Lessons Learned from the Lessons Learned from the World Trade Center World Trade Center Disaster Disaster Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine Uniformed Services University Clinical Professor of Emergency Medicine George Washington University Bethesda, Maryland, USA

Memorial plaque for the WTC victims presented by Iran University at the First Middle Eastern Conference on Emergency Medicine, October 2, 2001

Lecture Objectives Review the EMS and EM response to the Sept. 11, 2001 World Trade Center (WTC) disaster Review the EMS and EM response to the Sept. 11, 2001 World Trade Center (WTC) disaster Identify what went wrong and what went right with the responses Identify what went wrong and what went right with the responses Utilize the lessons learned in planning for mitigation of future events (which hopefully will not come to pass) Utilize the lessons learned in planning for mitigation of future events (which hopefully will not come to pass)

General Lessons Learned from This Disaster The U.S. public is not safe from major outside terrorist organizations The U.S. public is not safe from major outside terrorist organizations There is broad international sympathy and support for the victims of this type of disaster There is broad international sympathy and support for the victims of this type of disaster Domestic volunteer help and cooperation can be huge in response Domestic volunteer help and cooperation can be huge in response

WTC soon after construction

Sequence of Events in the WTC Disaster 8:42 a.m. : AA Flight 11 hits North Tower 8:42 a.m. : AA Flight 11 hits North Tower 9:00 a.m. : UA Flight 175 hits South Tower 9:00 a.m. : UA Flight 175 hits South Tower 10:05 a.m. : South Tower collapses 10:05 a.m. : South Tower collapses 10:28 a.m. : North Tower collapses 10:28 a.m. : North Tower collapses 5:25 p.m. : WTC Building # 7 (47 stories) collapses 5:25 p.m. : WTC Building # 7 (47 stories) collapses 11:45 p.m. : Last injured non-rescuer victim presents at St. Vincent's Hospital 11:45 p.m. : Last injured non-rescuer victim presents at St. Vincent's Hospital Noon the next day : last civilian freed from rubble and transferred to Bellevue Hospital Noon the next day : last civilian freed from rubble and transferred to Bellevue Hospital

South Tower strike

North Tower burning

Collapse of South Tower

South Tower collapse

Just after the South Tower collapse

North Tower burning after South Tower collapse

Ground Zero after collapse of both towers

Aerial view of lower Manhattan

Lesson 1 : Emergency Personnel are Brave but Therefore are at Risk for Death or Injury The WTC collapse was really unprecedented & unpredictable (remember WTC was supposed to "withstand a hit from a Boeing 707") The WTC collapse was really unprecedented & unpredictable (remember WTC was supposed to "withstand a hit from a Boeing 707") Therefore the hundreds of firefighters & police who entered the towers to attempt rescue or firefighting cannot be faulted for their entry Therefore the hundreds of firefighters & police who entered the towers to attempt rescue or firefighting cannot be faulted for their entry Lesson learned : Stage vehicles & secondary rescue teams several hundred meters back from a bombed building Lesson learned : Stage vehicles & secondary rescue teams several hundred meters back from a bombed building

Lesson 2 : Need for Backup Communications and Command Center New York City's (NYC) main EMS Communications Command Center was in the WTC & was destroyed by the collapse New York City's (NYC) main EMS Communications Command Center was in the WTC & was destroyed by the collapse There was not a fully operational backup center There was not a fully operational backup center Lesson learned : Have at least two geographically separate fully capable backup communication command centers Lesson learned : Have at least two geographically separate fully capable backup communication command centers

Lesson 3 : Need for Better Individual Unit Communication Links Prior to the disaster, Fire & EMS did not have direct field radio links to each other or to local hospital E.D.'s Prior to the disaster, Fire & EMS did not have direct field radio links to each other or to local hospital E.D.'s The available radios did not work consistently well within the WTC towers The available radios did not work consistently well within the WTC towers Lesson learned : Multichannel local unit radio system should link Fire, EMS, and local hospital E.D.'s Lesson learned : Multichannel local unit radio system should link Fire, EMS, and local hospital E.D.'s  Special intercom systems or lower frequency radios may be needed for use inside very large buildings, and should be tested ahead of time

Lesson 4 : Telephone Systems Fail Early in a Disaster This lesson has been learned in most prior disasters also This lesson has been learned in most prior disasters also Both landline & cell phone systems stop functioning early (due to call overload and/or transmission tower & line disruption) Both landline & cell phone systems stop functioning early (due to call overload and/or transmission tower & line disruption) Lesson (re)learned : Don't rely on local phone system ; Backup radio communications systems needed ; Public needs to be reminded to cease phone use early. Lesson (re)learned : Don't rely on local phone system ; Backup radio communications systems needed ; Public needs to be reminded to cease phone use early.

