Reverse triage

Reverse triage is the name Anna Pou and Rick Simmons adopted for Memorial Medical Center’s controversial practice of helping healthier patients before sicker ones during the Katrina evacuation. Its importance lies both in the decision it described and in the work the phrase was made to do: it cast an emergency choice as a recognizable triage principle, even though the rationale behind the term was narrow and conditions at the hospital were changing.

Meaning and Wartime Analogy

Simmons described reverse triage as the reverse of what a layperson might expect. The term had been used, though rarely, for theoretical wartime situations in which treating the most able-bodied first could help return them to battle and thereby aid the survival of a group. Simmons and Pou applied that analogy to the evacuation at Memorial. The book stresses a limit to the comparison: prioritizing healthier patients in this way was not typical battlefield practice.

The terminology offered a concise explanation for a difficult choice, but it did not itself establish that the choice was medically or ethically justified. Simmons’s adoption of the phrase was part of a proactive defense against a possible indictment. He studied triage and end-of-life issues, collected statements from more than one hundred potential witnesses, prepared exhibits concerning government abandonment, and sought to protect evidence and keep Pou’s conversations with Tenet officials confidential. In that setting, naming the policy was also a legal and public-communication strategy.

Evacuation Rules at Memorial

Reverse triage overlapped with, but was not identical to, Memorial’s decision to place patients with Do Not Resuscitate orders last in the evacuation sequence. The hospital’s doctors established that exception to the general protocol of prioritizing the sickest and those dependent on machines. There were four DNR patients in the intensive care unit, including Helen Breckenridge and Jannie Burgess.

A DNR order concerned whether to attempt revival if a patient’s heartbeat or breathing stopped. It was not the same as a living will authorizing the withholding or withdrawal of life-sustaining procedures in specified circumstances. Yet the evacuation rule gave the DNR label a much broader practical consequence: patients and families found that it could delay rescue. A daughter whose ninety-three-year-old mother had a DNR order asked to have it canceled after learning that her mother was being left behind. She had consented to no resuscitation in the event of cardiac arrest, not to exclusion from evacuation. Staff sought a doctor to remove the order, and the patient was moved toward rescue.

The classification also intersected with a longer history of unequal access to care. Burgess, a Black nurse who had worked for decades in New Orleans hospitals and nursing homes, had once been able to care for patients at private hospitals without being able to receive treatment there herself. Her presence among the DNR patients placed last connected the evacuation decision to a medical system in which categories and access had not been experienced equally. The evidence does not establish that race determined the DNR decision, but it makes the effects of a seemingly clinical sorting rule part of a broader history.

Scarcity and Foreseeable Failure

The crisis at Memorial was not simply an abstract contest between patient groups. Before Katrina, hospital officials had considered the risk of flooding and the vulnerability of emergency power equipment. After studying storm-surge models, plant operations director Eric Yancovich calculated that water could enter through the loading dock after less than four feet of street flooding and disable much of the medical center’s power distribution. He recommended raising vulnerable electrical switches and pumps, but a partial bid for the electrical work exceeded a quarter of a million dollars, and he recorded that the work was unlikely to be approved because of limited capital.

When floodwaters threatened, the backup generators themselves were only one part of the system. Critical components were at or near ground level, leaving the hospital vulnerable despite generators on the second floor. The generators had already run for two days, although disaster plans called for them to support the hospital for at least three; the 750-kilowatt units had not been designed for prolonged operation, and no on-site electrician or engineer was a generator mechanic. These circumstances do not by themselves determine which patient should have been evacuated first. They do show that the apparent scarcity shaping the triage decision arose amid known infrastructure risks and limited preparation, not from an unavoidable natural limit alone.

Reassessment and the Limits of the Label

The book’s later analysis questions whether a fixed triage framework can remain sound when resources and circumstances shift. The helicopters began arriving in force on Thursday morning, increasing evacuation capacity. The author identifies the decision to proceed with patient injections at the moment that resources expanded as a central tragedy of the Memorial episode. The point is not that more resources automatically resolved every clinical problem, but that emergency priorities required renewed assessment as conditions changed.

The investigation further sharpened the stakes without making toxicology findings interchangeable with proof of intent or cause of death. Of eighteen Memorial cases tested, nine were positive for morphine and roughly five or six for midazolam. Those results became part of the controversy that Simmons and Pou sought to frame through triage language. Reverse triage thus names more than a ranking rule: it marks the contested passage from emergency allocation to public and legal justification. Its wartime analogy could make the decision intelligible to outsiders, but it could not settle whether the policy fit the actual circumstances, whether it was reassessed as rescue capacity changed, or what obligations remained toward patients categorized as least likely to survive.