Editor's note: Dr. Lewis R. Goldfrank was interviewed on September 28, 2010. References and other details were added in support of Dr. Goldfrank’s account of what took place in NYU Langone Medical Center and Bellevue Hospital Center on September 11, 2001 and his description of what is being done locally and throughout the USA to prepare and respond to emergencies and disasters now.

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Medical Response to 9/11

On September 11, 2001 at 8:46, American Airlines Flight 11 struck the upper North Tower of the World Trade Center. In NY, it was the peak of rush hour, and many were just arriving to their offices. Dr. Goldfrank began to describe the standard and not-so-standard procedures at his hospital on that dreadful day: official channels (calls directly coming from telephone operators of Fire Department of New York (FDNY), New York City Police Department (NYPD) or Office of Emergency Management, OEM) of communications were lost; however, contact from other sources was rapid. Thousands were expected to be brought in to emergency departments across the city. Routine tasks were immediately eliminated, and people with non-urgent conditions were moved to other areas of the hospital. Ambulatory (outpatient) services were shutting down. Emergency services were discharging patients rapidly. Teams then began moving to the emergency department, prepared to treat burn patients, traumatized patients. The West Side Pier was set up as an emergency operating site.

“Nevertheless, efforts to treat the injured were far less demanding than a normal day at an Emergency Department of any hospital in the New York City area: most victims were already dead – incinerated,” said Dr. Goldfrank, and he continued explaining that another tragedy was just beginning to unfold. Since the people who were trying to help had very little to do because there were no patients to care for, and as compassionate human beings, they rushed to the scene to participate in the rescue. Surgeons, specialists in emergency medicine and internal medicine, and nurses from NYU and Bellevue were there. “Firefighters, Emergency medical personnel, police, volunteers and people in the community are still suffering from the consequences of exposure to high concentrations of inhaled material that came from the incineration of these immense buildings.” 

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<GettyImage No. 90302117, Caption: Collapse of World Trade Center South Tower and ensuing dust cloud rolling up Broadway in lower Manhattan.>

Physical and Psychological symptoms after 9/11: dealing with the horror

Dr. Goldfrank reported that rescue workers and others who were near the World Trade center on 9/11 and days during the clean-up operation had breathed very dense soot, containing calcium, dirt, and dust. <GettyImage No. 90302125, Caption: Remains of a crushed NYPD patrol car one day after the attack.>Visiting emergency departments around the city, they reported throat, eye and skin irritations. The afflicted were psychologically distressed. One patient came in saying, “I can’t bear it. My skin is covered with the remains of other people.” 
He continued explaining that months and years later, many still suffer from persistent cough and post traumatic stress disorder (PTSD). 
Six years after 9/11, the reduced lung function in firefighters and Emergency Medical Services (EMS) workers has not improved. <Ref 1.> Aldrich TK, Gustave J, Hall CB, et al. Lung Function in Rescue Workers at the World Trade Center after 7 Years. N Engl J Med 2010 Apr; 362(14): 1263-1272. <New English Journal of Medicine Figure 2> <Copyright © 2010 Massachusetts Medical Society. All rights reserved.> <Definitions: FEV1, Forced Expiratory Volume in 1 second (spirometric measurement); Percent of predicted (normal) FEV1 value is used to diagnose decreased respiratory function and airway disease, i.e., a percent predicted FEV1 value of less than 80% is suggestive of moderate COPD.> In a 2006-2007 survey of 46,322 adults who were exposed to World Trade Center debris, over 10% of new asthma cases were diagnosed post-event, with the highest risk among rescue and recovery workers at 20.5%.<Ref 2.> Brackbill RM, Hadler JL, DiGrande L et al. Asthma and Posttraumatic Stress Symptoms 5 to 6 Years Following Exposure to the World Trade Center Terrorist Attack. JAMA 2010 Aug; 302 (5): 502-516. Of these survey respondents with no PTSD history, nearly 10% still reported PTSD, which was associated with event-related loss of a spouse or job. 
The World Trade Center Environmental Health Center in Bellevue Hospital Center, an outpatient service, is dedicated to the physical and psychological well being of those who have suffered immense psychological complications from this terrorist act. Patients coming to the center will be treated even if they are without health insurance or cannot pay. 
Bridging the gap in health literacy
Dr. Goldfrank emphasizing education as a top priority in preparedness, asked, “How do you help people deal with stressful events, how do you help them and prepare them?” Collaborative efforts are taking place across New York City, New York State and nationally, in which resiliency, patient education, and methods to explain risks are discussed; these have brought about new programs in preparedness and prevention.
Educating medical centers, staff and patients and building new facilities to respond better to disasters
Looking back on that day, said Dr. Goldfrank, no one was prepared for the exposure to thick, heavy soot and particulate matter in the debris. Masks were inadequate or not used at all.

