What looks like unfeeling cruelty on the TV screen is most likely the result of hard but decent choices made by people who see exactly what we see, but who, unlike us, are charged with facing the chaos and turning it into hope....
Triage is not a way to decide whom to kill. Triage is a way to decide whom to save so that in the end the most people can be saved. Triage choices are tough, but they are necessary because doing nothing is a choice, and because following the loudest scream is a choice, and because only helping those on television is a choice, but all those choices are driven by impulse and are not supported by coherent moral values. If the resources were unnecessarily limited, and if the triage decisions were made in error we will know in time. The point now is that any finger-pointing must be mollified by a good dose of trust, humility and patience. Just because we see a helicopter on the news flying over a group of victims here does not mean that the helicopter is not following a triage decision to save a group of more needy victims there. Triage is where morality meets reality. It is precisely at times of chaos that morally informed but tough-minded triage decisions must be made, otherwise morality is simply a dilettante’s luxury and a mere intellectual puzzle for the philosophy classroom, but irrelevant on the street.
Comments?
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The first thing you do is get around it, either yourself, or as incident commander by sending somebody who perceives and reports clearly and swiftly. You're finding the threats to rescuers; finding the patients, sorting them into the code blacks, reds, yellows, greens (aka DRT, or dead right there, severe trauma, trauma, ambulatory). And then you plan, and then you direct or act. This can take 30 seconds on a single-car rollover with no car, structure, or wildfire in prospect; hours on a big fire. Done right it would take a day on a major event, but then you take a sector for your part of the process, and trust the competence of someone else in the other sectors. Even in those initial rapid assessments, you may be deciding who lives and who dies. But those decisions, in one sense, aren't really yours, they are the incident's. You have to take its impetus, its logic, and by a sort of jujitsu, convert its force to yours, or work within its force. By the terms of the incident itself, some are already dead (even though that may take a couple of hours to become medically demonstrable) and some don't need you save as a calming agent. The middle group is all you have to work with, the only place your efforts make a difference. But your information is always partial, your technology never quite sufficient, your workers and self human, your audience and judges conditioned by dramas that pass through a complete and satisfying dramatic arc in 48 minutes. For what it's worth, rescuers and officers have conciences and agonize over these triage decisions, sometimes for life. Did you know there are 2 job tasks that work out nearly fatal for an officer's career (ie, they either quit or commit suicide)? Investigating child abuse, and mass disasters.
The person you quoted gets this, and writes well. It's a message worth hearing, though it won't be by a lot of people.
Is it triage to keep the American Red Cross out?
Was it triage to be totally unaware of the situation at the Convention Center even though it was/is being reported LIVE?
Was it triage to not have heavy lifting helicopters available to help repair the breach earlier? (A five minute google search and phone call revealed the company who makes them offered help and got no response.)
Was it triage to not plan for an evacuation of the reugee centers even before the levee broke?
Was it triage not to inform people that 5 drops of clorox bleach and 30 minutes of standing yields safe, if unpalatable, drinking water? (Babies died of dehydration and nothing else.)
Was it triage to not end focus 100% on this disaster ASAP?
Was it triage to slow roll the LA's governor request for NM National Guard troops?
F***ing apologists. This is how you deal with the cognitive dissonance of the fact that your decision to help elect Bush is killing people.
I'm increasingly convinced that there are two groups of people talking about this, groups that don't have anything to do with party or race.
Those two groups are "grownups" and "children".
Rabbi Gellman is a grownup.
Elliott, you're not.
Charles? What in my list did not happen?
1.The Red Cross is barred from NO.
2.Chertoff and Brown were unaware of the Convention Center situation.
3.The levee break did not begin to be repaired until Thursday even though the plan was to start Tuesday afternoon.
4.Children died of dehydration when a gallon of bleach can produce hundreds of gallons of safe drinking water.
5.Despite fantastic claims, everyone who was paying attention knew the levees would most likely fail.
