The brilliant and harrowing Apple TV series Five Days at Memorial retells the true story of a hospital’s struggle in the aftermath of Hurricane Katrina in 2005. When the levees broke and the city of New Orleans’ infrastructure collapsed, Memorial Hospital and LifeCare (a nursing care facility sharing the same building) were left without food, water, power, or an evacuation plan.
In the wake of a natural disaster exacerbated by state, federal, national, and corporate failures, it was doctors and health care workers who were left to make life and death decisions for the sickest patients. With both hard-boiled realism and touching humanity, the series explores the moral and ethical dilemmas caregivers face when circumstances turn dire. In this interview, Awards Daily asks veteran trauma surgeon Carl Hauser to discuss those issues from a physician’s perspective.
Dr. Hauser has been a critical care surgeon for 40 years and is a visiting professor of surgery at Harvard Medical School. Before his tenure at Harvard, he was professor of surgery at New Jersey Medical School and University Hospital in Newark, N.J. where in 1997 he was featured on TLC’s popular show Trauma: Life in the E.R.
[Full disclosure: Dr. Hauser is interviewed for Awards Daily by his daughter.]
Awards Daily: Can you talk a little about your experience with disaster preparedness? You triaged on the ground during the Boston marathon bombing. You were also working in Newark, New Jersey, in 2001. Did you get overflow from the Trade Center collapse?
Dr. Hauser: I was the trauma surgeon on call when the mass casualty alert went out for the marathon bombing, but it’s not just mass casualty events that prepare you for disasters. What would be called a mass casualty event in most places in the country was what we called a Saturday night in Newark, where we might get 10-15 casualties before the bars closed. Same thing with downtown Los Angeles. I had nights in L.A. County where we’d operate on ten gunshots in an evening.
For the World Trade Center collapse, there was no triage—that was a binary event. If you were onsite you were morselized. If you weren’t onsite you probably didn’t have serious injuries. In mechanized warfare there may be 10 injuries for every mortality, but at the World Trade Center there were probably a hundred deaths for every significant injury. We got very, very few injuries from 9/11. We were all standing in ERs all suited up waiting for the first wave of injuries, and nobody ever showed.
In times of disaster you do the best you can with what you have. Same for pandemics, mass shootings, wartime. The standard of care becomes even more of a moving target than usual, and the moral high ground is a raft in high seas. But in cases where you know you can’t save everyone, some deaths are expected and the best outcome is the highest salvage rate.
Awards Daily: How realistic was the show’s portrayal of the corporate healthcare system? The fact that there were two corporate entities under one roof [Memorial vs. LifeCare] ended up causing real issues for the caregivers.
Dr. Hauser: Corporate healthcare! Ugh! This all has to do with optimal space utilization for the purpose of profit. The facility on the seventh floor was legally a separate “skilled nursing facility” (or “SNF”) belonging to Tenet, who had rented that space from Baptist. SNFs are often warehouses for the aged, dying, or non-functional (Emmett) where their “care” costs less than an “acute care” hospital. But SNFS are BIG business and the majority of the patients never go home. They are typically seen by physicians 1x per month since that’s all Medicare pays for. So it was not a surprise that no physicians were present, certainly in a storm. Although SNF patients tend to be a bit more “stable,” they are typically quite frail—so when environmental conditions deteriorated at LifeCare they rapidly became acute care patients.
But, since the SNF and the hospital were different legal entities, they literally had to have different (and independent) staffing and privileging. Applicable laws and regulations require that all caretakers (MDs, RNs) be separately privileged by each entity. So in this case, when everything else broke down, the only thing that didn’t break down were the legal barriers to providing care in another corporate institution. Eventually, the caregivers at Memorial said “fuck it” and took over healthcare at the nursing facility. It was clearly the right thing to do, although it was also against the letter of the law.
I found the show to be realistic and honest, and for me it was a painful reminder of how individuals trying to do the right thing have been suppressed in medicine by corporate and governmental self interests.
Awards Daily: Obviously the evacuation we saw on the show was a disaster because of the conditions and the resource shortages. But was that normal, what the hospital did with the colored wristbands?
Dr. Hauser: What they did with the wristbands was pretty standard triage. The bands were green, yellow, and black, I think. There were those who could walk on their own, there were those who needed help, and then there were those that had no ability to help themselves. From the first group, maybe they could get twenty-five per hour to the roof. The second group maybe ten per hour. The third group, maybe two per hour. So under those circumstances, it makes sense to take the first group first, because with a limited resource, you’re putting it into a group that can make the most benefit of it.