 

<GettyImage No. 90051520, Caption: Clean-up efforts of FDNY firefighters.>

Many were unaware of the importance of using respirators or did not know how to use them. Hospital staff experienced secondary exposure from debris on the clothing of people who were brought in for treatment. He compared their experience to what had happened in Japan during the sarin gas attack in 1993, where hospital workers were contaminated from the off-gassing of chemicals on the clothing of people exposed to the gas. 

This secondary exposure is now entirely preventable at Bellevue Hospital Center and NYU Langone Medical Center because as Dr. Goldfrank explained, people who have been exposed to noxious debris or a toxin can shower and change their clothes in a decontamination unit attached to the emergency department.

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<Photos 3&4 Caption: Decontamination Unit attached to Bellevue Emergency Department. Top photo, exterior; right photo; interior.>

 

After that, medical staff spend time with the patients, explaining the exposure, future risks, and how they should care for themselves now to reduce the risks. He explained that attending to the psychological well-being of these people is just as vital as the removal of noxious materials, and he concluded that the more patients know, the less chance they have of developing PTSD.
Another lesson learned from 9/11, said Dr. Goldfrank, was that instead of all medical staff rushing to the scene of an emergency, they should remain in their respective departments and do what they do best: surgeons doing surgery, and experts in emergency care or internal medicine working in their area of expertise. Those handling victims covered with debris or toxins should know how to use respirators and protective clothing properly to reduce the risk of secondary contamination. Medical personnel now realize that protecting themselves is just as vital as caring for their patients.

Educating community leaders and the public

Days and weeks after the attack, EMS workers, police and people from the neighborhood coming to the emergency department, complained that they had trouble getting to sleep, said Dr. Goldfrank, and those who spent so much time taking care of others forgot to take care of themselves. No one was around to take care of them, and they thought, “I’m in pretty good shape, and I’ll continue to go to work.” He asked, “How does a person develop the quality of resiliency to cope with a tragic event? How does a community get the strength to help those in need?” He explained that they as health professionals realized that medical information was not getting out to the people who were exposed. The community just failed to understand the immediate risks and how to take care of themselves. He continued by saying that New York in particular faces a unique problem: about 100 different languages are spoken by people of diverse backgrounds, cultures and immigration status. 
The Committee on Responding to the Psychological Consequences of Terrorism wrote a Public Health Strategy on the subject. 
<Ref 3.> Butler AS, Panzer AM, Goldfrank LR, Committee on Responding to the Psychological Consequences of Terrorism. Preparing for the Psychological Consequences of Terrorism: A Public Health Strategy. National Academies Press 2003. <http://www.nap.edu/catalog/10717.html>
The committee analyzing the biological-physical, psychological and sociocultural characteristics of people responding to a disaster concluded that all members of a society, in schools, in the workplace, and in religious, cultural, ethnic and community organizations, should actively participate to achieve preparedness. “Rigorous continuing education and improvement” of community leaders, primary health care and emergency response personnel will be the driving force to educate within their own communities and link into local and regional collaborative networks. 
Many initiatives are underway to educate the community, said Dr. Goldfrank. Centers for Disease Control (CDC) is awarding grants to local governments to educate the public on various health issues. The Iowa Department of Public Health has coordinated the mass media to run articles or programs on special health or science topics: such as the hazards of nuclear material or transmission of influenza. The New York City Department of Health and Mental Hygiene writes and distributes informational guidelines 10 different languages and has enacted training programs for leaders of the community and school boards, who can then explain health matters in terminology that the community can understand. It is especially valuable to get this information to children. He emphasized that “There are still too many people, who are afraid because they are uninformed; however, we need to convince people that as they you study more, they may become more uncertain, but in the long run, they will be better prepared. Everyone has assets and vulnerabilities to get them through a situation. Community leaders help people connect to their communities, be self sufficient and adapt to new circumstances. Disaster education includes all of these.” 
Professionals reaching out to their communities during times of crisis
Community action groups, ethnic groups, religious groups have given people the strength to deal with things they cannot understand, says Dr. Goldfrank, though it may not be enough. Human beings can pitch in and create new communities, and federal agencies are providing funding to do just that. The New York Department of Heath, supported by the Office of the U.S. Surgeon General, organizes such a group: the Medical Reserve Corps. <Note1> Medical Reserve Corps is a locally trained group of volunteer health professionals: doctors, nurses, dentists, technicians and others whose primary role is to distribute antibiotics or vaccines during a health emergency requiring mass prophylaxis. Besides the Medical Reserve Corps, Dr. Goldfrank mentioned that the volunteer community spirit is alive where he works, too. He described a new, large project, implemented at the New York University School of Medicine, to “improve the organization-based safety net and support in the community,” to connect with those who are most vulnerable during times of crisis. It is a system that “creates resiliency within the community—that reaches out to the community.” These registries are specific for various patient groups: homebound patients, elderly patients, those requiring dialysis or use of medical electrical equipment. Let’s say there is a power outage; no problem. NYU have a registry of those who require electricity for a ventilator, and volunteers can send people out to their homes with the proper backup equipment or send an ambulance. Let’s say a patient did not show up for a dialysis appointment. All dialysis scheduling is centralized in one registry, so NYU volunteers know who needs to get to the hospital and fast. What happens if there is a heatwave; no problem. All homebound patients are in a registry, and people at NYU medical school will rapidly respond and send a home help aide or volunteer from the local community to their homes. A timely response is a life saved.

