Everyone in America has their own story about that day--where they were, what they were doing, thinking, feeling on Sept. 11, 2001. But for the emergency responders who worked in and around New York City, that day doesn't just haunt them. For some, it's killing them.
In the immediate aftermath, those who died were hailed as heroes, and the country rightly swore to never forget their sacrifice. But it seems manyhave been forgotten. Reports are surfacing of serious physical conditions, and even death, among those who risked their lives to rescue the survivors and recover the dead. So far, three EMS personnel have died of what many believe to be the effects of toxic air they breathed while responding to the terrorist attacks.
Although their sacrifice has been less publicized than that of the firefighters or police officers, it's no less heroic. They risked their own lives to save the lives of others because, as one rescuer puts it, "That's what EMS does."
The massive explosion caused by the jet fuel of two planes, each carrying approximately 90,000 liters of fuel, created an enormous cloud of super-pulverized dust. Thousands of plate-glass windows disintegrated into billions of microscopic pieces of lung-destroying silica glass. The destruction of theTwinTowers turned 5,000 tons of asbestos into plumes of cancer-causing fibers.
Those who survived the collapse thought they would die of suffocation from the engulfing cloud. "It was like someone took your face and put it in sand. That's how bad it was," says Katherine Zarr, formerly a paramedic with the Fire Department of New York EMS (FDNY EMS). She has since left her job due to severe respiratory disease and other health problems.
When Hunter Ambulance EMT Dominic Heavey and an injured police officer crawled out from under an emergency services truck where they had sought shelter from the collapsing towers, the devastation was so complete that Heavey's first thought was, "God, don't let us be the only two people alive in lower Manhattan."
Everything that had been in theTwinTowers was completely destroyed. "There were 220 stories of office buildings but you didn't see a chair, a desk, a phone. Nothing. Just dust," says Jay Robbins, an EMT working for TransCare, formerly MetroCare Ambulance.
Within the first two hours after the collapse, FDNY EMS had improvised a safety sector, says Deputy Assistant Chief of EMS John McFarland. Emergency services personnel were instructed to wear masks, helmets and boots. However, not all rescuers had access to appropriate personal protective equipment (PPE) and even when available, masks were not always worn. According to McFarland, respiratory protection was enforced starting Sept. 13, and the department began dispensing respirator masks with cartridges.
Unprecedented health risk
The acrid dust and smoke created a health risk on a scale never before seen inU.S. history. Even after the initial collapse, fumes from the resulting fires continued to belch dangerous clouds of soot and noxious gas into the air for nearly four months.
Environmental Protection Agency (EPA) testing completed days after the collapse of the towers found elevated levels of benzene, dioxins, polychlorinated biphenyls (PCBs), lead and chromium still in the air. The complexity of the chemical compounds and particulate structure was unlike anything ever encountered.
David Newman, an industrial hygienist with the New York Committee for Occupational Safety and Health (NYCOSH), says that many of the dust particles, especially those in the air immediately following the collapse of the buildings, were measured at 10 microns or less. Particles that small are capable of doing damage regardless of the chemical content because of their ability to be inhaled deep into the lower lungs.
As a result, the time of the responder's arrival appears to be associated with the presence and degree of health problems. Studies have shown that the firefighters who arrived on scene prior to the collapse of the towers are significantly more likely to experience respiratory problems compared with those who arrived later.(1)
Who was exposed?
Twenty-four EMS supervisors were present along with the crews from 29 ALS units and 58 BLS units. Assuming the units had a minimum two-member crew on board, nearly 200 EMTs and paramedics were on site when the towers fell. By evening, approximately 400 additionalEMS personnel had made their way to the World Trade Center (WTC).
The primary EMS provider forNew York City is the FDNY EMS Command. The fire department contracts with hospitalEMS services (referred to as voluntary hospitals although the crews are paid employees) to supplement day-to-day 9-1-1 response. Both FDNY and the voluntaries responded to the WTC attacks along with volunteer and commercial ambulance services.
It has been widely reported in theNew York press that up to one-third of the 40,000 EMS personnel, firefighters, police and port authority offers involved in the rescue and recovery efforts are now ill.
After 60 months
Five years later, questions still loom about the health effects resulting from lengthy exposure to the toxic air. Despite recent deaths among rescue workers and numerous complaints of serious health issues, it remains difficult to demonstrate a direct correlation between the toxic air at ground zero and later health complaints.