The word triage comes from the Napoleonic wars. Napoleon’s surgeon created this system where there were three groups: You, you’re fine for now, go back to the battle. You, you’re gonna die, there’s nothing we can do for you. You in the middle, you’re injured and we’re going to take care of you. That’s still basically what we do, or a version of it. In the Boston Marathon bombing, the people who came in got armbands. Nobody got black armbands—nobody arrived dead or braindead. If you were bleeding and in danger of losing your legs, you got a red armband and you went to the OR as fast as possible. But that’s how you allocate care in mass casualty situations. You put armbands on people so you know who you’ll treat last. If someone’s brains are on the floor, you’re not going to send a bunch of caregivers to treat them while someone who is maybe not so badly injured and could make a full recovery goes without care. You don’t do that. That’s not just poor form, it’s wrong.
Awards Daily: This is a really controversial idea that the show centers around—basically the idea of human euthanasia. Ultimately they had a situation at Memorial where people were not going to get out, and so the caregivers, specifically Anna Pou, provided drugs to hasten death in a more humane way. The story at the time was hugely controversial, and it still provokes very strong reactions in people who watch the series. What would you have done in Anna Pou’s position?
Dr. Hauser: I’d like to think I would’ve done almost exactly what Dr. Pou did, except I might have tried to set up an ad hoc committee to validate the approach and judgments. But all that’s easy to say in retrospect. At the time, there probably wasn’t a real opportunity to do that, and it probably would have failed anyway, because most of the individuals involved didn’t have the ability to adapt their moral judgments to the circumstances.
Awards Daily: Some people consider Dr. Pou’s actions and think, what about the physician’s duty to “do no harm?” Do people have an overly simplistic idea about what that means?
Dr. Hauser: “First, do no harm” is commonly cited and typically completely misunderstood. The saying derives from a period in history where medicine actually had few, if any, valid treatments. The modern concept of medicine is to do good, bring health, restore normal function and alleviate suffering. “Primum non nocere” applies now where there are no clearly helpful treatments—and in those cases it’s important to avoid doing things that are untried, unproven and potentially harmful just to do something. I’m reminded of Steve Martin’s bit Theodoric of York: “He needs a good bleeding!”
In my experience, the common assumption that death is uniformly a “harm” just shows a lack of understanding and experience of death on the part of the assumer. Everybody dies eventually, and death (at least without palliative care) is almost always unpleasant. So to me, the relief of pain and suffering associated with dying where death is imminent is a distinct good, even if it hastens death.
Awards Daily: So it is possible that “duty of care” can, at times, include euthanasia, or what some people on the show called “mercy killings.”
Dr. Hauser: Euthanasia from the Greek “Eu – thanatos” literally means “a good death.” So if it’s truly euthanasia, it’s always merciful. That’s just the definition. Shooting a healthy person in the back of the head is quick and painless, but I don’t think anybody would call it merciful.
I would posit that the duty of care—where you cannot save a life and death is imminent—is to relieve suffering. We now call that “end of life care” and have organized training in palliation. That didn’t exist (or was in its infancy) in 2006, and we still have tremendous variation in its application across the country.
Awards Daily: You mentioned Emmett earlier. His situation was a bit different because he was awake and aware, and competent to make decisions regarding his own health care.
Dr. Hauser: That’s true. He also could not reasonably be moved. So, one way or the other, he is in what we call a lethal circumstance. He’s going to die. So the question then is how you deal with him personally.
I myself tend not to be paternalistic about people who have understanding. With people who are in my charge who don’t have understanding—someone who is brain dead—it’s not paternalism. They’re already dead. What people don’t realize is that many of the people who are in these nursing homes or SNFS, perhaps even most of them, have lived their life. They will never have any real life again. That wasn’t the case for Emmett, and that’s the person I would have handled differently.
Awards Daily: What would you have done differently in his case?
Dr. Hauser: Because he was conscious, I’d have asked Emmett. I would have told him, listen, I know people have told you that they’re going to get you out of here, but the truth is that you’re not. Because we don’t have the capability. I think the chances are well upwards of 95% that you’re not going to survive. So I can give you something that will make you go to sleep comfortably, or I can leave you here. Those are our choices.
But in those conditions and under those circumstances, there is just no way to sustain the patient’s life. It’s not going to happen. It’s not because we don’t want to. And it’s not just that the hospital can’t. Society as a whole can’t. The city can’t. The state can’t. The federal government can’t.
Awards Daily: Because those systems had effectively collapsed, and the infrastructure that could sustain his life was not going to come back in time to save it.
