On-Site Medical Care During the September 11th WTC Terrorist Attack Rescue and Recovery Effort and the National Disaster Medical System (NDMS)
The terrorist attacks on September 11, 2001, were the largest experienced on United States soil in contemporary history. These assaults resulted in nearly 3,000 deaths and multiple injuries and led to the immediate activation of the nations disaster medical care network, the National Disaster Medical System (NDMS). Rhode Island Disaster Medical Assistance Team (RI-1 DMAT) was one of the five teams placed on alert moments after the attack on the twin towers in New York City.
THE NATIONAL DISASTER MEDICAL SYSTEM AND DMATs
Disaster Medical Assistance Teams (DMATs) were first formed in the 1980s by the US government to provide health and medical support to state and local governments. These highly trained teams have_performed austere medical care at sites of natural disasters within the Unites States and its territories. DMATs are also prepared to receive military casualties. As the workforce of the NDMS, DMATs were first constituted from physicians, nurses, emergency medical technicians and support personnel, trained and equipped to triage and provide emergency care and transport for injured military personnel, transported from field hospitals to casualty collection points in the United States, then on to available beds. Fortunately, this system was never tested during the Gulf war or any other foreign conflict. The mission of DMATs has evolved since the Gulf war. As a highly flexible resource, DMATs have been charged with novel missions in recent years, including: support for the National Transportation and Safety Board (NTSB) operations on major transportation accidents, such as the Egypt Air 880 crash off the Massachusetts coast; pre-deployment to mass gathering events deemed to have national security special event (NSSE) status such as the Olympic Gaines in Atlanta (1996) and Salt Lake City (2002); and political events including the Democratic and Republican National Conventions and the inauguration of President George W. Bush. Recent DMAT activations for disaster response include events resulting from terrorism, such as the 9-11-01 World Trade Center disaster and the anthrax attacks in Washington DC and New York City. The development and expansion of DMATs has continued over the past twenty years. Additional specialized teams have been developed to provide support for specific types of disaster, locales and non-disaster events. The National Medical Response Teams (NMRTs) are one example of newly formed teams within NDMS. NMRTs are multidisciplinary teams with special training and equipment, enabling them to respond to scenes where mass chemical decontamination and medical management may be necessary. The International Medical Surgical Team (IMSuRT) is another recent addition to the NDMS family. This team is comprised of personnel and equipment, allowing for rapid deployment to an overseas incident, which involves US citizens. At the request of the US Department of State, the (IMSuRT) can provide medical stabilization and urgent, on-site surgical intervention in remote austere environments. A complete field operating suite can be deployed. Other specialty teams (such as burn and pediatric teams) target specific populations who may require specialty care. NDMS has grown to become a network of over 8,000 volunteers with special intermittent federal employee status, serving on well-equipped, highly organized teams, which comprise the backbone of the nation’s medical response to disasters and other public health emergencies, natural or man-made. The organization of NDMS was moved to the Department of Homeland Security and the Federal Emergency Management Agency (FEMA).
Each team within NDMS is responsible for recruiting personnel who obtain a federal appointment through application; maintaining and organizing federally issued equipment and supplies; and providing both classroom and field training in disaster medicine. For more information about NDMS, please contact 401-444-3806, or consult the NDMS web site: http:// www.ndms. dhhs. gov.
The NDMS emergency operations center in Rockville, Maryland, was activated at 9:45 a.m., 77 minutes after the first plane crashed into the world trade center in NYC. Immediately, the DMATs from New York, New Jersey, Massachusetts and Rhode Island were placed on alert status and subsequently given orders to respond to New York at 10:00 p.m., September 11, 2001. The teams that responded were first sent to Stewart Air Force Base, to stage and receive instructions. Meanwhile, New York City Emergency Medical Services, Fire Department of New York City and New York City Hospitals undertook initial care of patients. Many hospitals in Manhattan sent personnel and equipment to the site of the World Trade Center towers. Also, many volunteer health care providers flocked to staff impromptu patient care areas. This initial response to the terrorist attacks was prompt; however, the equipment and health care providers were disorganized. The federal health care response, on the other hand, was highly organized but due to bureaucratic hurdles, delayed.
At the outset of the federal response, the mission set forth for the DMATs was to assist NYC in the care of victims rescued from the fallen towers. The specifics of the mission changed as hopes for rescuing large numbers of survivors dwindled. The majority of the approximately 1,600 survivors were treated by local EMS and area hospitals. Injured patients were treated at area hospitals starting as early as a few minutes after the attack. Arrival of patients to hospital emergency departments peaked 3 hours after the event. After 7 hours more than half of the injured had received care and after 12 hours more than 70% were treated. 1 There was no strain on New York City’s hospital-based health care system, with the possible exception of burn center personnel.