"You wore [respirators] as long as you could, but they would just get saturated." --Adam Armstrong, Paramedic, FDNY
As a member of FDNY's hazmat-tactical unit and also a volunteer firefighter, paramedic Adam Armstrong was used to wearing self-contained breathing apparatus (SCBA).
However, the scorching sun and the heat of the fires, combined with the hard work of moving debris, made it difficult for those who seldom wear the gear to keep their respirators on their faces.
Regardless of whether masks were worn or not, Armstrong says, "We all have some form of respiratory problem."
The EMTs and paramedics interviewed for this story report they suffer from a persistent, hacking cough and/or insomnia, anxiety and post-traumatic stress disorder (PTSD). Some have recovered and report no further problems. Others experienced suspicious sinus and respiratory infections or periodic gastrointestinal issues, but have no ongoing complaints. Still others suffer effects so debilitating they've had to leave their jobs.
A study in the American Journal of Respiratory and Critical Care Medicine confirmed that emergency responders suffered breathing problems as a result of their work at ground zero.(2) Researchers compared baseline breathing tests taken in 1997 with results from tests conducted in 2002. Within the first year of the attacks, rescuers who had the highest exposure at ground zero were suffering a decrease in lung function capability equal to 12 years of age-related decline. A follow-up study is planned.
"We were actually criticized for going, but we felt we did what we were supposed to do." --Paramedics Pam Carlton and Ed Handler, Bravo Voluntary Ambulance Service
"We're the standard Tuesday morning crew," Pam Carlton says of herself and her partner Ed Handler. Both are long-time paramedics with the Brooklyn-based ambulance service. Along with EMT Aron Waks, they were dispatched to the site and were transporting a woman having an asthma attack when the towers collapsed. "She saved our lives," Carlton says.
Some in their organization felt they shouldn't have gone, since it left their area without coverage.
Other studies focusing on World Trade Center building survivors have yielded similar results. A CDC study of the health effects among adult survivors of collapsed and damaged buildings, excluding rescue or recovery workers, found that since 9/11, more than half reported new or worsening respiratory symptoms, a quarter reported experiencing heartburn or acid reflux, and two of 10 participants suffered severe headaches.(3) The study concludes, "The long-term ramifications of these effects are unknown."
Many of those who are ill point to governmental lapses in the days after the attack. The Environmental Protection Agency (EPA), the federal agency tasked with evaluating, mitigating and controlling risks to human health from exposure to air pollutants, was roundly criticized for providing false reassurances about the air quality following the collapse of the Twin Towers.
"Nobody down there ever raised a red flag. We are trained [that] when you say 'Hazmat,' everyone backs off. Nobody said, 'Hazmat.'" --Lt. William Gleason, EMT, FDNY EMS, Retired due to disability
"The last time I breathed air through my nose was Sept. 12," William Gleason says. On Sept. 16, he suffered the first of what would be numerous upper respiratory illnesses.
Despite ongoing sinus and respiratory infections, and even surgery, Gleason continued to return to ground zero, logging more than 100 hours at the site. By the end of 2004, the doctors at FDNY recommended he retire on disability. He is totally, permanently disabled, and he blames the EPA.
"I'm sick because it was the EPA's and DEP's [Department of Environmental Protection] job to warn us, and they didn't," he says.
A week after the attacks, then EPA Chief Christine Whitman announced that the air quality was "safe' to breathe," thus authorizing the return of the general population to lower Manhattan.
According to a report released in 2003 by the EPA inspector general, the agency "did not have sufficient data and analyses to make such a blanket statement." Air monitoring data, the report says, was lacking for several pollutants of concern, including particulate matter and PCBs.
Further, the inspector general found evidence that "the White House Council on Environmental Quality influenced, through the collaboration process, the information that the EPA communicated to the public through its early press releases when it convinced EPA to add reassuring statements and delete cautionary ones."(4)
The report concludes, "a definitive answer to whether the air was safe to breathe may not be settled for years to come."
Tip of the iceberg
Researchers expect many more responders to become ill--a fact that was painfully apparent to those interviewed for this story. Some illnesses, particularly asbestosis, cancer and mesothelioma, can take up to 15 years to surface, they say.
"I think you're going to see people who are going to develop nasty diseases," says Jack Delaney, director of emergency services for New York PresbyterianHospital.
So far three medical services personnel, all from FDNY EMS, have died of illnesses related to 9/11. EMT Tim Keller, 41, died on June 23, 2005, after prolonged health problems. Felix Hernandez Jr., a 31-year-old EMT, died of respiratory disease two months to the day after Keller. Paramedic Debbie Reeve, 41, died of a rare lung cancer on March 15, 2006.
