This is a very powerful book about a medical and social disaster in New Orleans following the flooding and then social misery that Hurricane Katrina and the monstrously myopic failures of regional, state and federal safeguards of flood control, planning and budgeting combined to impose on the populace of New Orleans in the Summer of 2005. The author has spared no effort to write an unusually meticulously researched book, including details that often shock one's imagination, from the "pink and baby blue footprints" (page 94) on one nurse's scrubs to the fact that the rain on the day of a rally of support for Dr. Anna Maria Pou, the ENT surgeon at the epicenter of the firestorm over the alleged euthanasia, was almost 81 years to the day of a canceled May Day event on the same spot. (page 436)  It is this attention to accuracy that renders this book so believable as almost real-time journalism, despite the occasional and mystifying fault in identifying strangers and relatives and spouses in the text.

The author is also remarkably fair to all the players on both sides of the ethical and legal battles over alleged homicide.  ("Alleged" since it was never legally proved and, as Fink states on page 448, "It was unclear whether Pou would ever tell the world exactly what she had done and why." On page 469: "She has never publicly discussed it.") We learn important personal facts,and attitudes of the doctors and nurses, the patients and their families, and the prosecutors, coroners, defense attorneys, and everyone at ground zero of this tragedy and its even more wrenching aftermath, an aftermath that left many of the players in different jobs, in different professions, and in far-removed states. Personal and professional friendships and relationships often suffered. The degree of co-operation afforded Dr. Fink in her interviews speaks to her talent, her persistence, and her ability to persuade most participants to speak their minds.

Too, Dr. Fink's running start from 1926, at the beginning of the book, gives important historical and cultural background of the medical and political and meteorological history of New Orleans leading up to Katrina. As such, it was well done and immensely useful in understanding why, at least at the local level, Katrina had the effects it did on New Orleans. Following the section on the legal battles surrounding the alleged euthanasia, Dr. Fink ends the book with an excellent review of current efforts and plans, primarily in the Western world, aimed at avoiding future medical shortfalls in the face of disaster. (As Dr. Fink writes, "Emergencies are crucibles that contain and reveal the daily, slower-burning problems of medicine and beyond - our vulnerabilities; our trouble grappling with uncertainty, how we die, how we prioritize and divide what is most precious and vital and limited; even our biases and blindnesses." page 464) At the heart of these discussions and plans are the varied approaches to triage, from the suggested immunity proposed by Pou and her supporters to the "business-as-usual" application of everyday bio-ethics to emergencies. 

Dr. Fink's review elucidates, all too painfully, the barriers to a fair legal judgment in this case by the avalanche of pressures falling upon the heads of litigators, coroners and grand jury members from the ill-informed citizens of New Orleans, skilled publicists masquerading as attorneys, and, sad to say, the medical establishment itself, including the AMA at its annual meeting in 2007. As Fink correctly sums it up, "Without a jury or a judge having yet ruled on Pou's case, without Pou having shared publicly what she had done, organized medicine's main response to the alleged murders at Memorial was to close ranks and defend itself." (page 428) 

Dr. Fink also includes an informed and current analysis of ethical, legal, administrative and political aspects of what is often called Mass Casualty Incidents, whether their etiologies be meteorologic, terrorist or infectious, like the imagined influenza pandemic discussed on pages 466ff. Lastly, Dr. Fink instructively relates the events at Memorial to more recent object lessons in catastrophic medical scenarios, e.g., the earthquake in Haiti in 2010 and Superstorm Sandy in October 2012 (both of which she attended), the latter of which lead to the successful evacuation of Bellevue Hospital, the clinical home of this database.

Save for some unexplained factual omissions and instances when the author seems to inject enough commentary to question objectivity, there is little to fault with this book or that which will detract from its usefulness to those interested in the medical humanities, especially medical ethics and the history of medicine. I think more art, especially photographs of some of the persons and places in this book, would have added as much to the book as they did to the New York Times article. This book should be mandatory reading for anyone at any level -- from local to state to federal -- involved in mass casualties and the medical response thereto. It will undoubtedly find itself, and rightly so, on the syllabi of many an MPH course. There are some interesting citations (new to this editor), from the Old Testament and the Napoleonic wars, that might prove of interest to students of literature and medicine, especially those references relating to the request of another to effect a merciful death (see "David" in this database).

The quintessential importance of this book, however, is its reconstruction of the confluence of the natural and manmade aspects of this tragedy, particular by particular. Five Days at Memorial provides what even the most learned of essays on this subject by the most learned of ethicists or legal scholars can not - the dissection and then regeneration of this catastrophe, at least on a local level, from the component particulars, including the political and cultural and social forces preventing adequate safeguards against such flooding to the differences between the re-actions of the staff at Memorial and that of Charity Hospital which suffered the same loss of power and plumbing but with the loss of only 3 patients (compared to the 45 of the former), and with evacuation of the sickest first, the opposite strategy at Memorial.

Arthur Caplan, the media's "go-to" medical ethicist for the past 20 years (and with good reason), has called the medical events at Memorial and their ethical analysis "an unsettled moral toothache" (page 454). It is a "moral toothache" precisely because there are no details, no closure as to motive, and no explicit narration of the events by the participants. 

For this reader, the portrait of Dr. Anna Maria Pou, seems to offer an hypothetical motivation for the potent (since carefully timed to be combined and therefore synergistically lethal) injections of midazolam and morphine, a psychological driver implicitly suggested by her very religious nature. When one reads the following:

"I did not know if I was doing the right thing. But I did not have time. I had to make snap decisions, under the most appalling circumstances, and I did what I thought was right. I injected morphine into those patients who were dying and in agony. If the first dose was not enough, I gave a double dose. And at night I prayed to God to have mercy on my soul." (pages 459-460)

one receives the distinct impression that Dr. Pou’s actions were motivated by her deep faith and a physician’s urge to relieve suffering, albeit perhaps more strongly paternalistic than medically indicated.

Even if Dr. Pou acted in accordance with her religious convictions, the question will always tantalizingly remain - until such time as one of the principals speaks up -- "But ... why then? Why at the last minute when the cavalry had arrived?"