6.Blanco requested help and the paperwork took days to process.
Who is being realistic (grown-up) and who is being willfully ignorant (child-like)?
They had a signed agreement with FEMA so FEMA knew exactly what was expected.
JP's Maestri said FEMA didn't keep its word
Mark Schleifstein
Staff writer
Jefferson Parish Emergency Preparedness Director Walter Maestri said Friday night that the Federal Emergency Management Agency reneged on a promise to begin relieving county emergency preparedness staffers 48 hours after Hurricane Katrina hit the New Orleans metropolitan area.
Maestri’s staff has been working almost around the clock since Katrina approached the Louisiana coastline on Sunday. Today, the staff is
expected to finally switch to a 12 hours on/12 hours off schedule, he said,
adding that they’re both tired and demoralized by the lack of assistance from federal officials.
“We had been told we would be on our own for 48 hours,” Maestri said.
“Prepare to survive and in 48 hours the cavalry would arrive.
“Well, where are they?” he said.
Maestri said the agreement was signed by officials with the Southeastern Louisiana Emergency Preparedness Officials Association, the state and
the Federal Emergency Management Agency as part of this year’s Hurricane Pam tabletop exercise. That exercise began the process of writing a series of manuals explaining how to respond to a catastrophic disaster. Financed by FEMA, it included a variety of federal, state and local officials.
Why are there 200 school buses in New Orleans that could have taken evacuees out of the city before the storm hit? Why didn't Michael Chertoff order them into action?
Oh.
It's the local officials' responsibility to prepare and enact emergency management plans. So I guess the local police chief and mayor would have had to take that step to keep people safe.
The feds have to do mop-up, and in this case the mopping up is pretty extensive because the local officials (mayor and governor) did such a lousy job in emergency preparedness.
Forgive me for expecting more from the President of the United States, aka the Commander-in-Chief, sometimes known as the most powerful person in the world. Forgive me for expecting more from the leader of the richest nation on earth as opposed to the leaders of one of the most corrupt and poorest cities in one of the most corrupt and poorest states. As far as I can tell, Nagin and Blanco have done a better job. They certainly cleared the decks and noone was on vacation.
1.The Red Cross is barred from NO.
I have not heard this. Can you provide a source please?
2.Chertoff and Brown were unaware of the Convention Center situation.
They claim it was the local authorities responsibility to make them aware of designated shelters. The state and local authorities claimed they never designated the Convention Center as a shelter - people made their own way there. Why would you expect FEMA to be watching TV 24/7 instead of dealing with the crises with the information they have?
3.The levee break did not begin to be repaired until Thursday even though the plan was to start Tuesday afternoon.
They were diverted because they were busy rescuing people off their rooftops. Whether or not people had the means to leave town, most if not all had the means to make their way to designated shelters like the Superdome. Those who didn't kept the available helicopters very busy.
4.Children died of dehydration when a gallon of bleach can produce hundreds of gallons of safe drinking water.
I sure as hell hope you weren't telling anybody to actually do this. Cholorine, boiling and iodine will kill off many organisms in water. They will NOT I repeat NOT do anything about chemicals and gasoline and all the other contaminants in the flood water.
5.Despite fantastic claims, everyone who was paying attention knew the levees would most likely fail.
This is what happens when decisions are made by cost-benefit analysis instead of the theory that all risk should be averted at all times. You can debate which is correct, but you can't deny that generations of politicians all went along with the former method in this case.
6.Blanco requested help and the paperwork took days to process.
Paperwork? What are you talking about. "On Friday, three days before Katrina's landfall, 10,000 National Guard troops were dispatched across the Gulf Coast. Lt. Gen. Steven Blum, commander of the National Guard, said bringing in more has been hampered by road conditions..." Bush declared the region a disaster area on Saturday - two days before the hurricane even hit. The problems since then have been of logistics. Not paperwork.