Most of the rescuers interviewed for this story are worried. Some said so outright, and others exhibited it by their facial expressions or pauses in conversation during our interviews.
Those who become ill must enter a bureaucratic morass of pension review boards and worker's compensation paperwork.
Members of FDNY EMS are eligible for pension benefits and Line of Duty Insurance (LODI). As city employees, they may also submit a claim for worker's compensation. EMTs and paramedics who work for the hospital services may receive worker's compensation and benefits according to their employer's compensation package.
"I miss my job. I really do. I'm only 39 [years old]." --Katherine Zarr, Paramedic, FDNY EMS, Retired due to disability
Katherine Zarr, a 20-year EMS veteran, was setting up a triage area near the towers when they fell, enveloping her in dust and debris. Today, she is home on disability and will probably never work again. "I used to hold three jobs before [9/11]. Now I walk up a flight of stairs, and I'm out of breath," she says.
Since the terrorist attacks, she has been admitted to the hospital 29 times with respiratory problems and takes 22 medications daily. Zarr also suffers severe panic attacks and has been diagnosed with post-traumatic stress disorder (PTSD).
"I really wish I was the person I was before this," she says. "I would give my right arm not to have been there."
FDNY offers counseling services and has a dedicated worker's compensation coordinator just for EMS (www.nyc.gov/html/fdny/html/units/csu/index.shtml). Deputy EMS Chief Jay Swithers' job is to serve as a liaison between individual FDNY EMS personnel and the worker's compensation system. He is also a paramedic and was present at both the 1993 and 2001 attacks on the WTC. "I know first hand exactly what they're talking about," he says.
Because EMS duties don't normally put crews in the position to develop respiratory diseases, such as the kind often seen in veteran firefighters, the worker's compensation board had considered 9/11-related health issues the same as an on-the-job injury. Employing that standard, all injuries or illnesses as a result of the incident needed to be documented and claims submitted within two years.
However, most of the illness began appearing after 2003, and claims filed after the two-year deadline have been denied. An appeals process is in place for denied claims, but it adds significantly to an already lengthy procedure. If the worker's compensation claim is denied, LODI is also denied.
Swithers admits the process isn't easy, but if the proper steps are followed in the proper sequence, most worker's compensation claims will be accepted. It also helps that department members are required to take annual physicals because those records document the change in health. Swithers says he's getting about a dozen inquiries per week.
It continues to frustrate FDNY EMS personnel that the firefighters, because they are self-insured and have their own pension, don't have to go through worker's compensation hearings or the New York City Employees' Retirement System (NYCERS). However, the situation can be even more desperate for emergency personnel who work for the hospitals, volunteer services or private ambulance companies, many of whom are left to fight compensation battles on their own.
Fighting through the process
Given the nature of Lt. Roger Moore's injuries, it seems that his claims would have been approved without much fuss. An EMT lieutenant with FDNY EMS, he had been at the command post at the WTC site when the first tower came crashing to the ground. As he was running from the collapse, he fell and caught the edge of a curb just above his kneecaps, rupturing both quadriceps bilaterally and fracturing his elbow.
As the dense cloud dissipated somewhat, two firefighters carried him to the relative safety of the American Express building and up three flights of stairs as the second tower fell. When a police launch took him away to New York Medical Center, Moore lost track of the firefighters. "I never got their names," he laments.
After two surgeries, he is still barely able to walk. He has a severe cough and never regained his sense of smell. His doctors say there is nothing more they can do for him and that he'll eventually need to use a wheelchair.
As a fire department employee, he received LODI benefits and unlimited sick leave. But he had to hire an attorney, at a cost of $8,000, to successfully fight for disability benefits. He did not apply for worker's compensation because any money he would have received would have been deducted from his pension.
Marianne Pizzitola, pension and benefit coordinator for the Uniformed EMS Officers Union, sees it time and again. "The only way to fight is through the process," she says. The biggest problem, she says, is that it simply takes too long for seriously ill people to successfully complete the process, especially if it goes through appeals. "The dust isn't the issue," Pizzitola says. "The issue is getting someone to say [that] we're sick because of what was in the dust."
"Part of me died that day. I will never get that person back." --Bonnie Jean Giebfried, EMT, Flushing Hospital Medical Center, on extended social security disability
An active, healthy person until fall 2001, Bonnie Jean Giebfried says she never failed a physical until after 9/11. Now she has $60,000 in outstanding medical bills for PTSD as a result of her experiences.
