On Aug. 30, 2005, a doctor climbed the stairs through a New Orleans hospital to the helipad, which was rarely used, and so old and rusted it wasn't even painted with the hospital's current name.
From that helipad over Memorial Medical Center, the doctor looked out over New Orleans, now flooding after Hurricane Katrina. He considered the more than 2,000 people in the hospital below — 244 of them patients.
Administrators had long-standing plans to manage hurricanes, flooding, loss of electricity and evacuations, but they weren't prepared to deal with them all at once, which is what the hospital faced during Katrina.
The staff had to decide who to save, and in a new book, Five Days at Memorial, writer and physician Sheri Fink reconstructs the choices they made. She tells NPR's Steve Inskeep about the sickest-last evacuation system they put in place, and how some doctors hastened their patients' deaths.
On what happened when hospital staff realized they were going to lose all backup power
"That's when the very first tough ethical decision arose ... which was: Who are you going to save first if you know that you may be hours away from all power going out? ...
"They decided that the babies would be saved first, and the intensive care unit patients, whose lives really depended on electricity. They also decided at that point who would go last, and that was patients who had do not resuscitate orders.
"The doctors all agreed with this decision and, by the way, it was a small group of doctors who took this burden of making this decision on their shoulders."
On why Memorial doctors decided that the sickest would be evacuated last
"As one doctor described it ... they would maybe have the least to lose compared with other patients. ...
"Doctors tend to be — and this is, some ethicists have explained this to me — doctors have kind of a utilitarian frame. If you ask them, 'Who gets the organ transplant?' it's going to be the person who they think could benefit the most from it, and other considerations might not be taken into account, like justice or fairness. ... So you're switching, in a disaster, sometimes from looking at what doctors normally are supposed to do, which is treat each individual patient to the max, to this more population-based approach."
On how Memorial doctors began hastening their patients' deaths
"At some point on the day that the power failed, a few hours after that, some of the doctors told me that they walked around the hospital, had a look at the situation of the patients and felt that hastening death was the right choice.
"You know, one of them had gone upstairs to the intensive care unit where there was just one patient left. Most of them had been taken out first, but she was very, very sick. She had this do not resuscitate order and had been held back. And he asked the nurse, 'Give her enough morphine till she goes.'
"The other doctor [John Thiele] actually was involved in injecting some of those patients on that Thursday, Sept. 1 of that year. ... And he also told me that the intent was to let these people die. He did describe to me having a moment after he did these acts where he did wonder whether it was the right thing. And he even hesitated just before he started injecting the patients and he asked the woman next to him, a nurse who was on the ethics committee, whether they could really do this.
"Now, one thing he didn't consider was staying there with the patients until they died."
On whether other hospitals are likely to face the same challenges Memorial faced during Katrina
"I saw it last year with [Superstorm] Sandy. After everything we should have learned from Katrina, we saw hospitals lose power, hospitals being evacuated in the middle of a hurricane, ICU babies taken out by hand down darkened staircases, hospitals that knew that they had vulnerabilities not evacuating in advance.
"We can't just say, you know, the government failed, the corporation failed. That's the easy way out. Yes, they have to do better, we have to do better. But then there's also this really important role, and I've seen it over and over again in every disaster or conflict zone where I've worked, that individual decisions can have a large and reverberating impact. There is a tomorrow after a disaster, and it's sometimes hard to remember that in the midst of it."