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EMS Response to the WTC Disaster
Author: Ron Eggers
Copyright: 9-1-1 Magazine, Feature Content
Originally Published in our Nov-Dec 2001 issue.
The World Trade Center terrorist attack September 11th stretched New York City resources to its limits...beyond its limits, in fact. It was the worst attack on U.S. soil in the history of the country. More than 5000 people were killed or are still missing. Some 8000 people were injured. Considering that an estimated half of the 50,000 people working at the WTC were already in the buildings, and that there were an equal number of people in surrounding office buildings, it's remarkable that the casualty count wasn't higher.
Many heroes came to light in the days after the attack. More than 300 firefighters and almost 100 police officers lost their lives responding to what was first believed to be a horrific accident. There was confusion on the ground when the first tower was struck. By the time the second tower was hit, confusion had turned to chaos in the streets. But, even with the chaos, emergency services workers of all kinds did their jobs, and did them well, under the most trying of circumstances.
While the casualty toll is high, one reason that there weren't more casualties is the rapid response by emergency medical personnel. Medical response in New York City is broken down into public and private sectors. The Fire Department of New York has a fleet of ambulances that it operates throughout the five boroughs of the city under a program it calls “Dynamic Deployment.” Rather than being deployed out of fire stations, ambulances are staged at local hospitals and high call areas. They are redeployed as the city's population shifts during various times of the day - for example, from areas with high business traffic during the daytime to evening and night deployments in more residential areas.
Fire department EMS units are augmented by not-for- profit (charitable) hospital ambulance services, referred to volunteer member participants. There are eight such member participant hospitals in Manhattan. While these ambulances are considered in the overall deployment requirements, they usually stay at their own facilities.
Above: Fire Department ambulances stage at St. Vincent’s Catholic Medical Center. On September 11th, they joined with private rigs to transport dozens of patients to local hospitals. Photo by Ron Eggers
Ambulances staffed by city and participant hospital paramedics are ALS (advanced life support) units. Both the public and private EMS units are dispatched by the Fire Department, which has about 3000 people assigned to the EMS division, a third of which are ALS paramedics. The Fire Department staffs more than 800 eight-hour ALS shifts per 24-hour period. Of those, about two thirds are department paramedics; this is bolstered by private ambulance companies that operate within the city. They are BLS (basic life support) units and are not dispatched by FDNY. Generally, these aren't factored into the dynamic deployment program unless there is a major medical emergency such as the WTC.
According to Dave Billig, spokesman for the FDNY, the department has an annual budget of over $800 million. He estimated that $170 million of that was allocated for medical response units. The department has over 11,500 members, of which 3000 are in the officer ranks. All of the firefighters are trained to the Certified First Responder Defibrillator level, sometimes simply referred to as CFRDs or CFRs. There are no real structured CFRD certification programs available, Billig said, so many firefighters, particularly those just joining the department, go one step beyond CFRD to EMT. When responding, however, they respond as firefighters, and do not provide medical assistance beyond the CFRD level.
All the agencies involved in the September 11th incident faced their own sets of challenges when they responded. It was more like operating in a war zone than in a civil disaster. One of the most daunting tasks was to bring out the wounded while the attack continued to unfold. Before the attack, there had been a lot of discussion, and some doubt, about whether the EMS system in New York City, which had been moved over to the Fire Department in 1996, would be up to a major challenge.
Paramedics in both the public and private sector had expressed concerns that multiple operational jurisdictions and overlapping public/private response responsibilities would cause problems in a major disaster. No one could have guessed just how major of a disaster they would face. To the surprise of some, considering the enormity of the disaster, the system worked extremely well.
As Bob Levy, a paramedic supervisor with St. Vincent, explained, "It's a fairly unique structure. It took a while to get used to, but now it's working well, even better than expected. I wasn't sure before (the attack), but all these guys did a great job working together."
Billig said he didn't have the precise number of ambulances that were on the scene during those first few hours, and was reluctant to venture a guess. "But there were lots and lots of them." Even ambulances from surrounding jurisdictions came into Manhattan as the tragedy was playing itself out.
Hurberto Rubet is a paramedic with the St. Vincent Catholic Medical Center at 12th Street and Seventh Avenue, not too far north of the World Trade Center. On the morning of September 11th, Rubet had just returned to his ambulance when his boss, Joe Davis, came running up to tell him that there had been a bad accident at the World Trade Center. At that time, there was no indication that it was anything else than a very bad accident.
"I was parked up a ways, so I couldn't see it," Rubet said. Usually the ambulances don't self dispatch, but in situations where the EMTs are aware of incidents with numerous potential victims, the rigs roll and call in their destination. Rubet pulled out into the street. "As soon as I turned onto 7th Avenue, I could see a gaping fire hole in one of the towers. It looked like a catastrophe."