"We went from heroes to zeros," she says. "That day we were the cavalry and the ASH units for a war we didn't sign up for, but we stayed and did our jobs. We didn't run away."
She spends her time helping others navigate the worker's compensation system. She has also become a reverend and has founded a survivor network called, "Heroes Helping Heroes," to assist first responders and their families.
The untold story, she says, is the struggle faced by family members of survivors.
That break may have finally arrived. Earlier this year, New York Police Detective James Zadroga's death became the first officially linked directly to 9/11. A coroner's report confirmed that Zadroga died as a direct result of inhaling toxic fumes at ground zero.
New York Governor George E. Pataki recently signed a bill that allows EMS personnel to retire with three-quarters benefits, bringing them in line with firefighter and police officer pensions. The law increases the pension of FDNY EMS personnel who worked more than 40 hours at the WTC or the Freshkills landfill where the rubble was disposed. The new law also covers EMS workers who were at the WTC site during the first two days.
On August 14, Pataki signed another bill that amends the worker's compensation law for 9/11 first responders. The governor initially opposed the bill because of the cost to the city and the lack of a definitive link between the health problems that workers suffered and 9/11.
The new bill eliminates the 2003 filing deadline and extends the filing window for claims. Now, responders may submit claims up to two years after becoming ill and will no longer have to prove that they are ill due to breathing toxic air at ground zero. The new law will also cover treatment costs while responders wait for their claims to be processed. Paid and unpaid rescue workers who were previously denied will be allowed to file a new claim.
Registries & monitoring programs
The multifaceted nature of New York City's EMS system means there's no unified place for information or assistance. That task is being handled, in part, by the World Trade Center Registry (www.wtcregistry.org).
Soon after the disaster, the New York City Department of Health and Mental Hygiene proposed the formation of a registry to track individuals who had been exposed to toxic fumes at ground zero. Since it was established in July 2002, the World Trade Center Health Registry has become the largest environmental health registry created in the U.S.(5)
As of June 2006, more than 70,000 people have enrolled. It's open to all who responded to the 9/11 attacks, regardless of where they live.
Other programs include the National Institutes for Occupational Safety and Health-sponsored WTC Medical Monitoring Program. It offers workshops, including one titled, "Accessing worker's compensation and related benefits." The program provides free, confidential medical monitoring examinations to workers and volunteers who responded to the attacks. Mental health assessments are offered as well.
Medical screening is also available through the WTC Worker and Volunteer Medical Screening Program at Mount Sinai Medical Center in Manhattan.
Asked about his ability to work as people were jumping to their deaths all around him, FDNY paramedic Adam Armstrong responded, "We face death all the time. We get very adept at going into action mode at the time and think about it later."
Because those in the EMS profession are used to witnessing unsettling sights, it's all the more upsetting to see prehospital providers in such emotional pain about 9/11. Among the most traumatic events reported were seeing civilians jump from the towers, watching co-workers die and losing track of their partner even for a few hours.
Marvin Bethea, a paramedic with St. John's Queens Hospital, who has since retired on disability because of the 9/11 attacks, says it was like an entire career had been compressed into one call. "If those buildings hadn't come down, we would have been treating thousands of patients." Instead, emergency crews waited all day for patients who never came.
Ambulance personnel stationed at the site to treat recovery workers say the most common complaints were eye irritation and respiratory problems, although there were also fractures, sprains and strains, and occasional chest pains. "Psychological trauma was evident, but not treated at the time," says Eric Jimenez, a paramedic with St. Vincent's Hospital who worked standby at the site. "People were very on edge. Others were depressed and withdrawn."
EMS in New York City
The primary EMS provider forNew York City is the Fire Department ofNew York (FDNY) EMS Division. More than 50 voluntary hospital systems contract with the city to provide additional 9-1-1 response units. They provide full-time, professional BLS and ALS service to specific areas of the city. Community-based volunteer ambulance corps cover neighborhoods during the evening hours.
Number of EMS calls in 2005: 1,141,114
Number of patient transports in 2005: 850,000
Number of FDNY EMS personnel: 2,900
Number of FDNY EMS stations (including two combined fire/EMS stations): 31
Average number of EMS calls per day: 3,100
Total number of ambulance tours per day: 957
Number of FDNY tours per day: (219 tours at peak) 575 eight-hour tours
Estimated number of voluntary hospital tours per day: 382
Estimated number of volunteer corps: 35
Size: 321.8 square miles
Area Description: New York City consists of five boroughs, each of which is a county. Brooklyn (KingsCounty) and Queens occupy the western portion of Long Island; Staten Island (Richmond County) and Manhattan are completely on their own landmasses. The Bronx, to the north, is attached to the New York State mainland.
