Memorial evacuation triage policy

Memorial evacuation triage policy was an improvised system for deciding which patients would leave first as staff moved more than one hundred patients through a hospital under disaster conditions. Its three categories turned a vast evacuation problem into a sequence that staff could act on, but the ranking also joined judgments about illness with do-not-resuscitate status, leaving consequential decisions in the hands of medical professionals without a particular protocol or a way to share the decisions with those affected.

Emergency Setting and Purpose

New Orleans faced a mandatory evacuation, but the order could not itself provide a way out for people without cars. Transport plans had serious gaps, traffic blocked roads, and ambulance dispatchers were overwhelmed with calls from hospitals, nursing homes, and homes. Some ambulances were stuck on the interstate; some began taking patients to the Superdome rather than out of the city. Meanwhile, roughly 2,500 hospital patients remained in New Orleans as Hurricane Katrina approached. An earlier emergency exercise had anticipated more than 2,000 patients in such a disaster, but officials had not worked out how to move them to safety through floodwaters.

At Memorial Medical Center, evacuation became a mass movement of patients from Memorial and LifeCare Hospitals of New Orleans toward lower floors and eventual transport. That morning, staff had difficulty finding enough official, color-coded triage armbands. They settled instead on three numbered categories, meant to speed evacuation. The ranking addressed an immediate practical constraint: patients needed different levels of assistance, and there were more people to move than could be handled at once. It did not emerge from a settled institutional triage system. Anna Pou and her colleagues had little, if any, training in triage systems and were not guided by a particular protocol.

Categories and Movement Through the Hospital

Category 1 was for patients in fairly good health who could sit up or walk, and these patients were prioritized first. Category 2 covered patients who were sicker and needed more assistance. Category 3 was reserved for those slated to leave last; it included patients doctors judged very ill and, following a decision made on Tuesday, patients with do-not-resuscitate orders. The arrangement thus used both an assessment of a patient's condition and the presence of a DNR order to determine evacuation priority.

Staff and family members carried patients downstairs on cots and stretchers gathered from around the hospital. Pou, sleeves rolled up, stood ready to receive them. Nurses opened charts and used flashlights sparingly to read diagnoses; a staff member wrote each category number with a Marks-A-Lot pen on a sheet of paper and taped it to the patient's clothing. Some numbers were written directly on hospital gowns. The process made the ranking visible to staff moving patients through the building, even as there was no broader system for communicating the decisions to the patients and families most affected by them.

The categories also shaped where patients waited. Roughly three dozen category 1 patients from Memorial and LifeCare were guided to the emergency-room ramp, where the initial plan was to send them out by airboat. Gina Isbell, LifeCare's nursing director, and Karen Wynn, Memorial's nurse manager, oversaw their care while they waited. Perhaps seventy category 2 patients were placed along a corridor leading toward a hole in the machine-room wall, a shortcut to the parking garage and ultimately the helipad. Around eighteen category 3 patients were moved to a corner of the second-floor lobby near a Hibernia Bank ATM and a planter of striped green dieffenbachia. These locations reflected the routes and stages of the evacuation, not simply abstract labels on a chart.

Care While Patients Waited

A category did not mean that a patient was abandoned while awaiting transport. Staff continued basic care: changing diapers, fanning patients, and offering sips of water to those able to drink. Family members often helped. But after patients were moved from their rooms on Wednesday, most other medical interventions were limited. That distinction matters: the ranking governed the order and practical handling of evacuation while taking place amid a broader shift away from treatment as usual.

At least one doctor passing through considered assigning people numbers efficient but distasteful. The discomfort lay partly in how a simple mark could stand in for a decision about when a particular person would be moved. Pou found the sorting heart-wrenching. In her later account, the shift from evacuating the sickest first to sending the sickest last reflected the doctors' sense that they would not be able to save everyone. The ranking therefore expressed not only a transport sequence but a judgment made under perceived scarcity, without an agreed protocol to settle what fairness should require.

Limits, Disclosure, and Significance

The system's most consequential limitation was that it combined categories that were not equivalent. A judgment that someone was very ill and a DNR order were both grounds for placement in category 3, even though the evidence describes the order as a factor in evacuation priority rather than as a separate measure of how much help a patient needed to be moved. The account also notes that triage judgments are uncertain: conditions can change, rescuers may disagree, and people who might survive can be mistakenly classified as unsalvageable. In a fast-moving emergency, a ranking can acquire the appearance of settled fact even when the underlying assessment is fallible.

Decision-making at Memorial was restricted to medical professionals. Once categories were assigned, no system was established to explain them to the people most affected, and in some cases staff actively withheld the reason. On a fifth-floor hallway, transporters stopped moving a bed-bound patient after seeing her DNR order and repeatedly maneuvered other patients around her. Nurses were told not to tell her daughter that the order was the reason; instead, they said other patients remained on the floor, without mentioning that the only other patient there was dead. This episode shows how the ranking could reach beyond evacuation logistics into family members' understanding of what was happening to a loved one.

The policy's significance lies in that collision of urgency and judgment. The numbered categories helped staff sort patients and organize crowded routes, but they did not resolve the moral questions embedded in the order of removal: who should wait, what counted as a reason to wait, and who had a voice in deciding. The improvised system made those choices operational before it made them transparent, leaving its practical efficiency inseparable from its ethical and human costs.