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Terrorismʼs Trajectory through NY EDs Leaves Helplessness, Frustration, and Sorrow

2001; Lippincott Williams & Wilkins; Volume: 23; Issue: 11 Linguagem: Inglês

10.1097/01.eem.0000288678.39360.d8

1552-3624

Ruth SoRelle,

Disaster Response and Management

The morning of Tuesday, Sept. 11, dawned crisp, cool, and quiet without a cloud in the New York sky. At New York University Downtown Medical Center, Antonio Dajer, MD, the assistant medical director of the emergency department, was on duty. He foresaw a quiet morning with only 12 patients left over from the night before. His hospital was five blocks from the Twin Towers of the gigantic World Trade Center.Figure: Rescue workers and firefighters sift through the rubble one week after the Twin Towers of the World Trade Center collapsed.Richard Westfal, MD, the associate director of the emergency medicine department at St. Vincent's Catholic Medical Center Manhattan, arrived at work at 7 a.m. He was less than two miles from the World Trade Center. Alan Simon was preparing his paramedics, emergency medical technicians, and ambulances at the Maimonides Medical Center ambulance division. Nancy Kwon, MD, was walking into Bellevue Hospital prepared to teach students. She was not even on duty. Susi Vasallo, MD, an emergency physician at Bellevue Hospital, was on Long Island, not scheduled to work. Joseph Ornato, MD, was chairing a meeting of investigators involved in the National Public Access to Defibrillation project at a Marriott Hotel just across the Brooklyn Bridge from Manhattan. In the background, the tall bland spires of the World Trade Center provided a common landmark. It all changed at 8:45 a.m. when a passenger jet, American Airlines Flight 11 out of Boston, hijacked and dramatically off course, plunged into the north tower of the World Trade Center, creating a cavernous hole in the building and igniting an inferno. Less than 20 minutes later, a second jet, United Airlines Flight 175 also from Boston, followed suit, crashing into the south tower of the World Trade Center, exploding on impact. People, unharmed and injured but all terrified, streamed from the buildings. The World Changed With that booming explosion, the world changed for those experienced emergency physicians and paramedics and thousands more on and near the island of Manhattan. In the wild hours that followed, one came near death while others found themselves processing patients as quickly as possible. Still others found themselves near despair as they realized that there would be no more patients coming. “You can't see the towers from our emergency department. But I heard a plane flying low and then a crash,” said Dr. Dajer. The chief of his hospital called a “code yellow,” and everyone mobilized. Dr. Dajer busied himself organizing his people and the trauma instruments and supplies. He had medical students line up bags of intravenous fluid. “It was rapid organization and deployment,” he said. “We knew we would be getting patients in five minutes.” At St. Vincent's, Dr. Westfal was notified within minutes of the first crash that “something” had happened at the World Trade Center. It was almost like the other shoe dropping because he had been at the hospital in 1993 and dealt with the fallout from the World Trade Center bombing. At first he assumed that the crash was an accident, but when the second plane crashed, “I knew it was terrorism,” he said. He drew on his 1993 experience and immediately began to designate other areas in the hospital for treating patients. They set up 20 beds in the rehabilitation wing's gymnasium, 12 beds in the recovery room of the operating suite where all elective surgery had been canceled, eight beds in the endoscopy suite, eight in the dialysis area, and 25 beds with oxygen in the hospital's psychiatric wing. They were all staffed with physicians and nurses called in from the hospital pool. “We have done these drills before,” he said. “We got burnt in 1993. This time we had these areas set up right away.” Congregating in the ED At Bellevue Hospital, emergency medicine residency director Jeffrey Manko, MD, was there when the disaster was called. “The news spread like wildfire,” he said. “Every single doctor, nurse tech, aide, or anyone who thought he or she could help in way, shape, or form congregated in the emergency department. They were looking for direction. They all wanted to do something. We set it up so that we could have handled thousands of patients,” he said. Dr. Kwon, for example, walked in at 9 a.m. to teach her students and ended up joining in the response.Figure: Three firefighters, covered in soot and dust, take a break from working amid the rubble where the Twin Towers once stood.Mr. Simon got the word early, and was with his ambulance crews at the foot of the North Tower at the triage area across from the World Trade Center at the corner of West and Liberty streets. “I got out of the ambulance, and saw the fire on the 80th story. I saw people falling out of the building, and the police were yelling at us to go and help them. There is no way to help someone who has