Lesson 5 : Computer Communications May Still Function Despite Phone System Malfunction communications were able to be maintained to NYC E.D.'s throughout the disaster even when the phone lines did not function (probably due to automatic delayed electronic routing of messages) communications were able to be maintained to NYC E.D.'s throughout the disaster even when the phone lines did not function (probably due to automatic delayed electronic routing of messages) Lesson learned : Prearranged links should be set up between Fire & EMS command centers & E.D.'s ; personnel should be assigned to staff & monitor these communication computers Lesson learned : Prearranged links should be set up between Fire & EMS command centers & E.D.'s ; personnel should be assigned to staff & monitor these communication computers

Lesson 6 : Better Monitoring & Recording of Specific Personnel Responding into a Danger Zone is Needed There was no early perimeter control of the scene, so identity of many of the responding fire & police units in the WTC was not initially known There was no early perimeter control of the scene, so identity of many of the responding fire & police units in the WTC was not initially known There was also only limited identification & tracking of later volunteers at the site There was also only limited identification & tracking of later volunteers at the site Lesson learned : Establish perimeter control with police early. Identity of all units & personnel entering the danger zone needs to be tracked & recorded by communications center. Lesson learned : Establish perimeter control with police early. Identity of all units & personnel entering the danger zone needs to be tracked & recorded by communications center.

Lesson 7 : Special Rescue Arrangements Are Needed for Top Floors of High Buildings Almost no one on a floor above the level hit by the planes survived Almost no one on a floor above the level hit by the planes survived Could they have been rescued from the roof ? Could they have been rescued from the roof ?  Helicopter response limited by smoke & the FAA grounding all non-military aircraft Lesson learned : Roof rescue techniques need preplanning. Lesson learned : Roof rescue techniques need preplanning.  One company has proposed use of quick-pull parachutes for those on high level floors

Smoke and dust plume preventing aerial evacuation from the North Tower

Lesson 8 : After a Building Collapse, Most Secondary Injuries Are Due to Dust and Smoke Many early response personnel were not equipped with respirators Many early response personnel were not equipped with respirators Many secondary injuries were eye irritation and corneal abrasions Many secondary injuries were eye irritation and corneal abrasions Lesson learned : Early provision of respirators & eye protection for responding personnel is important Lesson learned : Early provision of respirators & eye protection for responding personnel is important  Bring extra stocks of these to scene for non- rescue personnel also

Smoke and dust plume after the collapse

Lesson 9 : Hospital E.D. Pre-planning and Conducting Disaster Drills Pays Off The response by New York University Downtown Hospital is widely regarded as a model for other hospitals to emulate The response by New York University Downtown Hospital is widely regarded as a model for other hospitals to emulate  Closest hospital to WTC (4 blocks away)  170 beds, Level 2 trauma center  6 operating rooms  29,000 average annual E.D. visits prior to the disaster  In 1993 saw 250 patients from the WTC bombing

Lesson 9 Continued NYU Downtown Hospital E.D. fully activated pre- practiced disaster plan and Hospital Incident Command within 10 minutes of the plane strike NYU Downtown Hospital E.D. fully activated pre- practiced disaster plan and Hospital Incident Command within 10 minutes of the plane strike Extra central supplies brought to E.D. Extra central supplies brought to E.D. E.D. attending on duty (Dr. A. Dajer) coordinated the staff response E.D. attending on duty (Dr. A. Dajer) coordinated the staff response All present E.D. patients rapidly transferred to inpatient units All present E.D. patients rapidly transferred to inpatient units

Lesson 9 Continued NYU Downtown Hospital staff mobilized under Incident Commander : NYU Downtown Hospital staff mobilized under Incident Commander :  8 surgeons and 5 surgery residents  14 internists and 30 IM residents  4 Ob/Gyn attendings and 16 residents Patient flow handling : Patient flow handling :  Rapid triage by E.D. attending at door, then assignment of one resident to take patient to specific resuscitation room (where surgical staff were waiting) or to other "appropriated" inpatient areas (cafeteria, clinics, etc.) where the patient was fully assesssed & then treated by the medical staff

