Two lobbying groups, chosen by Louisiana to collect emergency requests from hospitals and nursing homes during Hurricane Katrina, found themselves instead scrambling to arrange private rescues when government teams became preoccupied with plucking citizens off rooftops. The inability to quickly direct National Guard and other government rescue teams to health care facilities had deadly consequences.
Dozens of fragile patients died in sweltering heat and other taxing conditions that lasted for days.
A Catholic nun reported trying for four days to get rescuers to her nursing home, only to watch them pass by in the street. Another home administrator, trapped amid looting and chaos, carried a gun for the first time in his life just to protect patients.
It wasn't supposed to happen that way.
"We are an advocacy organization on behalf of hospitals. Overnight we turned into a hospital emergency center," Louisiana Hospital Association president John Matessino said, summing up how his group rose to rescue coordination amid the chaos.
Some are now asking why lobbyists, instead of emergency experts, were left to devise life-and-death solutions by patching together church and tour buses, private ambulances and religious volunteers.
The state gave both the Louisiana Nursing Home Association and the Louisiana Hospital Association permanent seats at the state emergency operations center in Baton Rouge and trained them to track health facility needs and relay information to authorities who would dispatch the help.
But that plan disintegrated under the magnitude of Katrina's destruction, leaving the lobbying groups to scramble to find private alternatives when government rescuers couldn't get to facilities.
The nursing home lobby's chief, Joe Donchess, called his experience inside the state disaster center "somewhat nightmarish." The effort to locate and dispatch private rescue resources to desperate facilities often resulted in delays of hours or days after the hurricane struck on a Monday, he said.
"Those patients that should have gotten out by Wednesday morning didn't get out till Friday afternoon," Donchess said, recalling the days-long effort to get rescuers to New Orleans' Bethany Home, where the state attorney general says eight bodies were found.
Both lobbies quickly learned that they - as well as their state government handler - lacked the clout to make nursing homes and hospitals a higher priority for National Guard and government rescue teams. Even when teams were dispatched to hospitals or nursing homes, they often diverted to rooftop rescues.
"The priority mission was picking people off of rooftops and out of water," said state Health Officer Jimmy Guidry, the main contact for the hospital and nursing home lobbies in the Louisiana disaster center.
Guidry said he argued for nursing home and hospital requests but "it seemed like forever to get all the transportation that was being asked for."
Louisiana emergency operations spokesman Mark Smith said the choice boiled down to "if the water is about to come over the roof of someone's house do they have a need greater than the elderly person lying in their bed in the nursing home? ... They're not about to die because they're about to get swept away by a flood."
The wait was too long for some elderly people. More than 215 bodies were recovered from hospitals and nursing homes in Katrina's aftermath, according to the Louisiana Department of Health and Hospitals.
Some died during or before the storm, or drowned in the rushing floodwaters that ensued. Others died in transit, or just waiting.
Those who survived had their own scars, in some cases due simply to the stress of having to move either before or after the storm. Many elderly have ended up in psychiatric facilities to deal with trauma, said Dr. David Henry, a Shreveport geriatrician who examined dozens of elderly bus evacuees.
Louisiana Attorney General Charles Foti is formally investigating deaths at three nursing homes and Memorial Medical Center, and is examining circumstances at 15 other facilities.
Foti has filed 34 counts of negligent homicide against the owners of St. Rita's nursing home. The owners dispute the charges, saying they feverishly boated and swam patients to safety after floodwaters rose 10 feet in 20 minutes.
At the region's 13 major hospitals and several smaller facilities, rescuers ultimately evacuated 2,170 patients and more than 9,000 staff and family members by the end of the first week after Katrina.
The focus of Foti's investigation has been on the facilities' own actions and whether they adequately prepared for evacuation. Little attention has been given to the state's preparations and the extraordinary role bestowed upon two trade groups.
"The issue is, how does a state assume responsibility for the rescue of its most vulnerable citizens," said Larry Minnix, president of the American Association of Homes and Services for the Aging. "That's a responsibility of government in a crisis. Associations should play their part, but to rely on association to do that is putting them in an absolutely precarious position."
The hospital association's Matessino said his Baton Rouge office was stacked with boxes of supplies, and his walls plastered with lists and flow charts as he pressed companies for diesel, oxygen and medical supplies. His team hunted down trucks to ferry supplies to New Orleans.
Both health associations placed frantic calls to state Sen. Sherri Cheek in northern Louisiana to seek out church buses.
A call crackled through Pastor Leland Crawford's cell phone when he was already barreling south from Waskom, Texas. The Nursing Home Association needed him at a hurricane-wrecked home in Bogalusa.
The pastor and three friends maneuvered through a maze of downed trees, arriving to find two tour buses also had made it, along with some National Guard troops. They spent the night painstakingly lifting frail patients into the buses, hoping ambulances soon would come for a dozen who were in worse shape.
At Lafon Nursing Home, the nights were dark and phones were out on the second floor, where staff had gathered more than 100 residents after three-foot floodwaters submerged the ground floor.
For four days, Sister Augustine McDaniel, the administrator, searched the now-dry roadway for rescue, her attorney Evans Schmidt said.
"Please get somebody to help," she told police and firefighters she encountered. "Don't forget we're at 6900 Chef Menteur." Communications were spotty, they told her. They'd do what they could.
Nobody came until Thursday when a staff member's relative found a bus. He loaded three dozen patients aboard and promised to return for more. But the bus driver became spooked by random gunfire and didn't return, Schmidt said.
When choppers finally clattered down on Friday, the home contained 17 dead by Sister Augustine's count. The state reported 22 bodies.
In the historic French Quarter, 65 elderly patients and 20 staff members wilted inside the two-story Maison Hospitaliere home. One patient had died just before the hurricane. Attendants found two more lifeless in their rooms. They wrapped the bodies in plastic.
Looters ravaged the nearby Wal-Mart. One night Maison's administrator, Andrew Sandler, gingerly held a loaded pistol for the first time, thinking someone was in the courtyard.
"You could see fires. You could smell smoke," he said. "I was abandoned. I was terrified."
Sandler reached Donchess, who arranged for church buses both Wednesday and Thursday. They never made it, nor did private buses that Sandler himself contracted. Finally, five buses and an escort of state troopers arrived Friday.
"Joe was wonderful. He said, 'Stick with me.' He's the one who got us out," Sandler recalled.
Despite the praise, Donchess won't forget the lesson of Katrina.
"Somebody better make damn sure that hospitals and nursing homes are made a higher priority next time around," he said.