While Rubet was heading towards the scene, Davis put the hospital on alert. The staff was told to prepare for 400 to 500 potential patients. The first patients came into St. Vincent within a half hour.
Rubet reached the scene within minutes and reported his position to dispatch. At that point dispatch was aware that a major incident had occurred, but it still wasn't aware of the extent of damage or the fact that the assault was still continuing. Working under extremely difficult conditions, dispatchers were trying to assess the extent of the damage while trying to come up with the best plan of attack.
Above: Paramedics Hurberto Rubet (left), a paramedic with the St. Vincent Catholic Medical Center, and Bob Levy, a paramedic with FDNY. In New York City, the fire department runs the first-due paramedic ambulances while privates like St. Vincent’s provide back-up. Both were invaluable on September11th – Rubet barely escaped the collapses. Photo by Ron Eggers
"We started to set up a triage," he said. "At that point, both towers were still standing. That's when we heard a tremendous explosion and felt a wave of heat from above." The second plane had hit the second tower. Within half an hour, the first tower was starting to come down. "Things started dropping from above. Debris was falling all over. The ambulance directly behind us was crushed."
Rubet evacuated the scene as quickly as possible. He was five or six blocks away when the main part of the tower came down. "We could see that cloud in the rear view mirror." Rubet admitted that was frightening, but he kept his mind on his work. "We still had patients to deal with, so we treated as we retreated." With the help of other patients, he loaded more patients into the ambulance, as he retreated.
"We tried to regroup and figure out some way to get the most patients out." Some of the patients that required treatment were transferred to the private BLS units that were just arriving. That freed up ALS units."
Rubet was surprised how well the different ambulance services worked together. "There was a tremendous response. The city EMTs were great. We all worked together."
Several city EMTs echoed that sentiment. As Byron Melo, a FDNY EMT who spent several days at ground zero, said,"that was something of an extent that we never expected. We've always had a good working relationship with the other ambulances, but this worked even better than expected. There was an extra level of cooperation." For example, ambulances dropping patients at St. Vincent were being restocked, regardless of their affiliation.
When things settled down a little, Rubet was dispatched back into the area, and was in the vicinity of the ground zero just before the collapse of the second tower. Fortunately, there wasn't a lot of vehicle traffic in the area, but there were lots of people. Because of the people running everywhere in all directions, evacuating the second time proved to be more difficult than the first. "They were jumping on the back and holding onto the sides. It was amazing."
One of the problems that should have been anticipated but wasn't was communications related. St Vincent's ambulances could stay in touch with the Fire Department's dispatch by radio, but they couldn't reach the hospital directly. Ambulance-to-hospital communications is normally handled through Nextel's cellular-based radio system, but cellular service was knocked out, disrupting direct vehicle-to-base communications. The hospital had Fire Department communication capabilities, but those channels were too busy handling heavy radio traffic. Without direct communications, it was difficult to coordinate patient delivery.
Altogether, some 900 people were treated at St. Vincent. Interestingly enough, while there certainly were some serious injuries, including patients who had to be transferred to a specialized treatment burn unit, many of the patients that came into the hospital weren't injured seriously. "I knew just by the extent of the explosion and the fact that there weren't that many serious injuries that the death toll would be high," Rubet said. From his perspective, there wasn't much he could have, or would have, done differently, other than maybe not going back into the area the second time.
The Fire Department's Dave Billig was reluctant to talk about some of the lessons learned during the operation. "It's still an ongoing operation, so we really haven't had a chance to look at everything closely." But there were a couple of points that came up several times when talking to medical personnel. One was the positioning of triage. There was an informal consensus that the triage area should have been positioned further away from ground zero. But then, as one fire fighter pointed out, who could have guessed at the scale of the disaster?
Another point that several ambulance drivers mentioned was the surprise of being dispatched back directly into the collapse area. As one EMT, who preferred not to be named, said, "I couldn't believe they were sending us back in." Like Rubet, he was lucky to get out the second time.
Considering the extent of the devastation, the amount of damage to the World Trade Center and the surrounding areas, and the number of potential victims, by all indications, the medical emergency response system in New York City proved itself admirably.
Above: Not all of the EMS rigs deployed to the World Trade Center survived when the towers came down. Photo by Michael Bascom
Ron Eggers is a Senior Editor with NewsWatch Feature Service, covering technology and public safety. He's also a Public Information Officer for the Orange County, CA, chapter of American Red Cross; a member of City of Costa Mesa Emergency Planning committee; a member of the city's Community Emergency Response (CERT) Team; and a member of MESAC, Costa Mesa's emergency communications Ham radio support group.