Editor's note: The patient involved in this fascinating story, Sgt. John McLoughlin, is one of the central characters in Oliver Stone's film World Trade Center (released Aug. 9). The film follows McLoughlin (Nicolas Cage) during his entrapment and rescue, and also honors two of his many rescuers -- tactical paramedic John Busching and trauma surgeon John Chovanes, DO, who treated McLoughlin for Crush Syndrome.
However, what isn't detailed in the film is that more than three-and-a-half years after the terrorist attacks on the World Trade Center, paramedic Busching contacted JEMS author and lecturer Bill Raynovich to let him know how important he feels it is for EMS personnel to understand and properly treat Crush Syndrome. This is their first-hand account of what happened on 9/11 and how it affected each of them.
On Monday, Sept. 10, 2001, I traveled from Albuquerque, N.M., to Pittsburgh, Pa., to attend the National Association of EMS Educators (NAEMSE) Symposium. I awoke Tuesday morning to the same horrific scenes that haunted the entire civilized world on 9/11. Q My first action was to call Joann Freel, executive director of NAEMSE, to find out what arrangements were being made to transport the more than 500 EMS educators who were expected to arrive in Pittsburgh over the next few days, to New York or Washington, D.C., as volunteer responders. I imagined a train or caravan of buses filled with several hundred EMTs and paramedics, everyone prepared to do their part in the rescue effort by filling in for EMS shifts and transporting patients en masse to multiple hospitals in other cities.
As it turned out, hundreds of EMS educators were grounded in cities all across America and unable to board their prearranged flights to attend the conference. In addition, when NAEMSE contacted FEMA with an offer to send help to New York, the offer was declined due to security concerns and the logistics involved.
Although it felt weird and wrong to me at the time, NAEMSE went on to hold a "skeleton conference" with about 300 educators in attendance -- and for good reasons. First, it was soon evident that there wasn't much we would have been able to contribute to the rescue or medical response efforts. Most of the victims were either dead or alive and free of danger; there wasn't a significant need for mass triage, treatment and transportation. The situation would likely have been much different had the towers remained standing, toppled over sideways or collapsed with huge structural beams and building materials flying in multiple directions and over a wider area.
Second, as educators, it was important for us to band together, reflect on the incident and begin to focus on the new educational challenges that would be thrust upon us.
For me, 9/11 was not an incident that required my EMS training and skills; rather, like many other prehospital care providers, the incident brought only the politics of international cultural conflict and ultimately war. But for those who were in New York City, Washington, D.C., and Shanksville, Pa., this was a life-changing EMS event of epic magnitude. I offer my sincerest appreciation to those who responded to help others at the scenes of those tragedies that morning.
This is one of the true stories about 9/11 that I_ve been given the privilege to tell. It_s a personal and first-hand account of the heroism and EMS care rendered to Sgt. John McLoughlin, who suffered from Crush Syndrome. The officer is portrayed by Nicolas Cage in the 2006 film World Trade Center.
This article would never have been written if not for the desire of a single responder to offer his personal thanks to a single educator and deliver a sincere message: Keep on teaching providers about the important implications and treatment of Crush Syndrome.
A Belated Phone Call
On May 12, 2004, two years and nine months after 9/11, I was driving across the desert back to my office in Albuquerque when I received a call on my cell phone. The caller identified himself as John Busching, a New York City police detective and tactical paramedic with the newly formed Tactical Medical Team of the NYC Emergency Service Unit (ESU).
I was both curious and uneasy about the call. I figured it was either a prank or that something very bad must have happened to someone I knew. Instead, Detective Busching asked me if I would like to hear about a Crush Syndrome patient he had treated on 9/11.
As a conference presenter on the topic of Crush Syndrome for many years and the author of "Crush Syndrome," the January 2000 JEMS continuing education article, I was intrigued but still somewhat puzzled. I had no idea why Busching would call me out of the blue more than three years later. However, after he told me the entire story, I understood why.
Here is Busching's account of his involvement in a dramatic rescue on 9/11.
In Busching's Words
I was sitting at home finishing breakfast before heading for work that morning [9/11] when I received a telephone call from a friend telling me that a plane had crashed into the World Trade Center. I turned on the news and watched as the second plane crashed into the second tower [the South Tower, 2 WTC]. I quickly gathered some extra clothes and started in to work.