So What in my list did not happen?
What in your list did happen the way you claim?
Here's another example of not triage, but criminal incompetence. This woman knows about triage and she is astonished by the non-response.
http://head-nurse.blogspot.com/2005/09/standby.html
I recommend this blog be added to your regular reading list. Totally non-political and compelling.
Jennifer. 1. It was on the redcross.org website explaining why they hadn't entered the city.
2. You have never, ever been in a crisis management center. Large screen tv's tuned to several channels are constantly on. This is true of evey operations center I have ever been.
3. Heavy lifting helicopters not involved in rescue were idle. Emails to the company that had them indicated they had offered assistance and not heard back.
4. You put the bleach in and let it sit for two hours. You pour off the top (volatiles including gasoline, and don't touch the sediment). Don't comment if you don't know what you're talking about.
5. I was responding to the claims that help was slow in coming because the levee breach was unanticipated. It most certainly was anticipated. The NOAA hurricane warning mentioned it.
6. That's right. The NM Guard did not get deployed because noone in Washington signed off.
Do you think before you apologize?
Elliot: The nurse's blog reveals how horrible the situation is, that's for sure. I don't see the criminal incompetence.
If you'll recall, medevac helicopters and vehicles were being shot at by armed thugs while hospitals were trying to evacuate. It would seem like a logical solution would be to then try to get that situation back under control, and then resume evacuations.
Clearly the situation is absolutely terrible - worse than anything we have ever seen. That doesn't necessarily translate to incompetence. Sometimes things are just terrible.
In this case, I would say any incompetence was in the planning stage. Why in the hell weren't people taken out of the city faster? Someone mentioned on another thread that they should have had emergency vehicles moving through neighborhoods blaring evacuation notices. They've done that when I was a kid here in Hawaii. They should have used available vehicles to at least move people to the Superdome. Yes it was terrible there, but not having to spend all their time rescuing individuals house-by-house would have alleviated a lot of resources.
Local officials being able to control the criminal response earlier would also have alleviated resources and allowed more of the aid that was on standby to be disbersed. Then a heavy handed martial response would never have been required.
Jennifer. How old are you? First, much of the lawlessness came because the hopelessness started to stretch into days instead of hours. Secondly, many/most of those helicopter pilots are ex-military. Had you given them the choice, they would have flown in under fire. That may have been a triage decision, I truly don't know, but it seemed to me to be an overly cautious decision of people without leadership.
The point is I'm not so smart. These things are obvious to me. Secondly, I'm not Paul Farmer (read Tracy Kidder's "Mountains Beyond Mountains" if you want to be truly humbled). In other words, I have obligations here. I did discuss going with the Red Cross, but my wife vetoed the idea. You want to attack my wife or me for listening to her?
1. It was on the redcross.org website explaining why they hadn't entered the city.
After an admittedly quick glance, I don't see it. But I will say that many rescue volunteers on standby have said they haven't been able to move in or do anything because of the danger from lawlessness as well as the impassable roads, etc. This really sucks, but I don't understand what you want - let hapless rescue workers in to be hijacked and shot?
2. You have never, ever been in a crisis management center. Large screen tv's tuned to several channels are constantly on. This is true of evey operations center I have ever been.
Well then it does seem odd that they didn't notice the convention center, doesn't it? Makes you wonder how you could possibly be right.
3. Heavy lifting helicopters not involved in rescue were idle. Emails to the company that had them indicated they had offered assistance and not heard back.
Communication was a major problem. With no power, no working cell phones and certainly no email, they may not have been heard.
4. You put the bleach in and let it sit for two hours. You pour off the top (volatiles including gasoline, and don't touch the sediment). Don't comment if you don't know what you're talking about.
I have searched all over the Internet for the answer to this very question. Because this was my first response too - why aren't people purifying the flood water and drinking it? You are the very first person to make this claim. EVERY other source said the only thing you could reliably eradicate from water were organisms. I tend to doubt your authority here.
