Medical triage in disasters

Medical triage in disasters is the allocation of limited care and rescue capacity under conditions in which ordinary systems have failed. In the account of Hurricane Katrina, triage is not confined to choosing which patient receives treatment first: it also determines who can leave, who must wait, and whether a medical label is mistaken for a judgment about a person’s claim to rescue. The contrast between patients’ needs and the fragmented systems meant to help them makes triage both a clinical practice and a test of institutional responsibility.

Beyond ranking patients by severity

Disaster triage is often imagined as a bedside ranking of patients by urgency. The Katrina crisis exposes a wider chain of decisions. A city evacuation order could not move people who lacked cars; officials knew transportation plans had serious gaps, including too few drivers. Residents who could leave were already caught in traffic, while people without another option were directed to the New Orleans Superdome, designated as a shelter of last resort. The mayor specifically urged people with medical conditions, including those requiring dialysis, to go there, without clarifying what care would be available.

Transport capacity was itself scarce. Dispatchers at Acadian Ambulance were overwhelmed by requests from hospitals, nursing homes, and homes. Many of the roughly two dozen ambulances made available were stuck on the interstate, and some began taking patients to the Superdome instead of out of the city. At Chalmette Medical Center, ambulances took an initial group of critically ill patients but did not return. One nursing home’s contracted bus service failed when its dispatcher reported having only two buses and no driver. These circumstances show how a patient’s prospects could be determined before any clinician assessed that patient: access to a vehicle, a driver, a route, or a functioning rescue plan became part of the triage environment.

The risks were foreseeable. A federal emergency exercise in New Orleans had modeled more than 2,000 hospital patients during a catastrophic hurricane, and officials reported that about 2,500 patients remained in the city as Katrina approached. Yet planners had not resolved how to move so many people out of a flooded area. Only two of roughly eighteen hospitals in and around New Orleans had placed both their generators and electrical switching equipment above ground-floor level; Memorial Medical Center was not among them. A shortage of transport and vulnerable infrastructure thus compounded the decisions made inside hospitals.

The DNR-last rule at Memorial

At Memorial Medical Center, leaders established an exception to the usual evacuation priority for the sickest patients and those dependent on machines: patients with do-not-resuscitate orders would go last. Four patients in the intensive care unit were affected, including Helen Breckenridge and Jannie Burgess. When staff brought Breckenridge downstairs, a doctor ordered them to take her back because she could not go in the first sweep. On another floor, a bed-bound patient with a DNR order was repeatedly passed over as other patients were moved toward evacuation.

The distinction matters because a DNR order has a limited meaning: if a patient’s breathing or heartbeat stops, staff should not attempt resuscitation. It is not, by itself, a request to withhold other treatment or to forgo rescue. It also differs from a living will, which under Louisiana law could address withholding or withdrawing life-sustaining procedures in a terminal and irreversible condition. Yet Richard Deichmann later explained that he understood DNR patients to have a certified terminal or irreversible condition and believed they had the least to lose if disaster struck. In practice, the evacuation rule treated a resuscitation instruction as though it were a broader forecast of prognosis and a reason to defer rescue.

That classification had consequences for people whose histories could not be reduced to it. Jannie Burgess had worked for thirty-five years as a licensed practical nurse, after taking up nursing to support her children. Because of racial segregation, she had been able to care for patients in many private hospitals while being unable to receive care in them; she was born shortly after the hospital opened as Southern Baptist Hospital, but it took more than four decades before she could be a patient there. Her presence among the DNR patients connects the immediate evacuation decision to a longer history of unequal access, without establishing that the DNR rule itself was applied on racial grounds.

Labels, consent, and the chance to be rescued

The consequences of treating DNR status as a rescue category became plain when a patient’s daughter learned that her mother was being left behind. The daughter had agreed to the order after her oxygen-dependent, ninety-three-year-old mother was admitted for the storm, reasoning that resuscitation after cardiac arrest would not make sense. Faced with the prospect that the order was also being used to defer evacuation, she said she had not understood it to mean that her mother should not be rescued. She asked for the order to be canceled; a doctor was sought, and the patient was moved downstairs toward the helipad and survived the immediate ordeal.

On LifeCare Hospitals’ seventh floor, Angela McManus likewise tried to rescind the DNR order for her frail, seventy-year-old mother, Wilda. Staff told her no doctor was available to do so. The two situations reveal how patient autonomy could be constrained by the emergency’s staffing and procedures: a family member might have a right to request a change, but that right offered little practical protection if no clinician could be found to act on it. The DNR label could therefore function less as a carefully revisited instruction than as a fixed sorting marker.

The evacuation process also altered what counted as urgent over time. After a day or two in the heat, dehydration had become a severe threat, particularly for patients unable to drink independently. An initial effort to stop treatments that might slow movement toward the helipad had to be reconsidered when depriving patients of fluids threatened their chances of surviving. Meanwhile, about a dozen patients classified as category 3 remained near the second-floor ATM, wearing large DNR tags, as other patients waited for transfer through an opening into the parking garage. Triage here involved not only assigning priority but repeatedly confronting the effects of delay and of decisions made for speed.

Care under pressure and uneven access

Not every consequence of crisis triage came from a formal rule. Karen Wynn saw how fear and exhaustion narrowed attention. An outpatient arrived through floodwaters for a scheduled chemotherapy appointment, only to be told treatment could not be given. A dialysis patient from the neighborhood waded to the hospital overdue for treatment. A couple with small children who rowed up to Memorial were turned away; physician Bryant King protested that they had to be helped, but the family was refused. Wynn believed the hospital could take no more people, while King was particularly troubled that those being turned away were nearly all African American. The scene presents a genuine limit on capacity alongside the unequal burden borne by people who had few alternatives; it does not resolve that tension by making either observation disappear.

The experience at public Charity Hospital offers a striking comparison. It had flooded and lost power, plumbing, computers, telephones, and elevators; it had no helipad or corporate overseers, and its patient load was approximately twice Memorial’s across its two campuses, with fewer staff per patient. Its evacuation was not complete until Friday afternoon, September 2, a day after Memorial’s. Nevertheless, fewer than ten patients died there. Staff accounts described continued care in patients’ rooms, regular meetings every four hours for workers from doctors to janitorial staff, and morale-building efforts including a flashlight talent show. The comparison does not by itself establish why outcomes differed, but it cautions against treating adverse conditions or patient volume as sufficient explanations for what happened.

The wider meaning of disaster triage

The book places individual hospital decisions within a network of failures: delayed evacuation, inadequate transportation, poor communications, insufficiently robust backup power and water, and confusion among agencies. More than a thousand people died immediately in New Orleans, many in medical facilities, while others suffered amid disrupted health care. In that setting, triage was shaped by systems that had already determined who could reach safety and by institutional judgments about whose needs could wait. A rule intended to organize evacuation could magnify danger when it misread the scope of a patient’s instruction or failed to account for the consequences of delay.

A later example in Port-au-Prince extends the problem from evacuation priority to scarce treatment. After the 2010 earthquake, an American field hospital recorded one patient as Jane Doe 326; her name was Nathalie LeBrun, a thirty-eight-year-old woman who needed oxygen. A tank ran out, another was found, and a portable concentrator repeatedly overheated; because it required electricity, it also depended on generator fuel in short supply. The episode underscores that disaster triage takes place inside fragile supply systems, not apart from them. Across these cases, the central question is not only how to rank patients, but how institutions can make allocation decisions while preserving the difference between limited treatment, a refusal of resuscitation, and abandonment of a person who remains alive and in need of help.