Lesson 9 Continued By 10:00 a.m., 200 patients had been seen in the NYU Downtown E.D., and 3 sent to O.R. By 10:00 a.m., 200 patients had been seen in the NYU Downtown E.D., and 3 sent to O.R. In the second hour, there was another huge "surge" of patients with crush and trampling injuries, & inhalation and eye injuries from the dust from the Towers' collapse In the second hour, there was another huge "surge" of patients with crush and trampling injuries, & inhalation and eye injuries from the dust from the Towers' collapse By 11:00 a.m. 350 patients had been processed through the E.D. By 11:00 a.m. 350 patients had been processed through the E.D. Over 500 additional non-injured people were also sheltered by the hospital from the thick dust cloud outside Over 500 additional non-injured people were also sheltered by the hospital from the thick dust cloud outside

Lesson 9 Continued Summary of first day caseload for NYU Downtown Hospital : Summary of first day caseload for NYU Downtown Hospital :  21 Hospital admissions  18 transfers by ambulance to other hospitals  12 I.C.U. admissions including 4 R/O MI's  4 operating room cases  3 deaths  117 rescuers treated from 11:00 a.m. to midnight

Lesson 9 Continued The response by St. Vincent's Hospital (closest Level One Trauma Center to WTC, about 1.5 miles away) is also widely regarded as exemplary The response by St. Vincent's Hospital (closest Level One Trauma Center to WTC, about 1.5 miles away) is also widely regarded as exemplary  Hospital disaster plan quickly activated by E.D. chief  Elective surgery cancelled  Extra treatment beds set up (20 in gym, 12 in recovery room, 8 in endoscopy, 8 in dialysis, 25 in psychiatry)  Physicians & nurses called in from hospital pool  Portable X-ray machines mobilized  Head & burn trauma patients quickly transferred by ambulance to other hospitals

Lesson 9 Continued Summary of first day case experience for St. Vincent's : Summary of first day case experience for St. Vincent's :  350 patients by midnight  6 patients with ISS > 15  Was outside the cordoned off area and did not have the difficulties of electric power and steam outage that affected NYU Downtown Hospital

Lesson 9 Continued Bellevue Hospital also had quick, effective large scale disaster response Bellevue Hospital also had quick, effective large scale disaster response  E.D. command posts set up  E.D. cleared of patients  Hospital staff mobilized  One doctor assigned to each incoming patient  Saw 120 patients from WTC –22 admissions, 10 O.R. cases, 5 patients with ISS > 15 (plus 3 transferred from NYU Downtown Hosp.)

Lesson 10 : E.D. Caseload From a Disaster Has an Initial Surge, Then Tapers Off NYC Dept. of Health Rapid Assessment Team collected data on all E.D. cases seen at 5 Manhattan hospitals NYC Dept. of Health Rapid Assessment Team collected data on all E.D. cases seen at 5 Manhattan hospitals  From 8 a.m. Sept. 11 to 8 a.m. Sept. 13  1688 total E.D. patients in this time  1103 (65 %) were WTC victims  10 % of cases had missing data

Time presentations of the WTC casualties

Lesson 10 Continued 1103 WTC disaster victims : 1103 WTC disaster victims :  Median age 39 years  66 % male  26 % arrived by EMS  29 % were rescue workers  16 % were hospitalized  0.4 % (4) died in E.D.  0.3 % (3) died in O.R.

Causes of Death in the WTC Victims Who Died in the E.D. or O.R. at NYU Downtown and St. Vincent’s 2 cases of prehospital blunt trauma cardiac arrest 2 cases of prehospital blunt trauma cardiac arrest One case with severe burns One case with severe burns One non-trauma cardiac arrest One non-trauma cardiac arrest One firefighter with blunt chest and abdomen injuries died in O.R. One firefighter with blunt chest and abdomen injuries died in O.R. One head-injured patient died in O.R. One head-injured patient died in O.R. One blunt trauma patient died in O.R. One blunt trauma patient died in O.R.

Time Distribution of WTC Victim E.D. Patient Presentations 50 % presented within 4 hours 50 % presented within 4 hours 71 % presented within 12 hours 71 % presented within 12 hours 49 % had inhalation injuries 49 % had inhalation injuries 26 % had ocular injuries 26 % had ocular injuries 19 % (27 cases) of admitted cases had burns 19 % (27 cases) of admitted cases had burns 2 % of rescue personnel injured had burns 2 % of rescue personnel injured had burns

Number and Types of Injuries in the WTC E.D. Patients INJURY Number % % Inhalation Ocular Laceration Sprain Contusion Fracture Burn Closed Head8661 Crush Hospitalized (n = 139) Seen & Released (n = 606)

Comparison of Injuries in Rescue Workers and Non-rescue Survivors INJURY Number % % Inhalation Ocular Sprain Laceration Contusion Fracture Burn62336 Closed Head31112 Crush3151 Rescue Workers (n = 279) Non-rescuers (n = 511)