I was assigned to Floyd Bennett Field [Brooklyn, N.Y.] as an instructor for the specialized training school of the New York City Police Department Emergency Service Unit (ESU). While driving to work, I initially followed a Port Authority Police vehicle as it moved through traffic with lights and siren toward the World Trade Center. I knew the driver, George Howard. He was someone I had trained with in the past. I got off at my exit, and he continued on to the scene. I later learned that he was killed by falling debris just as his unit arrived.
On my arrival at Floyd Bennett Field (ESU's specialized training school and storage and equipment repair facility for specialized vehicles and base for the NYPD Aviation Unit), there weren't any vehicles left to take to the scene. So I reported to the Aviation Unit commanding officer and was informed that other arriving ESU officers and I would form a team that would rappel onto the roof of the second tower.
Another rappel team was already in the air assigned to rappel onto the first tower hit [the North Tower, 1 WTC]. However, the obstructed visibility and turbulent conditions on the roofs of both towers prevented the plan from being implemented, and the towers collapsed before we could gain access.
When the towers collapsed, the rappel teams were dissolved and split between the two NYPD Bell 412 helicopters with an NYPD ESU EMT and a paramedic on each, and awaited calls for medical evacuations (MedEvacs) that never came.
At approximately 1800 hours, both MedEvac teams were airlifted to an area near the WTC on Manhattan Island to join the ESU search andrescue (SAR) teams. The teams were again split, with an EMT and a paramedic assigned to each. Almost immediately, my team was notified of an ongoing rescue of two trapped Port Authority Police officers.
On arrival, I was sent to the top of a hole where a patient lay buried in a pile of rubble approximately 20 feet down. I met John Chovanes, DO, at the rubble pile.
Dr. Chovanes, of Narberth, Pa., had been at home packing his car to go on vacation when a friend told him that a jetliner had crashed into the World Trade Center.(1) He was a second-year resident in emergency medicine at the University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine (UMDNJ-SOM) at that time, and he was also a former paramedic. While driving through Allentown, Pa., he had heard a broadcast of New York Mayor Rudy Giuliani appealing for medical personnel to come immediately to the site and help, and he drove straight to New York City.
Dr. Chovanes told me that the patient still trapped in the debris was reported to be in severe pain and gave me a supply of morphine sulfate to administer if the victim proved stable enough. The other patient, Officer Will Jimeno, had been treated and successfully removed prior to my arrival.
To gain access to the patient, I had to traverse a large steel "I beam sloped in a downward 45-degree angle under two pieces of tented concrete flooring, drop down another four feet and crawl 20 feet into a space about 18" tall and 24" wide.
When I reached the patient, I identified myself as a paramedic and he identified himself as Sgt. John McLoughlin of the Port Authority Police Department (PAPD). He was in excruciating pain from his waist down and was lying prone, buried just below the waist in concrete dust and rubble.
He was wearing a turnout coat and firefighter-style helmet, having responded to the Towers as part of a rescue team. McLoughlin was alert and oriented x 3 (person, place and time) and had a strong and steady pulse at 80 beats per minute. He hadn't received any medical care before I arrived. The rescuers who had gained access to him had been giving him water by mouth, and he had vomited several times.
Fires were burning under and around us, and changes in wind direction filled the hole with smoke. To get a steady stream of fresh air, we [FDNY] put a fire hose line into service, directed away from us. This proved to work very well in pushing the smoke away, but occasionally its back spray soaked not only us rescuers, but McLoughlin. So we kept his turnout coat on him to keep him as warm and dry as we could.
I administered oxygen at 8 L/min via a non-rebreather mask and started an IV with a 14-gauge angiocath on the back of his left hand. I ran in 1 L of normal saline, wide open. The morphine tubex and the IV administration set were incompatible, so I didn't administer the morphine right away.
When I returned to the top of the hole, Dr. Chovanes and I discussed McLoughlin's condition and the severity of his pain, and we agreed that we needed to give McLoughlin morphine for the pain. Dr. Chovanes drew the morphine out of the tubex with a straight needle and entered the hole to administer it.
When Dr. Chovanes resurfaced, we met and established our treatment plan. We had to be prepared for certain contingencies in the event that the rescuers could not get McLoughlin out, if he became unstable or if the scene became even more unstable and dangerous. For any of these possible events, we realized that we would have to be prepared to do rapid bilateral amputations of his lower extremities high on his thighs.
