lessons learned from the world trade center disaster

1. 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

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

3. 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)

4. 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

5. WTC soon after
construction

6. Sequence of Events in the WTC
Disaster
 8:42 a.m. : AA Flight 11 hits North Tower
 9:00 a.m. : UA Flight 175 hits South Tower
10:05 a.m. : South Tower collapses
10:28 a.m. : North Tower 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
Noon the next day : last civilian freed from rubble
and transferred to Bellevue Hospital

7. South Tower
strike

8. North Tower burning

9. Collapse of South
Tower

10. South Tower
collapse

11. Just after the South
Tower collapse

12. North Tower
burning after South
Tower collapse

13. Ground Zero after collapse of both towers

14. Aerial view of lower Manhattan

16. 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

17. 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

18. 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

19. 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.

20. 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

21. 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.

22. 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

23. Smoke and dust
plume preventing
aerial evacuation
from the North Tower

24. 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

25. Smoke and dust
plume after the
collapse

26. 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

27. 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

28. 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

29. 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.
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.
Over 500 additional non-injured people were also sheltered by the
hospital from the thick dust cloud outside

30. 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 11:00 a.m. to midnight

31. 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

32. Lesson 9 Continued
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

33. 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 >
15 (plus 3 transferred from NYU Downtown Hosp.)

34. 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

35. Time presentations of the WTC casualties

36. 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.

37. 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
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.

38. 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

39. Number and Types of Injuries in the
WTC E.D. Patients
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 11
Fracture 27 19 19 3
Burn 27 19 12 2
Closed Head 8 6 6 1
Crush 6 4 2 0.3
Hospitalized (n = 139) Seen & Released (n = 606)

40. Comparison of Injuries in Rescue
Workers and Non-rescue Survivors
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
Rescue Workers (n = 279) Non-rescuers (n = 511)

41. 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

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

43. 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

44. 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

45. 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

46. 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)

47. 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

48. 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

49. 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

50. Winning design for the reconstructed World Trade Center

51. July 2003