Sources: Fire Department ofNew York Web site, FDNY officials, Regional Emergency Medical Services Council (REMSCO) of New York City.
"I can now live with the images. They're not as vivid, not as haunting."
--Lt. Richard Erdey, EMT, FDNY EMS
Richard Erdey, an FDNY EMS EMT, says one of his worst memories is of an unidentified EMT wearing an orange helmet with yellow trim, who walked out of the dust toward him immediately after the collapse. The EMT said he was looking for his father, a firefighter. Erdey convinced him to get into the ambulance, but the young man later escaped when the unit stopped. "He went back into the dust, and I couldn't find him," Erdey says. "It still bothers me. I want to know who he was and if he is OK. That would give me full closure."
Every EMT or paramedic interviewed for this story report they experienced, or continue to experience, physical and emotional issues. Officials at FDNY EMS and the voluntary hospital EMS services acknowledge that they have seen an increase in smoking, drinking, angry outbursts and marital problems among their employees. Some interviewed say they have haunting memories of the day. One says he has contemplated suicide.
Although both FDNY and the voluntary hospitals offered critical incident stress debriefings (CISD), most of those interviewed say they have been skeptical about taking advantage of the counseling for fear that what they said would end up in their records.
"I thought this was going to be my last day on the job. I couldn't go on knowing I sent people out to die." --Capt. Dawn Diaz, Paramedic, FDNY EMS
When then Lieutenant Dawn Diaz, a 17-year veteran at FDNY EMS, got the call that a plane had hit the World Trade Center, she dispatched one of her best crews thinking, like everyone else, that a small plane had accidentally flown into the tower.
As it became evident the incident was much more serious, she was required to stay behind to run the operation, recall personnel and set up extra ambulances. "Throughout all of that, in the back of my head, I'm thinking I sent these guys to die," she says.
Twelve hours later, her crew returned safely. To this day, discussing it brings tears to her eyes.
Several EMTs and paramedics mention that they prefer the peer-to-peer CISD sessions coordinated by the Regional EMS Council of New York City (REMSCO).
The forgotten remain loyal
When New York City furnished to the media a list of the rescuers who had perished, Dominic Heavey with Hunter Ambulance says he was particularly upset to see that after the names of the firefighters and police officers, at the very end of the list, was "Others." Included in that category was Heavey's partner Mark Schwartz and MetroCare Ambulance EMT Yamel Merino. "That made me really angry," he says.
A common frustration among EMS workers is that they are seldom mentioned in discussions of 9/11 heroes. At a special screening of the World Trade Center, the new movie directed by Oliver Stone, it was noted that the film ended with a dramatic black screen that listed the numbers of New York firefighters, police and Port Authority personnel who were lost that day. Although fire department EMTs and paramedics were depicted EMS losses were not listed. The two EMS members of FDNY, Carlos Lillo and Ricardo Quinn, were included as New York City firefighters who died on Sept. 11.
The irony is not lost on some inEMS. "I never heard anyone screaming for a cop or firefighter that day," St. John's Queens Hospital paramedic Marvin Bethea says. Regardless, if New York City becomes the target of another terrorist attack, EMS would still be there. "They know we wouldn't let people die. No matter how badly they treat us," he says.
'"'m supposed to save lives, not be one of the victims." --Eric Jimenez, Paramedic, St. Vincent's HospitalÏManhattan
When Eric Jimenez finally returned to St. Vincent's Hospital on 9/11, he was so covered in dust he was nicknamed, "Powder," a name he keeps to this day.
What concerns Jimenez the most is what happens next time. "I don't feel safer. I feel we are underprepared," he says. "Unfortunately, we are not learning from our mistakes. It's just another disaster waiting to happen."
The Department of Homeland Security offers free training, but Jimenez and his co-workers must use their vacation time to attend. Every so often, the hospital offers classes for additional training, he says. "The first thing they tell you is that they expect some of us to die. That was definitely not in my job description," Jimenez says.
After six years, Jimenez says he doesn't want to be a paramedic in New York City any more.
1. Prezant DJ, Weiden M, Banauch GI. "Cough and bronchial responsiveness in firefighters at the World Trade Center site." New England Journal of Medicine. 2002;347:896-815.
2. Banauch GI, Hall C, Weiden M. "Pulmonary function after exposure to the World Trade Center collapse in the New York City Fire Department." American Journal of Respiratory and Critical Care Medicine. 2006;174:312-319.