Dr. Chovanes began to develop a plan to do an emergency amputation while I needed to develop a plan to keep McLoughlin from bleeding to death with only the equipment and supplies that I had in my medical pack. Triangular cravats were the best materials I had for tourniquets, but Dr. Chovanes was certain the cravats wouldn't be effective in stopping bleeding from severed femoral arteries. We had to find a better method to control arterial bleeding. We searched through the other equipment and supplies that we had on hand and located the pliers of two Leatherman utility tools. We decided to use these as forceps on the arteries and secure them with electrical tape if amputations became necessary.
Dr. Chovanes' plan for the amputation was to use a cordless Sawzall reciprocating saw. He said he would lightly sedate McLoughlin with Valium and morphine. This was a risky medical option for sedation, because of the CNS and respiratory depressive effects of these drugs. If McLoughlin were to stop breathing, there would be no way to secure his airway because he was laying prone, and we wouldn't be able to administer Narcan during the complicated extrication in which many rescuers would be lifting him up the 45-degree angle steel beam.
Throughout the night and into the next morning, Dr. Chovanes and I rotated into the hole to monitor McLoughlin's condition and administer morphine. We had to re-establish IVs several times because the patent lines would occasionally be pulled out during the digging of dust and rubble that entrapped him.
Prior to the removal of the last debris from around McLoughlin's lower legs, I rotated into the hole and established IV access in his left antecubital fossa using a 16-gauge angiocath. Then I administered 1 L of saline mixed with 44 mEq of sodium bicarbonate. Within the hour, McLoughlin was freed and extricated on a backboard.
The rescue team pulled McLoughlin onto a nylon stretcher and then into a Stokes basket, and carefully dragged him up and out of the hole. Hundreds of rescuers passed him, hand-to-hand, to a waiting ambulance.
On arrival at Bellevue Hospital, McLoughlin was conscious and alert. He had no broken bones or other major traumatic injuries. His condition was diagnosed as Crush Syndrome. He eventually underwent more than 30 operations to remove dead tissue and muscle from his legs. He went into kidney failure during his hospital stay and was placed on periodic renal dialysis.
Soon after his hospitalization in the trauma center, McLoughlin developed life-threatening sepsis, was placed in a medically induced coma and kept on a respirator for about a month. He came very close to losing his legs and dying on more than one occasion during his months of hospital care. McLoughlin persevered and survived, however, and was eventually able to return to his home and job.
McLoughlin underwent years of physical therapy and was later promoted to lieutenant. He is retired now and doing well. He walks without the use of a cane or crutches.
I was the first paramedic to contact McLoughlin, 10 hours after the collapse and his entrapment, and I was the last person to provide his care when he was eventually freed, after nearly 22 hours. The only medical care he received throughout his entire ordeal was delivered by Dr. Chovanes and myself.
The Story Behind the Story
This was an amazing story to hear while driving through the New Mexico desert in 2004. But a few questions lingered in my mind. So I asked John, "Why did you call me to tell me this story now? I don't get it. That was three-and-a-half years ago."
Why Busching Called
Well, you know how it is, I'm sitting around the training center, talking, just passing time with one of the other instructors, Randy Miller, who is also a tactical paramedic. I told him the McLoughlin story and how the chief of surgery at the trauma center credited our care of McLoughlin during his entrapment with saving his life. I told Randy that I just wasn't sure it was true, because I didn't know enough about the patient's injuries and condition to fully understand what had gone on. Then Randy said to me, 'Yeah, that's some story. It sounds like he had Crush Syndrome.'"
I said, "The surgeon at St. Vincent's Hospital said that's what he had, but I'm not so sure why our care made any difference. I've looked up Crush Syndrome in the paramedic textbooks, and they have about two sentences that say to give oxygen and IV fluids. They really don't explain much about it."
Well, soon after we spoke about what happened that day, Randy remembered that he had purchased a copy of theJEMS [EMS Today] Conference tape on Crush Syndrome in 1999, so he gave it to me to listen to.(2) It really covered Crush Syndrome clearly and explained exactly what happened to McLoughlin that day. I passed it on to others in our department, and FDNY EMS is revising their training and protocols for Crush Syndrome based on the principles presented in that tape.