5. I was responding to the claims that help was slow in coming because the levee breach was unanticipated. It most certainly was anticipated. The NOAA hurricane warning mentioned it.
Ah, well, I disagree that help was slow because the levee breach was unanticipated. I think help was slow because the city was unreachable.
That's right. The NM Guard did not get deployed because noone in Washington signed off.
What is the NM Guard? If you read my response to you, you would see that 10,000 Guard troops were positioned across the gulf coast. They moved in as quickly as they could given the circumstances.
Elliott: How OLD am I? Why would you care? If you think my points aren't worth responding to, don't. What a ridiculous question.
What race are you?
Jennifer. Because from what you write you seem inexperienced, but not stupid.
http://www.google.com/search?hl=en&q=Clorox+%22drinking+water%22&btnG=Google+Search
Elliott: The second link on your google search produces this fact:
"Four items must be considered if chemical disinfection is to be effective: (1) the water must be free of turbidity or dirt"
You don't even need to go on from there. The flood waters are hardly not turbid or filled with dirt.
G-d. That's why you let it stand. First you tell me you can't find anything, now you tell me that one link in a search that produces thousands proves I'm wrong. I take it back, you may just be stupid.
My comment doesn't seem to have posted.
Letting water stand does not free it of dirt. It merely allows it to settle.
Wallow in your own self righteousness Elliott. Too bad you weren't in charge - everyone would have been saved.
Elliot, how many people did you see on TV with gallons of Clorox conveniently at hand as they waited for help on the Interstate or at the Convention Center? For heaven's sake, if rescuers could have gotten Clorox to those poor people, they could have gotten bottled water to them instead. This whole argument about whether it would work or not is pointless -- nobody has any bleach!
And even for those who did manage to find some bleach somewhere, just what method did you have in mind for teaching them how to use it? Communications are OUT in New Orleans, remember? No cell phones, no regular phones, no TV. Now, leafletting might work -- but I wouldn't recommend dropping in gallons of Clorox along with the leaflets!
It is so easy to sit in blame and holler about what should have been done. It is a whole lot harder to get up, stop yammering, and do something. Everybody else is just as sick as you are over the poor, desperate people on the Gulf Coast. But don't kid yourself that your empty talk is doing anything to help them. There will be a time for blame, and there will be plenty of blame to go around, but you don't have to be a Bush apologist to realize that we aren't there yet. This is the time to help -- and if you don't have a way to help, then have the grace to keep quiet and get out of the way while others get the job done.
Elliott:
The subject of the original post was an extremely well-written and accurate description of a concept at the center of any well executed response to emergencies both great and small --- triage.
I know it is accurate because I experienced it in Vietnam more than 35 years ago. The only reason I am not participating in its execution in the Southeastern US now is because I am recuperating from minor heart surgery I received yesterday afternoon.
You seem to have assumed the Rabbi's description for the information of all was an "apology" for mistakes made in the wake of the worst natural disaster in the recorded history of this continent.
Do you really believe that the best use of time right now is indicting those who spending vast amounts of time and energy trying to cope with this unprecedented disaster? That is like beginning the 9/11 Commmission's work on 9/16. How many lives do you think that will save? How much medical treatment will that provide? How many mouths will that feed?
Please use your obvious intelligence, zeal and powers of expression to constructively add to the immediate effort to help those whose lives have been forever changed by Katrina.
Beginning tomorrow, through the Benjamin Franklin Legal Foundation, (www.benlegal.com) I will be organizing volunteers for existing community service organizations in the Atlanta and other communities throughout the country who are providing aid to Katrina's victims. I would be honored to have your support. Please contact me if you are willing to help.