Comparison of Time of Presentation of WTC E.D. Cases to Prior Disasters Usual prior presentation pattern : Usual prior presentation pattern :  First wave of survivors with minor injuries (self extricated, not via EMS)  Second wave of more severely injured (most via EMS)  Subsequent waves of survivors rescued during extrication WTC pattern : WTC pattern :  One immediate large wave  Second wave the next day mostly rescuers

Actually one other patient remained hospitalized longer at NYU Downtown Hospital (patient had severe degloving injury)

Lesson 11 : Better Communication & Use of Incident Command System Needed for Field Medical Units Several ad-hoc "field triage" hospitals were set up, one near WTC, one on Staten Island, & one in Liberty Park Several ad-hoc "field triage" hospitals were set up, one near WTC, one on Staten Island, & one in Liberty Park  These were organized separately & did not have direct communications with each other or the nearby E.D.'s Lesson learned : Field "triage hospitals" should have unified communications & be under medical incident commander Lesson learned : Field "triage hospitals" should have unified communications & be under medical incident commander

Lesson 12 : Medical Personnel Will Readily Volunteer in a Disaster Each NYC hospital quickly mobilized more of its own physicians & nurses than it needed Each NYC hospital quickly mobilized more of its own physicians & nurses than it needed Hundreds more volunteered on standby from elsewhere in New York state Hundreds more volunteered on standby from elsewhere in New York state Pennsylvania had over 300 emergency physicians volunteer & be ready to deploy in 6 hours (arranged by ) Pennsylvania had over 300 emergency physicians volunteer & be ready to deploy in 6 hours (arranged by ) Over 2000 other Pennsylvania physicians & medical personnel also volunteered for standby Over 2000 other Pennsylvania physicians & medical personnel also volunteered for standby

Lesson 13 : Volunteers Should Wait to be Called In by Local Authorities Volunteers arriving at a disaster scene on their own (unrequested) can : Volunteers arriving at a disaster scene on their own (unrequested) can :  Become victims themselves  Overcrowd the scene  Be a supply & resource burden The Pennsylvania & other mobilized volunteers contacted the NYC E.D.'s directly to be notified if response needed ; further communication with local police & EMS would also be needed before arrival The Pennsylvania & other mobilized volunteers contacted the NYC E.D.'s directly to be notified if response needed ; further communication with local police & EMS would also be needed before arrival

Lesson 14 : Disaster Declaration Needs to Account for Volunteers' Medical Licenses The only out of state personnel officially mobilized were Federal Disaster Medical Assistance Teams (DMAT's) who have federally validated licensing & malpractice coverage The only out of state personnel officially mobilized were Federal Disaster Medical Assistance Teams (DMAT's) who have federally validated licensing & malpractice coverage To use other out of state medical personnel, government authorities must declare or provide "Good Samaritan" legal protection for volunteers (or temporary ad hoc licenses) To use other out of state medical personnel, government authorities must declare or provide "Good Samaritan" legal protection for volunteers (or temporary ad hoc licenses)

Lesson 15 : Even Modern Buildings Cannot Resist Fire from Jet Fuel- Laden Large Aircraft WTC collapse apparently mainly due to extreme heat from jet fuel fire weakening steel beam structural supports WTC collapse apparently mainly due to extreme heat from jet fuel fire weakening steel beam structural supports If future buildings are to be plane "strike proof", they will have to be able to resist this type of fire If future buildings are to be plane "strike proof", they will have to be able to resist this type of fire

Lesson 16 : Post Incident Stress Debriefing Is Important This was realized & planned for early for field rescuers, hospital staff, & the public This was realized & planned for early for field rescuers, hospital staff, & the public Two Critical Incident Stress Management (CISM) Command Centers were set up Two Critical Incident Stress Management (CISM) Command Centers were set up  60 CISM certified chaplains were utilized Federal CISM team also sent Federal CISM team also sent

Lessons Learned From the WTC Disaster : Summary Hospital and city multiservice disaster planning and drill practice are important Hospital and city multiservice disaster planning and drill practice are important Backup command centers & communication links are needed Backup command centers & communication links are needed Volunteerism can help salvage a big disaster Volunteerism can help salvage a big disaster The enormity of this tragedy will hopefully stimulate multinational efforts to prevent this sort of event from ever happening again The enormity of this tragedy will hopefully stimulate multinational efforts to prevent this sort of event from ever happening again

Winning design for the reconstructed World Trade Center

July 2003