The WTC Disaster: A First Person Account from the ED
(Copied from the EMED listserv)

I am an ED attending at Bellevue Hospital which is about 2.5 miles from the WTC and the largest ED in Manhattan. I worked the afternoon and nights of 9/11 and 9/12. These are my observations and criticisms on how things went in the first 48 hours, we have not yet had a full faculty debriefing yet. Overall, the hospital response was tremendous, normally Bellevue is an incredibly inefficient place and it was amazing to see how the hospital could actually all come together.

The ED was cleared out and remaining patients immediately were admitted or discharged. Radiology, the OR and ICUs were all ready and had about 5 times the normal capacity. The reality was that there actually not that many patients to be treated and there were way too many people milling about the ED. I believe we saw about 200 patients in the main ED during the first 12 hours (this excludes urgent care). Only a few patients had major trauma, the vast majority had mild to moderate smoke inhalation, conjunctivitis, acute stress reactions or minor injuries. There were surprisingly few lacerations. There were no patients that I am aware of that got decontaminated, though everyone was covered a fine white dust with rumors that it may be anthrax. The Department of health and the CDC began a survey on the evening of 9/11 for screening of possible bioterrorism.

Specific issues

Triage
Triage is and still remains, close to nonexistent. Initially, most of the patients went to either St Vincent's, a smaller level one center about 1.5 miles closer to the WTC than Bellevue or to NYU Downtown Hospital a small community facility very close to the WTC which is not a trauma center at all. Some seriously burned or patients with head trauma were brought to NYU Downtown which was quickly overwhelmed and later had to be transferred. We received a burned rescue worker yesterday that probably should have been taken directly to Cornell (the only burn center in Manhattan) 40 blocks to the north. There was little or no field triage and most patients arrived without tags. Bottom line: In a disaster most patients will be brought to the closest hospital, not the most appropriate hospital.

Communications
The whole scene downtown was chaos, there was no functioning incident command system and we had no idea of how many patients to expect. Baseline EMS communications in NYC is bad enough, we have no direct contact with the ambulances. Our preparedness for patients was basically rumor driven from what we could gather from the TV and police radios. Many times in the first 2 days we would hear about potential victims, clear out the ED and then just wait for hours without any patients showing up. I do not know if St. Vincent's ever became close to being overwhelmed and if they did, I do not believe there was any surefire way of communicating with them or the other area hospitals as to capability and diversion. Cell phones and landlines often did not work. We apparently were able to be in contact with the other City run hospitals, but any future plans should put into place some sort of inter-hospital radio system with direct communication with the on site command center.

Security
Security would have been a major problem if we had received thousands of patients. As it was, numerous people were able to filter back looking for their lost love ones. Telling these poor people that we had no record of their relative was an emotionally trying and distracting experience. If the terrorists had wanted to do damage to our hospital, it would have been extremely easy to get through. Additionally we had numerous community volunteers that showed up. There was no way of ascertaining their qualifications other than it seemed like someone on staff knew who they were. A hospital disaster plan should have a tight organized security plan and there should be some sort screening process for volunteers.

Pre made IDs that say "Volunteer ED physician" etc. would have been helpful.

Participation envy/ disaster voyeurism Since there were so few survivors and so many people wanting to help, there was an overwhelming feeling of frustration and helplessness. When sick patients did come in there were so many physicians around the stretcher that care was interfered with. Dozens of people from medical students to EM, Surgery and Cardiology attendings went down to "ground zero." In my opinion, this was a huge mistake fueled by this desire to help and voyeurism, especially after initial reports that there was nothing to do and that it was extremely dangerous. A number of our residents almost got trampled on day 3 when a building threatened to collapse.

There were plenty of trained EMS workers at the site, transport times were short and none of our physicians is trained in USAR. The only things that I conceive that a physician could have done at the site would be to treat hyperkalemia/rhabdo, give ketamine for a field amputation and perform the amputation if so trained. Any other procedures could either have been performed by EMS personnel or waited until the hospital because the patient would have already survived many hours or days.

The above criticisms aside, the hospital's response excellent. I believe that we could have handled over a dozen major trauma victims at one time and hundreds in the first 48 hours. It is too bad there were so few survivors.

Douglas Yoshida MD
Asst. Clinical Professor of EM
Attending EM Physician Bellevue Hospital and NYU Medical Centers

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