Dr. Hauser: That’s correct. It takes a lot of infrastructure to sustain life for somebody like that. That infrastructure was already, first of all, gone, and that little bit that there was was being used to save more lives rather than his life. Now, in Emmett’s case he could not be moved to the helipad. But even if Memorial had the physical capacity to move him—I’m not sure what the weight limits are for helicopters—he weighs 380 pounds, right? Let’s say he weighed 300. And let’s say the average pediatric patient weighs 30 pounds. Now, if you’re put in the position to choose, are you going to put 10 pediatric patients on a helicopter, or one 300 pound paraplegic—that’s a triage question. Society makes these value judgments all the time.
Now on the other hand, you could make another argument, another judgment, that if you had ten people in who have had multiple strokes and are now drooling in a SNF with no quality of life, and don’t know their kids when they come to visit them—are you going to put those ten people on a helicopter instead of Emmett, who was with it and conscious? Now, I might have had something to say about that. But I don’t rationally think that was a choice on the table at Memorial.
Awards Daily: You’d have prioritized Emmett’s thinking, conscious life over simply “life” which could be defined as someone who had a heartbeat but might not have brain function.
Dr. Hauser: Yes. That’s because to me, first of all as a physician but second as a thinking, and I hope caring person, to me life is consciousness. Life is not a heartbeat. That’s bullshit. Born-again heart-beating fetus bullshit.
Awards Daily: In terms of the actual health portrayed on the show, was there anything you saw that you’d have done differently?
Dr. Hauser: I think they provided what health care they could. I know from long personal experience that providers cannot provide equivalent care under circumstances where there’s limited capacity. If you don’t have an OR you can’t do an operation. If there’s no lights, you can’t do an operation. Now, maybe there are some operations you could do by flashlights or candle light, but they’re only very limited. This is just realism. So, the standard that you’re held to is only the standard that you’re capable of under the circumstance. That’s well defined, legally.
If you’re a passerby and someone collapses in the street from a heart attack, your responsibility as a doctor (as far as I’m concerned) is to take care of them. Now, some doctors will continue on walking, because they’re thinking “if he dies, someone will sue me.” But if you’re out in the street, your standard of care is not the standard of a cardiologist in the ER. It’s the standard of a passerby on the street. You provide CPR. I’ve had this happen on airplanes and I’ve provided CPR. Some doctors shrink in the corner and don’t raise their hand, I suppose because they live in fear of being sued for malpractice.
But from what I saw of the actual medical care that was delivered at Memorial, for what they had, they did the right thing universally. There wasn’t anything they did that was wrong. Now there wasn’t that much that was done right, because there simply wasn’t much they could do at a certain point, other than try to keep them cool, etc. Really the only thing they had was palliation, which they did at the time that they thought all reasonable hope was gone.
Awards Daily: Reasonable hope is a good way to put it. I think from a religious perspective, though, you might hear some people argue that there’s always hope.
Dr. Hauser: Yeah, there could be a miracle. But your job as a physician is not to rely upon miracles or to hold out for them. That’s not a reasonable place from which to practice medicine. It’s not acceptable.
Awards Daily: If the patients were simply left at the hospital without hastening their death, what would have happened to them?
Dr. Hauser. They would have died. It just would have taken them an extra 24 or perhaps 36 hours. They would have died of dehydration and sepsis. Overwhelming bloodstream infections. For the length of time it took them to further deteriorate and die, they would have been sitting in their own urine and feces. That’s the reality. And as far as I can see, that outcome for them was basically 100% guaranteed. When the National Guard came and said “everybody out, we gotta go, no more boats”—when that happened it was over. That was when all hope, all reasonable hope, was gone. Nobody was coming back for them.
Remember that you’ve got 20,000 people in the Superdome. Are you going to spend your resources ferrying water to those people, or to a few patients who are DNRs in a nursing home who are not aware of their surroundings? Are you going to spend those resources airlifting food to the people in the Superdome, or airlifting nursing home patients to an ICU in Baton Rouge? Because remember, if they do get out of there, although they were nursing home patients, now they’re decompensated nursing home patients. Now they can’t just go to another nursing home; they have to go to at least an acute care hospital, and probably most of them to ICUs.
Even though they had been stable in a SNF, once they decompensate, they’re in decompensated heart failure or decompensated pneumonia—decompensation by its definition means they have acute risk of death, which means any place they go they’re going to have to get an acute care bed.