The federal medical resources brought into NYC provided on-site medical care for the large number of rescue workers who responded to search and rescue victims in the rubble. The number of personnel working under dangerous conditions reached tens of thousands. Those rescue and recovery personnel faced:
1. Unstable ground
2. Collapsing structures
3. Falling debris
4. A debris field full of sharp metal fragments
5. Particulate contamination of the atmosphere
6. Smoke and fire
7. Confined spaces
8. Fear of a concomitant biological or chemical attack
9. Psychological insult from the large-scale terrorist attacks
The federal medical assets included DMATs, an IMSuRT, Burn and Pediatric Specialty DMAT’s, Veterinary Medical Assistance team (VMAT, utilized to treat close to 1,000 ill or injured canine members of search and rescue teams), Disaster Mortuary Response Team (DMORT), CDC and Commissioned Core Readiness Force (CCRF, military counterpart to civilian DMAT). Most patient care was rendered by the DMATs. DMAT operations in NYC continued until late October. Many of the DMATs in the United States rotated through the medical care facilities established in NYC. Rhode Island DMAT was among the group of five DMATs which initially responded to the disaster scene in NYC. Rhode Island DMAT was involved in patient care of rescue workers and in the construction of the primary satellite patient care facilities in and around the disaster site.
The DMAT on-site base of operations was established at the New York Community College yard, with a main treatment facility and a communications and command tent. These structures were remote from the debris field, located within a secure perimeter and guarded around the clock. The teams also established four satellite treatment facilities surrounding the WTC complex. These were immediately adjacent to sites where rescue efforts were concentrated. These facilities were either located within undamaged structures, or in tents and had the capability of being moved rapidly if work sites shifted. The location of the DMAT facilities is shown in Figure 1. All facilities were equipped with emergency medical equipment and supplies. Staffing consisted of physicians, nurses, paramedics, emergency medical technicians and logistic personnel. Most patients presenting to the treatment facilities were treated on site and discharged. A small percentage of patients was stabilized in the treatment facilities, and then transferred to hospital emergency departments in New York City for further treatment.
During the rescue and recovery efforts in New York City, rescue workers required over 8,000 medical and almost 5,000 psychiatric treatments. The majority of medical treatments were for injuries occurring among rescuers within the debris field. The rate of injury was most acute during the first two weeks of the operation, corresponding to the “rescue” phase and dropped off significantly during the “recovery” phase2. Firefighters, law enforcement officers and construction workers were injured most frequently. There was, however also a significant rate of injury among medical personnel, mostly among search and rescue team members. Injuries encountered most were soft tissue, ocular, orthopedic and thermal. A large number of patients presented with medical emergencies including appendicitis, cardiac disease, heat related illness and respiratory ailments. Psychiatric complaints included sleep and eating disturbances, uncontrollable fear, depression, mania and in a few cases acute psychosis with hallucinations and paranoia. Treatment at the on-site facilities included suturing, closed reduction and splinting of fractures and dislocations, corneal foreign body removal, re-hydration, treatment for bronchospastic disease and initial diagnosis and stabilization of medical and surgical emergencies.
The injuries encountered were in direct relationship to the hazards at the site of the disaster. Ocular injuries were in most cases secondary to the high concentration of particulate matter in the air surrounding the disaster site in the weeks after the terrorist attack. Dense and constant smoke from fallen and burning structures resulted in respiratory ailments, such as acute bronchospasm, upper respiratory infections and sinusitis.
The New York City Department of Health promptly responded to the smoke hazard by instituting a mask-fitting program. Adequate supplies of facemasks were distributed, but compliance with this program was poor. Communication with full-face masks obstructing the mouth was a factor limiting their usefulness. The large amount of bent and broken metal and glass debris piled up at the site resulted in lacerations to the arms of rescue workers, particularly on warm days when turnout gear was not worn. The rough terrain and obstacles also resulted in multiple falls, with some serious head and neck injuries.
Falling debris contributed to injury. Many buildings surrounding the World Trade Center Complex had shattered windows, which continued to fall days after the attack. These buildings were subsequently covered with netting to prevent further injury. Unstable buildings were a risk to workers. All DMAT personnel were briefed each day on evacuation procedures and signals. Relay points were established and evacuation routes were marked with fluorescent paint. Indeed, a building did collapse during the rescue operation; however, no injuries occurred due to these safety measures.
The rescue and recovery operation in New York City was one of the largest and longest in history. The complexity involving coordination of resources from law enforcement to medical care was immense. New York City’s preparedness, in the years preceding September 11, 2001, with interdisciplinary training, regular disaster exercises, well funded emergency management structure and committed leadership, resulted in swift and organized response. RI DMAT was integral to this effort. Similar operations after terrorist events in smaller cities, with more limited resources, may have differing response characteristics. It is encouraging, though, that the City of Providence and the State of Rhode Island, despite their small size, have made disaster preparedness a priority, dedicated considerable resources to preparedness and have become one of the leaders in the United States.
1. Anonymous. Rapid Assessment of Injuries Among Survivors of the Terrorist Attack on the World Trade Center-New York City, September 2001. MMWR 2002; 51:1-5.
2. Suner S, Coittone GR, Jay GD, et al. Injuries Among Workers during the 2001 World Trade Center Rescue and Recovery. Acad Emerg Med 2002: 9:502-3.
Selim Suner MD, MS, FACEP
Selim Suner, MD, MS, FACEP, is Assistant Professor of Surgery in Emergency Medicine, Brown Medical School.
Selim Suner MD, MS, FACEP
Rhode Island Hospital
593 Eddy Street
Providence, RI 2903
Phone: (401) 444-6237
Fax: (401) 444-6662
Copyright Rhode Island Medical Society Nov 2003
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