Individuals reaching out during times of crisis

Besides medical people contacting patients in registries, it is essential, says Dr. Goldfrank, for us, as members of the community to participate and strengthen ourselves (psychologically) so that we can do things that are valuable: call 911 for general emergencies, 311 for medical emergencies, and 212POISON for accidental ingestion or suspected poisoning. When a person reports a poisoning to the emergency department of a hospital or to 212POISON, a poison control center operator inputs the information into the local surveillance system, integrated with the centralized CDC system; and in effect, poisoning cases, wherever they may be, are continuously monitored and analyzed. If the number of cases exceeds the norm over two standard deviations, the CDC will flag it as a potential disaster or epidemic and have it immediately investigated by public health service officers. Individuals’ reporting an emergency is the first step, says Dr. Goldfrank, “to help people prepare for things that are rare and may never happen.” 
He continued to explain that there are more people dying from personal or neighborhood disasters than from terrorist activities. Just under 3,000 people died from the 9/11 attack. Every year in the USA, about 30,000 people die from influenza complications and another 30,000 die from alcohol-related injuries. Thousands died from the heat wave in Europe in 2003. These are preventable, everyday tragedies that do not have to happen, and we can do our part in their prevention.
<Ref> Impacts of Summer 2003 Heat Wave in Europe: UNEP Environmental Alert Bulletin [Internet]. United Nations Environmental Program. Available from: http://www.grid.unep.ch/product/publication/download/ew_heat_wave.en.pdf

Medical Countermeasures 

After 9/11 and threat of anthrax in letters in New York City, the Strategic National Stockpile (SNS)
<Photo 5> Caption: Strategic National Stockpile (SNS). 
Push packs of necessary medicines and equipment for public health emergencies: terrorist attacks, disease outbreaks, and natural disasters.

Program was initiated to “supply medicine and medical supplies to protect the American public during a health emergency that is severe enough to cause local supplies to run out.” 

<Note2> Strategic National Stockpile (SNS) program is managed jointly by the Department of Homeland Security and Department of Health and Human Services. http://emergency.cdc.gov/stockpile/

For a biohazard such as anthrax, even one occurrence will be immediately investigated by the CDC. If US authorities confirm the threat, they will immediately distribute antidotes or special medicines to local areas that are then distributed by local authorities to communities.
<Ref > Davis M, Kammersall MS, Altefogt BM, Rapporteurs, Forum on Medical and Public Health Preparedness for Catastrophic Events Institute of Medicine. Dispensing Medical Countermeasures for Public Health Emergencies: Workshop Summary. National Academies Press 2008. http://www.nap.edu/catalog/12221.html

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In New York, public emergency teams and Medical Reserve Corps volunteers distribute medicines to everyone at Point of Dispensing (POD) locations. As an additional countermeasure, the US Postal Service will ensure rapid delivery of medical countermeasures in response to a large-scale biological attack.
<Ref > U.S. post Office to deliver antidote in case of anthrax attack. Published 4 January 2010. http://homelandsecuritynewswire.com/us-post-office-deliver-antidote-case-anthrax-attack

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Message to Doctors in Japan

Dr. Goldfrank ended saying, “Our life is much, much safer than it ever was. If doctors worked harder and other professionals and leaders in government worked harder to understand that we are uncertain about many, many aspects of life, that the risks of terrorism are far less than the risks we have every single day, and if we took care of them every day, and worked together more carefully, we would develop better community resilience to withstand the normal events that are terrible, and we would be better prepared for the rare events that would be terrible as well.”