Louisiana is more than the setting for the disaster at Memorial Medical Center: its flood-control history, emergency response, and legal choices shape the book’s account of how a catastrophe became a prolonged dispute over responsibility. The narrative connects the state’s earlier decisions about who would bear the costs of flood protection to the consequences of Hurricane Katrina and, later, to legislation intended to shield medical professionals working in disasters.

Flood Control and Unequal Risk

The book traces Louisiana’s flood vulnerability through the Mississippi River floods of 1927. Two weeks after a Good Friday storm, floodwaters from the upper Mississippi reached the state. On state orders, workers dynamited a levee below New Orleans to ease pressure on the levees protecting the city. The decision sacrificed St. Bernard Parish and Plaquemines Parish to protect New Orleans, at the request of the city’s business elite, who did not provide the restitution they had promised. The resulting grievance, the account notes, persisted into the next century.

The disaster also changed the structure of flood control. The Mississippi floods prompted the Flood Control Act of 1928, which assigned the U.S. Army Corps of Engineers responsibility for improving the lower river’s levee and flood-control systems. The federal government assumed full responsibility for the river, while the Corps received immunity from liability for damage resulting from its work. In later decades, the Corps also became involved in flood-protection projects for New Orleans, including drainage canals leading to Lake Pontchartrain.

Meanwhile, the New Orleans Sewerage and Water Board secured funds to improve drainage. An engineer designed what was then the world’s largest pump, and fourteen were custom-built for the city. By the end of the twentieth century, drainage capacity had nearly quadrupled, reaching more than 45,000 cubic feet per second. Yet greater pumping capacity did not erase uneven exposure: during flooding described in the book, the area around Baptist Hospital, Lakeview, and Gentilly faced higher and more persistent water than much of the city. The basement of Baptist Hospital filled with eight feet of water, disrupting the hospital for a second time in its short history.

Katrina and the Emergency in New Orleans

As Hurricane Katrina approached, forecasts shown at Memorial Medical Center warned of potentially prolonged uninhabitability, severe damage, power outages, and water shortages. New Orleans Mayor Ray Nagin issued an immediate mandatory evacuation order at about ten in the morning. Its delay had cost precious hours while officials considered logistical and legal questions, including whether he had authority to require residents to leave. The book notes that state law allowed the governor and parish presidents—and, by extension, the mayor—to order an evacuation.

The order applied to a population whose ability to comply was sharply unequal. Many residents lacked cars or another way out, while traffic already obstructed the interstate. The city designated the Superdome as a shelter of last resort and offered shuttle buses for people unable to leave independently. Nagin specifically urged people with medical conditions, including those on dialysis, to go there, but did not explain what assistance they could expect. The gap between a command to evacuate and the practical means to do so forms part of the broader emergency setting in which hospitals had to plan for patients and staff.

At Memorial, efforts to organize transport revealed both local initiative and dependence on outside resources. A hospital in Baton Rouge agreed to take Memorial’s babies, including sixteen critically ill infants; Coast Guard helicopters were expected to transport them and some adult intensive-care patients. The National Guard also promised to move thirty-five medical and surgical patients to a Tenet hospital in Texas in high-water trucks. These arrangements left many other patients and people in the hospital, while communications from officials and hospitals conveyed concern that government assistance would not meet the scale of need.

Investigation and Disputed Evidence

After the storm, Louisiana became the center of an investigation into deaths at Memorial and other health-care facilities. The condition of the recovered bodies complicated the inquiry: they had remained in heat for more than a week, making blood testing unavailable. At the request of the attorney general, the Orleans Parish coroner agreed to seek autopsies and tissue sampling by a federal disaster mortuary team. Investigators sent samples from eighteen Memorial bodies to National Medical Services, Inc., a forensic toxicology laboratory in Pennsylvania. An early report on those cases found morphine in nine and midazolam in roughly five or six others.

The findings did not settle what the drugs meant. In a later review, twenty-three of forty-one bodies from Memorial and LifeCare tested positive for morphine, midazolam, or both. The laboratory director cautioned that postmortem tissue results were harder to interpret than blood tests from living patients, especially after prolonged exposure to heat. Investigators and experts considered patients’ medical histories, possible drug accumulation, the effects of the drug combination on breathing, and whether estimated effects corresponded to the known timing of deaths. The book presents the toxicology as evidence requiring interpretation, not as a conclusion that by itself establishes dosage, cause, intent, or criminal responsibility.

Experts and officials disagreed about how far the evidence could support a cause-of-death determination. Steven Karch argued that drug levels in bodies exposed to prolonged heat could not reliably establish the amounts present before death, and advised leaving causes undetermined. Michael Baden emphasized that the drugs were present and argued that no competing cause of death had been identified in the cases he discussed. Cyril Wecht challenged Karch’s position with a small experiment comparing samples exposed to hot, humid conditions with refrigerated samples; he found no significant difference in drug levels, while acknowledging the limits of the study. Coroner Frank Minyard weighed these conflicting views while considering the prospect of a trial and the consequences of a disputed verdict for the city’s recovery.

Criminal Proceedings and State Policy

Louisiana’s criminal investigation culminated in the arrest of Anna Pou, Cheri Landry, and Lori Budo on allegations of second-degree murder involving four patients. Attorney General Charles Foti’s office debated whether to pursue first-degree murder charges, which could carry the possibility of the death penalty, or reduce the charges to manslaughter. The prosecutors retained the second-degree murder charges. Foti publicly stressed that the accusations were allegations and that the women were presumed innocent; the decision whether to seek indictments belonged to Orleans Parish district attorney Eddie Jordan and a grand jury.

The case unfolded amid arguments about responsibility for the disaster itself. Pou’s attorney, Rick Simmons, said Louisiana had abandoned the hospitals during the period when many of the events occurred, and defended Tenet by contrasting the company’s role in rescuing patients with the state’s absence. That accusation sat alongside a wider record of failures by public agencies and private organizations, as well as reports examining decisions and inaction throughout the response. The book thus places the contested conduct inside a wider failure of emergency preparedness without treating that context as an automatic resolution of individual culpability.

After the grand jury declined to indict Pou, she worked with Simmons on three disaster-immunity bills in the Louisiana Legislature. The bills passed unanimously in 2008. They immunized health-care professionals from most civil lawsuits for work performed in accordance with disaster-medicine protocols, except in cases of willful misconduct, and urged prosecutors to await a medical panel’s findings before bringing criminal charges. At the time the bills were written, the protocol language was included in the hope that a protocol would later be created. Pou also advocated similar legislation in other states.

The book contrasts that legislative response with national guidance on the limits of disaster medicine. The Institute of Medicine’s reports stated that neither law nor ethics supported intentionally hastening death, even in a crisis. Louisiana’s laws addressed liability and prosecution procedures, but did not themselves establish a clinical protocol or answer the ethical question of whether emergency triage could extend to deliberately causing a patient’s death. The state consequently remains a setting where flood-control policy, unequal evacuation capacity, forensic uncertainty, and the limits of disaster-care immunity converge.