fallen 80 stories. “Some of my crews went inside the building. Then the building began to come down,” he said. It was 10:05 a.m., and the South Tower plummeted straight down to the streets below, exhaling a massive plume of dust and debris that covered the people in the streets below. At 10: 28 a.m., the North Tower also collapsed, releasing an even larger cloud of debris and smoke. Already, a third jet, American Airlines Flight 77, had crashed into the Pentagon at 9:43 a.m., three minutes after the Federal Aeronautics Administration halted flight operations across the nation. At 10:10 a.m., another hijacked plane — United Airlines Flight 93 — crashed in Shanksville, PA, a rural area southeast of Pittsburgh, another flying bomb whose mission was averted by passengers. “We had just checked in and someone said, “Run! The building is coming down,” said Mr. Simon. His ambulance was buried and crushed by the rubble. He managed to dig himself out of the debris after he regained consciousness. “All I could think about was my partner. My back and neck were killing me. I couldn't see anything [through the dirt and debris.]” Finally he made his way to a nearby building, stumbled through it and saw some EMS people, who promptly put him in a collar and on a backboard. Ambulance on Fire One factor ambulance personnel had not considered was that the soot and debris would clog the air filters of vehicles. After bouncing about a block across the rubble, the ambulance overheated and caught on fire. The paramedics started wheeling him toward the piers where they were planning to evacuate people on boats. All Mr. Simon could see was the sky overhead. When they got to the pier, another ambulance finally arrived. He was crowded in with another EMS chief with respiratory problems, a guy with a broken leg, another with eye problems, and another with a fractured arm. All five patients and an EMT crowded into the back of the ambulance and then considered where to go. “The EMT said there were taking us to Beekman [the former name of NYU Downtown Medical Center]. We said, ‘No way. Get us out of Manhattan.’” Finally they ended up at Lutheran Hospital, even though the ambulance also overheated in the traffic. Back at NYU Downtown, Dr. Dajer and his troops were finding that the EMTs' first thoughts were that of the many patients. They began to get patients within five minutes of the plane's impact. “Some patients were a block or two away, but had been hit by falling debris,” he said. “The ambulances scooped them up and then came to us.” In the initial rush that lasted about three hours, NYU saw 150 badly wounded patients, he said. In total, they treated 445 patients in that first 24 hours — 119 of them police officers and firefighters. “We saw everything from people with third-degree burns to head trauma to crush injuries of the chest. Every conceivable trauma. Lots of fragments from the plane showered down on the people below causing horrible injuries. The aviation fuel fell on them as well. The burns were severe,” Dr. Dajer said. By 9 a.m., the emergency department was full of doctors. The physicians from the medical side whisked people upstairs. All the surgeons came running,” he said. Doctors from NYU Hospital uptown came as well as others from Bellevue. There were enough doctors, but someone had to organize them so that each patient got the physician he needed. During a July 31 drill, Dr. Dajer had made up his own technique for dealing with this kind of disaster. “I decided to make sure that each patient had a doctor responsible for him or her.” Even though the normal disaster procedure involves yellow, green, and red coding of patients, he felt it worked better to make each patient the responsibility of a single physician. Dr. Dajer was receiving patients and helping to stabilize them as they came in. His attending emergency physicians oversaw the various rooms at the treatment areas budded off “almost like an amoeba” into new rooms in the hospital. Some were in the cafeteria. “I was surprised how quickly it got organized. One person was in charge to know what was needed. We all knew whom to go to. “One of our goals was to evacuate patients as soon as possible,” he said. Disabled patents with fractures went to the Hospital for Joint Diseases, he said. Those with head trauma went to Bellevue, and the burns went to the burn unit at Cornell University Medical Center. There was no paperwork. They put the patients in ambulances, and they went. A Lion's Share St. Vincent's Manhattan also got a lion's share of the early patients. When the telephones got tied up, they used portable radios. A portable x-ray unit in the rehabilitation gymnasium made diagnosing the patients' problems easier. Dr. Dajer worked with a nurse to triage the patients during that first day — at least 350 of them. “We kept the sickest,” he said. Those they could send to other hospitals safely, they did. There were four deaths. Two patients with trauma came in with cardiopulmonary resuscitation ongoing. They eventually died. One burn patient died, and a firefighter with chest pain and severe abdominal injuries died in the operating room. The earlier