John Busching's telephone call to me was one of the best calls an EMS educator could ever hope to receive. I'm pleased and honored to be able to share the facts of this historic case with the readers of JEMS, but I also feel compelled to "beat the drum" about Crush Syndrome one more time. The pathophysiology is complex and can be challenging to understand, but the patient presentation with a history of being "crushed" and the prehospital treatment are easy to learn and carry out, and can mean the difference between life and death.
It's this simple: If the patient has been trapped with an object or debris compressing muscle mass (with distal pulses present) for at least four hours (or at least two hours with hypothermia), give the patient oxygen and start IV fluids prior to releasing the compression from the muscle mass and run the fluid at a rate of about 500 mL/hour, up to 3 L, or until you arrive at the hospital.
Put an amp of sodium bicarbonate in the second 1,000 mL bag that you infuse to counter the acidic toxins that will be released into your patient_s bloodstream when pressure is relieved from the compressed muscle mass. The sodium bicarbonate counteracts the highly toxic mixture of hemoglobin, high levels of potassium (hyperkalemia) and highly acidotic (metabolic acidosis) blood serum in the crushed areas. If this toxic mixture enters the patient's central circulation, the patient will be at high risk of sudden ventricular fibrillation, microemboli in the lungs and renal casts that will likely cause renal failure and result in death.(1,2)
In general, most patients do well with just oxygen, electrolyte IV lines and sodium bicarbonate administered as a slow infusion with every second bag of IV fluids. Patients who do not receive the appropriate treatment have a high mortality rate, with many dying of infections 20Ï26 weeks after they have been rescued.
The Nebraska Midlands Crush Syndrome Protocol that accompanies this article was approved by the Midlands Protocols Committee for the Metropolitan Omaha area in April 2006 and represents a progressive EMS system's approach to treating Crush Syndrome (see p. 62).
To learn more about Crush Syndrome, read the two review articles that are listed in the references. One, by Smith and Greaves, is in May 2003 Journal of Trauma, and the most recently published is by Sever, Vanholder and Lameire, in March 9, 2006, New England Journal of Medicine.(3,4) Also, you can read the January 2000 JEMS CE article that I authored.
One final note of thanks: Just as John Busching made a belated call to thank me for doing the Crush Syn_drome lecture and article for JEMS,I would like to offer belated thanks to Ronald D. Stewart, MD, my friend and mentor of 28 years, who first introduced me to Crush Syndrome and sent me off to lecture about it at the 1979 April-in-Indianapolis conference.
1. Mary Ann Littell: "First response to terror." The Magazine of the UMDNJ-SOM.www.umdnj.edu/umcweb/.
2. Raynovich W. "Crush Syndrome" (lecture and audio tape). EMS Today, Denver, 1999.
3. Smith J, Greaves I: "Crush injury and Crush Syndrome: A review." Journal of Trauma. 54(5 Suppl):S226-S230, 2003.
- Sever MS, Vanholder R, Lameire N: "Management of crush-related injuries after disasters." NEJM. 354(10):1052-1063, 2006.
- 4. Raynovich W: "Crush Syndrome: Indications and treatment options."JEMS. 25(1):82-92, 2000.
Crush Syndrome Protocol
*Approved by the Midlands Protocols Committee, April 5, 2006. Omaha-Western Region, Neb.
General Trauma, Acute Traumatic Emergencies, Crush Syndrome (aka Bywaters Syndrome)
This protocol should be applied to adult 150 kg patients who are being rescued from being trapped by having an extremity muscle mass compressed for more than four hours, or more than two hours in a cold climate, but also who have pulses distal to the compression. Preventive treatment for Crush Syndrome is secondary to primary interventions for acute traumatic injuries. The risks of Crush Syndrome are greater if the patient's extremity is hard, swollen, edematous, cold and insensitive.
A. Management -- Priorities for Treatment
a) Airway, Breathing, Circulation and C-Spine immobilization, as with all trauma patients.
b) High-flow oxygen at the time of release.
c) Two large-bore IVs of normal saline via regular administration set @ keep-vein-open rate prior to extrication and releasing compression.
d) Run the normal saline IV line wide-open at the time muscle compression is released; adjust the administration rate for the second bag to 500 mL per hour after the first bag has been infused.
e) Mix 50 cc of NaHCO3 into the second bag of normal saline.
f) Administer up to 3 L of normal saline (after ensuring clear lung sounds and no shortness of breath present), over the first 90 minutes following release of compression.