Sincerely,
Jim Rhoads (vnjagvet)
Jim,
Thank you for the opportunity to help. I do believe this (both help and outrage) is the best time to do this; I know that the Bush administration on the other side is certainly calculating to the last decimal point the political implications. Talking points are emerging (beyond the outright lies) and they need to be countered because we live in an age of unprecedented propaganda by our government (read "Propaganda" by Elul and you will come away haunted by his prescience). People have a short attention span and are easily manipulated so you must make your points before complacency sets in. Good examples certainly are 9/11, the Iraq War, and the tax cuts. I would have preferred that the Commission started work on 9/16 instead of a lot of work that did start happening on 9/16.
The talking points that are being used to deflect accountability are:
1. It was a natural disaster; unprecedented and unexpected in its scope. The unprecedented point might be true, but the unexpected is certainly not true. It's an insult to our intelligence. This is where I see the Rabbi's point going. He and his Priest partner are in the Bush camp and so I cannot believe that he wrote this essay in the absence of any political context.
2. The local and state officials are just, if not more, at fault. This is patently ridiculous given the resources of the federal government and the primacy of the federal government in responding to these type of disaster situations. Althouse has been flogging this talking points in other areas so I see this post and those other posts and see her writing as part of a tableau all designed to deflect accountability; all the while she insists she is a centrist.
3. We should focus on the short-term and hold the accountability to later. This is a repeat point from my introductory paragraph, but by the time you allow this administration to organize its propaganda machine you have already lost the battle. Look at Prof. Althouse's ongoing insinuations against Ms Gorelick.
In short, thank you for your respectful response to my outrage, but I will continue to argue. I don't care about Prof. Althouse or Jennifer, but maybe someone who came to this thread will confirm that the Red Cross is not being allowed to help or that the hurricane warning included the probability of massive post-hurricane flooding and then will not swallow the lies the next time, or, most importantly, in 2006 or 2008.
Elliott:
Is advocacy for your view of Presidential failings truly more important than the immediate needs of between five and ten million of your fellow citizens?
After all, it is more than one year from Senate and Congressional elections and more than three years from the next Presidential election.
Can't some of this wait until after immediate needs are met? Or it your sense of triage that those immediate needs can wait?
This seems to me like a judgment regarding priorities that might be difficult to defend were it made by someone in an official position.
VNJV
Jim,
Eventually the short-term always becomes the long-term. My donation has already been made. I will not be going to the Southeast. I have no doubt that nothing I say or do in opposition or support of the relevant agencies at any level will change one iota what they do. Thank G-d, it appears they are finally getting in gear and coordinating properly. I will contact you tomorrow, but it seems you may be under the misapprehension that I am an attorney. Given what I can offer, in my opinion, this is the best use of my time in any hurricane related way right now.
Elliott:
I did not assume you were an attorney. I inferred from your communication skills that you had some post graduate education and, perhaps, were a professional, an administrator, or an executive who might have some contacts in your community.
My email address is enabled in these comments. If you don't mind, we can communicate further that way about this so we don't use Ann's bandwidth.
VNJV
There's really no such thing as my bandwidth. I don't pay for bandwidth or have any limitation on it, here on Blogger (Google). Comment away -- or email each other. Whatever you want.
Here in Germany (or, for that matter, anywhere in Europe) you would probably have to use a magnifying glass to find very many followers of president Bush and his like (or ilk). (If you want to get an idea, why I personally don't care for his ideological stance, take a look at my blog - the only one in English, the rest are in German - "THE B(RAT) IN THE BOX AT THE ULTIMATE LEVER?"
- http://beltwild.blogspot.com/2005_04_01_beltwild_archive.html.)
Nevertheless, the liberal use of words like "moron", "asshole", "freeze-dried brain" [I really like that one J] etc. is not an adequate substitute for a rational analysis of the chain of causation which has led to those consequences of the natural disaster, that could have been avoided if adequate measures with a reasonable cost-benefit ratio had been taken in advance.