Awards Daily: So even if by some miracle an evacuation crew had come back for Emmett and the others after a couple days—which didn’t happen—those patients would have been in such a deteriorated state that their lives very probably could not have been saved. And they all would have required ICU beds during a mass casualty event. This is not something that people in the “why didn’t you just leave them there and wait for someone to rescue them” camp have likely thought about. They aren’t thinking about the resource shortages, where they would go, how sick they’re going to be when they get there. Those were things that pretty much only doctors would have been thinking of.
Dr. Hauser: It’s much easier not to think about it. But Anna Pou was thinking about it. She was the one who had the more global vision. It’s easy enough, if you weren’t there, or if you’re a prosecutor afterwards to say, “No one should have the right to take a life.” Well, I’m sorry, but some people have the responsibility to. The reality is that everybody in Acute Care Medicine has been in the position where they’ve had to make life and death choices for others. Everybody. Period. Apportioning ICU beds in the COVID crisis has been the most obvious recent public dilemma. We have a shortage of monoclonal antibodies to COVID, who’s going to get it? We need a ventilator bed, who is going to get it?
But I’ve done forty years of critical care and I can tell you that every ICU has these questions happen every day. If there’s ICU bed pressures, who do we send out of the unit when that’s a danger to them because someone else is sicker? When do we give up on a hopeless case to give the bed to someone with a higher chance of recovery? Anyone who says they don’t have these discussions about patients in these circumstances is a liar. The buzz phrase, though, is goals of care. “What are the goals of care?” What that really means is: why are we still keeping this person alive? There’s a euphemism for everything in modern medicine. It’s a politically correct way of saying: how are we going to talk the family into pulling the plug so that we don’t have to take responsibility for it. Well, family is not around at Memorial, and there’s no way to contact them. Somebody’s got to step up.
Especially in ORs, surgeons are expected to be “captain of the ship,” and so are trained to step up like that. Then unfortunately, if something goes wrong (or is perceived to have gone wrong), corporate healthcare entities are quick to point to the surgeon as bearing the ultimate responsibility. Being captain of the ship leaves you exposed. You can go down with the ship, and that’s what very nearly happened to Anna Pou. But what the hippocratic oath is really about is about putting your patients before yourself, and that’s what she did. She wasn’t thinking “I’ll play it safe so that nobody can sue me.” Instead, she did what she thought was right and merciful for the people in her care at her own peril. Death is not a harm in a circumstance like that—anybody who thinks it is ain’t been there.
Awards Daily: In the series, Emmett’s wife was suing the hospital for killing her husband. At that point, everyone—the doctors, the hospitals, the politicians, the insurance companies—they were all protecting themselves. So there was silence around what happened to Emmett. It doesn’t seem like anyone reached out to her. Do you think that honest communication early on with the patients’ families would have helped them understand and feel more at peace with what happened to their loved ones?
Dr. Hauser: Corporate Healthcare systems are primarily financial entities, not healthcare entities, and so their first and last instincts are to protect their profits from lawsuits. So of course no one reached out to Emmett’s wife. They should have.
If it were me having the conversation, I would tell the family “your [loved one] was dying. Our choices were to abandon them and let them die in misery or to give them palliative care which would allow them to feel a lot better but would hasten death.” I might also explain that normally in hospitals we have committees that decide this, and we have machines that give the drugs slowly so that death occurs over a period of time rather than being more abrupt. But in principle, it’s not different from what we would have done in more everyday circumstances. Of course, you have to feel out the family member and your responsibility is to bring them understanding and “closure”—not to cover your own ass. And they’d have to know that you’re totally honest about that. That’s how I’ve dealt with patients and families my whole professional career, and I’ve never been sued. Because I’m up front and honest, and for the most part, it’s hard to overstate how much people appreciate that.
Awards Daily: Some people said that Dr. Pou was “playing God.” Others thought she was a hero. Was Anna Pou a hero? Or was she just doing her job?
Dr. Hauser: Both. Sometimes that’s what it means to be a hero—just doing your job when other people chicken out. What people called “playing God” here, I call “stepping up.” Everybody knows that stepping up is dangerous, but some do it anyway. We want “the right thing” to be some absolute set of values because it’s easier to keep our society going that way—but life isn’t that straightforward, unless you’re the Unabomber.
The “right thing” changes depending on the circumstances. When you see a lot of dying and suffering, you know that death and life are not so black and white. You know that life is not always a blessing and death is not always a harm. You know that death can be merciful. Is that a mercy killing? Well, call it what you want.
I’ve pulled out traches [tracheostomy tubes]. I’ve shut off ventilators. I’ve turned up the morphine drip. I’ve explained to families who take their loved one home to die what to do. That’s not playing God. That’s being a doctor.
You can watch the limited series Five Days at Memorial on Apple TV+.