bombing had taught the staff to take disaster drills seriously, and they were ready when the call came, said Dr. Westfal. “We knew to set up the secondary treatment areas right away.” At Bellevue, planning paid off, said Steven Menlove, MD, the hospital emergency department's disaster coordinator. He set up a command post. The emergency department was cleared out, and there were lots of doctors waiting. “The first patient arrived in a cab on his own with a knee injury. He just jumped in a cab and sped here. The ambulance arrivals began half an hour after that.” “I'm guessing that in the first 24 hours, we saw roughly 100 to 150 patients, and only about 10 people went for surgery,” he said. “Maybe 15 or 20 of those were serious traumas.” All of those serious traumas came in during the first few hours. After that, most of the patients had minor injuries or eye or respiratory problems from all the dust in the air, he said. A handful of people was admitted with chest pain. Laboratory staff brought a blood gas machine down to the ED, and there were portable x-ray machines sent by radiology. The people of New York waited in lines blocks long to donate blood. “Eventually, we ran out of bags to collect it,” said Dr. Manko. Dr. Vasallo said the news of the disaster put her into her car and on the road to Bellevue from Long Island as soon as she heard. Later, she went down to the site, as did a number of residents. The first person they treated was a firefighter who was pulled out with multiple injuries and fractures. She is not sure, however, that having an advanced life support station at the scene was what was needed. What she saw was a lack of coordination and communication. That was to be expected, said Mr. Simon of Maimonides' ambulance division. When he arrived at the World Trade Center, he found the EMS command center set up in the middle. No one expected the buildings to collapse. “It should have been five to six blocks away,” he said. Communication among EMS One reason there is confusion about how many people perished is that no one was registering the volunteers going in, Mr. Simon said. “The buildings were meant to withstand a 707 going into them. I don't know about a 767. Thank God they imploded instead of toppling,” he said. He said he is not sure how many in the emergency medical services community died in the buildings. He knows one part-time paramedic from his unit was lost when he went in as a firefighter. Doug Yoshida, MD, a Bellevue emergency physician, said there is little communication among EMS units in New York. That was magnified during the disaster, he said. “There was no way to communicate with the other hospitals because the telephone system was down and cell phones usually didn't work. It would have been difficult if there had been a lot of victims and the hospitals started to get saturated.” Dr. Ornato was chairing his public access defibrillation meeting when a loud speaker in his hotel suddenly told him and his group to evacuate the building because a plane had hit the World Trade Center. As they were moving toward the door, the loudspeaker came on again, “You have to evacuate right now because the World Trade Center has been attacked.” Outside, they could see a large, dark plume of smoke rising out of Manhattan. He checked his PDA and learned that two commercial aircraft had collided with the Twin Towers and that it was probably a terrorist attack. As he and a friend walked down the street, they were suddenly confronted by a distraught woman emerging from the subway. She had been in the first tower when it was hit and had managed to dive into the subway tunnel, taking the first train that came along. “Then we saw the first building collapse,” Dr. Ornato said. With a large plume of smoke and debris headed their way, he and his colleague ducked back into the hotel for cover. “We went inside and got the group of emergency physicians, nurses, and medics together. I asked for a moment of silent prayer, and then we rolled up our sleeves,” he said. Because they doubted they would be allowed to help at the hospitals, they decided to set up a first aid and triage area in the hotel lobby to deal with the possibly injured patients evacuating across the Brooklyn Bridge. One group went to the foot of the bridge to direct people to the hotel. They were in the lobby of the hotel when they felt the second building collapse. One of their units flagged down a fire unit and was told that doctors, nurses, and medics were needed to help with the disaster. They were told to commandeer a city bus, and help set up a triage unit at the foot of the World Trade Center. They all donned New York City Fire Department shirts they had been given earlier and grabbed the portable communication equipment and medical supplies they needed. They were at the foot of what had been the Twin Towers less than an hour after they collapsed. “It looked like Mars,” said Dr. Ornato. “Everything was gray, black, and white. There was a foot and a half of debris. I have never seen so much paper and so many shoes in my life.” As they set up their triage area, they found 40 large tables in a nearby building. “We set up