While nobody in their right mind would blame the hurricane itself on president Bush of his party, politics does seem to have made a few mistakes inside and outside of the timeline that has been given in the opening lines of this blog discussion. Also, mistakes seem to have been made on all three relevant political levels: local, state and federal. Therefore, if I venture a prediction, the Democrats will not be extremely eager to dig deeply into the pre-history of the disastrous consequences of hurricane Katrina.
Long before Bush came into power, the levees could have been improved on in order to withstand a hurricane of category 5 instead just category 3. With 500.000 people involved, and a lot of valuable property, any rational cost-benefit-analysis would have called for such action long before.
However, while the Democratic Administrations have not been eager to do more about this than Republican Administrations, also the people and politicians of Louisiana and New Orleans do not seem to have pressured enough (and, when it comes to co-financed measures, spend enough) to change political priorities.
And if you do not spend enough money to raise and enforce the levees, and make sure that the pumps keep working independent of central power supply, why not at least construct the Superdome as a kind of "dual-use"-building with enough toilets, generators and drinking water supplies to serve as Noah's Arc when the deluge comes?
And if you have not even done that, you still would be able to stock more supplies, if you have a 72-hour-warning for a category 5 hurricane.
From what I have read about the catastrophe, the present budget cuts of the levee program have not been the cause of the collapse of some stretches of levees. So while George Bush may have to bear the possibly belated and inadequate reaction of FEMA, it would appear to me that he cannot fairly be blamed for causing the catastrophe any more than previous administrations.
However, much as the Democrats may not be to keen to have all the political shortcomings uncovered, they will of course be happy to lay the blame on president Bush. And, ironically, the Republicans (and in particular that upper crust of society, which finds its interests well served by the Republicans) might have the very same interest, namely to see the debate focus on persons rather than on long-term political concepts.
Even if the political upsurge of the "I-know-best-what-to-do-with-my-money"-ideology did not cause the disaster, everybody in the world (not just in the USA) might take it as a lesson that the balances between those private interests, that are immediately visible, and those interests, which are termed to be the interest of society as a whole, but which are, in effect, private interests on a different time scale and a different intellectually scale (which is not easily accessible for everyone) have to be determined rather differently from what the egoists and libertarians would like to see and to a certain extent have already achieved to have.
I really do hope that the Democrats in the USA and the "Democrats" all over the world will understand this and that they will not be content with having some more or less symbolic political figure removed (or simply bashed, and not even removed).
In this context, the most strange and worrying comment on Katrina that I have read was Mr. Gelman's Triage-article "Katrina’s Triage. It is a grim but inescapable fact that not everyone in New Orleans could be saved" (http://www.msnbc.msn.com/id/9178815/site/newsweek/). I do not know which political preferences Mr. Gelman has, but to me his words sound very much like he wants to take the heat off president Bush. This is not the worst though (because, even in my own opinion, Bush gets – on this occasion – more criticism than ne actually deserves). What really upsets me, are the words in his last pagraph:
"Finally, I believe we are compelled to acknowledge that no possible scenario of human existence will ever free us from more than occasionally having too much need and not enough help. Killer storms, wars, famines and other natural catastrophes will test us forever. That is the most sad fact of life here on planet earth. And in the face of temporarily scarce lifesaving resources, there will always be those whose idea of helping is to scream, accuse and point fingers at people they hated before the storm. Thank God, however, there will also be people like the smiling nurse on the hospital rooftop. I am glad I am not in New Orleans now, but if I were there, I would want to be standing right next to her."
Wars are not, and famines very often not "natural catastrophes", and whether we will be having "too much need and not enough help" depends, in many situations, on whether we have prepared for such catastrophes (or, thinking of clima change, tried to avoid them) or whether we have funneld the funds into private pockets. Even and particularly the religious fundamentalists should pay heed to the biblical simile of the foolish virgins. And those, who do not have the money to construct their own levees around their own property (as has been suggested, ironically, I assume, in some blog comment) have any reason to question the libertarian and related ideologies.
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