Lessons Learned from the

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Lessons Learned from the World Trade Center
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
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Memorial plaque for the WTC victims presented by
Iran University at the First Middle Eastern
Conference on Emergency Medicine, October 2, 2001
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Lecture Objectives

• 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
• Utilize the lessons learned in planning for
  mitigation of future events (which hopefully will
  not come to pass)

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General Lessons Learned from This Disaster

• 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
• Domestic volunteer help and cooperation can be
  huge in response

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WTC soon after construction
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Sequence of Events in the WTC Disaster

• 842 a.m. AA Flight 11 hits North Tower
• 900 a.m. UA Flight 175 hits South Tower
• 1005 a.m. South Tower collapses
• 1028 a.m. North Tower collapses
• 525 p.m. WTC Building 7 (47 stories)
  collapses
• 1145 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

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South Tower strike
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North Tower burning
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Collapse of South Tower
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South Tower collapse
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Just after the South Tower collapse
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North Tower burning after South Tower collapse
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Ground Zero after collapse of both
towers
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Aerial view of lower Manhattan
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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")
• 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

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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
• There was not a fully operational backup center
• Lesson learned Have at least two geographically
  separate fully capable backup communication
  command centers

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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
• 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
• Special intercom systems or lower frequency
  radios may be needed for use inside very large
  buildings, and should be tested ahead of time

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Lesson 4 Telephone Systems Fail Early in a
Disaster

• 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)
• 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.

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Lesson 5 Computer Communications May Still
Function Despite Phone System Malfunction

• E-mail 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 e-mail
  messages)
• Lesson learned Prearranged e-mail links should
  be set up between Fire EMS command centers
  E.D.'s personnel should be assigned to staff
  monitor these communication computers

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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 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.

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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
• 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.
• One company has proposed use of quick-pull
  parachutes for those on high level floors

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Smoke and dust plume preventing aerial evacuation
from the North Tower
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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 secondary injuries were eye irritation and
  corneal abrasions
• 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

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Smoke and dust plume after the collapse
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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
• 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

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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
• Extra central supplies brought to E.D.
• E.D. attending on duty (Dr. A. Dajer) coordinated
  the staff response
• All present E.D. patients rapidly transferred to
  inpatient units

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Lesson 9 Continued

• 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
• 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

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Lesson 9 Continued

• By 1000 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
• By 1100 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

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Lesson 9 Continued

• 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 1100 a.m. to midnight

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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
• 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

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Lesson 9 Continued

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

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Lesson 9 Continued

• 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
  gt 15 (plus 3 transferred from NYU Downtown Hosp.)

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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
• 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

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Time presentations of the WTC
casualties
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Lesson 10 Continued

• 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.

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Causes of Death in the WTC Victims Who Died in
the E.D. or O.R. at NYU Downtown and St. Vincents

• 2 cases of prehospital blunt trauma cardiac
  arrest
• One case with severe burns
• One non-trauma cardiac arrest
• One firefighter with blunt chest and abdomen
  injuries died in O.R.
• One head-injured patient died in O.R.
• One blunt trauma patient died in O.R.

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Time Distribution of WTC Victim E.D. Patient
Presentations

• 50 presented within 4 hours
• 71 presented within 12 hours
• 49 had inhalation injuries
• 26 had ocular injuries
• 19 (27 cases) of admitted cases had burns
• 2 of rescue personnel injured had burns

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Number and Types of Injuries in the WTC E.D.
Patients
Hospitalized (n 139)
Seen Released (n 606)
INJURY
Number

Number

Inhalation
52
37
300
50
Ocular
10
7
185
31
Laceration
25
18
80
13
Sprain
17
12
85
14
Contusion
29
21
66
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Fracture
27
19
19
3
Burn
27
19
12
2
Closed Head
8
6
6
1
Crush
6
4
2
0.3
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Comparison of Injuries in Rescue Workers and
Non-rescue Survivors
Rescue Workers (n 279) Non-rescuers (n
511)
INJURY
Number

Number

Inhalation
118
42
268
52
Ocular
108
39
96
19
Sprain
44
16
64
13
Laceration
23
8
87
17
Contusion
44
16
54
11
Fracture
13
5
33
6
Burn
6
2
33
6
Closed Head
3
1
11
2
Crush
3
1
5
1
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Comparison of Time of Presentation of WTC E.D.
Cases to Prior Disasters

• 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
• One immediate large wave
• Second wave the next day mostly rescuers

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

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Lesson 12 Medical Personnel Will Readily
Volunteer in a Disaster

• 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
• Pennsylvania had over 300 emergency physicians
  volunteer be ready to deploy in 6 hours
  (arranged by e-mail)
• Over 2000 other Pennsylvania physicians medical
  personnel also volunteered for standby

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Lesson 13 Volunteers Should Wait to be Called
In by Local Authorities

• 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

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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
• 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)

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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
• If future buildings are to be plane "strike
  proof", they will have to be able to resist this
  type of fire

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Lesson 16 Post Incident Stress Debriefing Is
Important

• This was realized planned for early for field
  rescuers, hospital staff, the public
• Two Critical Incident Stress Management (CISM)
  Command Centers were set up
• 60 CISM certified chaplains were utilized
• Federal CISM team also sent

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Lessons Learned From the WTC Disaster Summary

• Hospital and city multiservice disaster planning
  and drill practice are important
• Backup command centers communication links are
  needed
• 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

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Winning design for the reconstructed World Trade
Center
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July 2003
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