the equivalent of a 40-bed field hospital,” Dr. Ornato said. “Each bed had one or two nurses or medics assigned to it. But we only treated 19 patients over the next 12 hours. That was the saddest part.” Searching for Survivors The first wave of patients who came out before the buildings went down went to the nearby hospitals. But after the building collapsed, the only patients were those searching for survivors. Tony McKay, an EMS supervisor at Staten Island University Hospital assembled off-duty personnel to set up a field hospital to receive patients evacuated to the island. “We saw only 80 patients,” he said. “We probably outnumbered the patients three to one. That was the disappointing part of it, that there weren't that many survivors.”Figure: Firefighters work to clear rubble in downtown Manhattan following the Sept. 11 attack.More patients were ferried to Liberty Park, a result of a lack of communications, he said. “That is the kind of thing that people will critique,” he said. Dr. Dajer at NYU Downtown said “it was amazing to see a hospital so ready for action. Everyone was organized and revved up. But more patients, unfortunately, didn't come. After the towers collapsed, we saw no more survivors. There was an eerie feeling that we were smothered in a cloud of dust and a blizzard of soot.” In the ensuing days, his hospital was without telephones and on emergency power. Supplies had to be brought in on foot. “The unfortunate thing was that we had so many people to help and so few patients in proportion to the help we had,” said Dr. Manko. “You had to be moved by the spirit and camaraderie that was palpable in the institution and the city.” Later he went down to the site of tragedy. “I have no illusion that anyone in the medical profession was a hero in all of this,” he said. “The heroes were the firefighters, paramedics, and police. To watch them in action had to make one stand in awe of what they were doing. As a native New Yorker, it was surprising. The definition of success in all of that was to be anyone who could do anything to help someone else. It was not measured in money or titles, just in the kindness to others. “I am proud of the residents and faculty and other departments in the hospital for banding together. We would have been able to accomplish so much more.” Desperate to Help At St. Vincent's, people also were desperate to help, said Dr. Westfal. Treating the patients who came in waves of 20 or 30 every 10 minutes was the “good time,” he said, because they were using all their skills and abilities to the utmost. “About 11:45 p.m., it stopped,” he said. “We have not had another victim since then. We have treated many of the rescuers who were injured. But it was very upsetting when it stopped. I had another shift of people coming in. We wanted to treat more of the survivors. We wanted them to dig them out and bring them to us. But they never came. “It particularly affected the paramedics on the scene,” Dr. Westfal said. “They were in the hot zone — paramedics from all over the city. All the paramedics in New York City brought 3,000 patients in from the hot zone,” he said. The city lost at least nine EMTs and paramedics, he said. The numbers, however, are incomplete. During the disaster, Dr. Westfal said he counted more than 500 physicians from the tri-state area who came in to help. More than 450 nurses showed up, and the community volunteers outnumbered them. “In those night hours when we didn't have patients, we would have waves of five or six firefighters covered in soot and debris come to the emergency department, and say, ‘We have to go in there’. Our partners are in there,” said Dr. Westfal. He would let them in and walk them through. Their friends were not there, but they had to check for themselves. It was desperation born of tragedy. At the same time, the clerks and registrars were overwhelmed with telephone calls. People wanted them to check to see if their husband, wife, brother, or son was at the hospital. Even after patients stopped coming, the phone calls continued. “I missed that,” he said. “I apologized to them later. “I am used to dealing with tragedy, and I have almost never felt that an incident has gotten the best of me,” Dr. Ornato said. “I must say this has gotten the best of me. The magnitude of frustration was and is so high. Lots of people are calling us heroes. We weren't. As we were going back to the Marriott on the bus, we were all angry and deflated. We came across a fire crew that had been working at the World Trade Center all day. Their truck had been decimated. They were walking across the Brooklyn Bridge with all their gear on their backs. “We got the bus driver to stop for them. These guys came on. They were beat, exhausted and emotionally spent. We all moved back and they sat in the first few seats with their gear. We gave them a round of applause. One of the lieutenants looked up, and said, ‘We don't deserve that. We didn't save anyone.’ That summarized the way we all felt. We would have saved anyone they could bring to us. They just weren't there. “I never thought I'd live to see thousands of people die right before my very eyes.”