,” she advised them. At four p.m. on Sunday, the National Hurricane Center warned for the first time that battering waves and a mountain of water forced up by Katrina’s winds—towering as high as twenty-eight feet above normal tide level—could overtop some levees protecting the city. Pou had resolved to stay in case anyone trapped in the city needed the kind of specialized care she and few others could provide. Pou’s department did most of its roughly 1,000 surgeries a year at Memorial, and she decided to base herself there.

As the surgical staff hunkered down that Sunday evening, the endoscopy suite they had claimed for quarters took on the atmosphere of a slumber party. Many of the nurses and Pou were coevals. They had grown up in New Orleans, attended private and Catholic schools, and now, with time to talk, they found they had friends in common. The nurses knew Pou’s first serious boyfriend from his work as an anesthetist at Memorial. “If you saw him now!” they teased her. He was a sturdy man with playful eyes, apple cheeks, and a lopsided smile who now had a wife, three daughters, and a graying, receding hairline. Pou took out her lipstick and began applying it. “What are you doing?” a nurse asked her. “It’s midnight! What are you doing?”