EMS Providers Recall 9/11

There was no way to fully plan for what happened on Sept. 11, 2001 because no one could ever have expected the massive loss of life and destruction that occurred simultaneously in New York City, Arlington, Va., and Shanksville, Pa.

“It was the unexpected times the unimaginable,” says Fire Department of New York (FDNY) Assistant EMS Chief John Peruggia.

Those who responded to 9/11 have not fully survived the event–because what they experienced has not ended. The trauma of that day continues to plague the physical and mental health of many of the responders and, in many cases, shatter their families in a never-ending reverberation of pain and suffering.

The reality is that the death toll from the attacks grows larger each year. And although physical wounds have healed, the emotional scars remain for many of the responders a decade after 9/11.

However, the ripple effect of that day hasn’t been all bad. In New York City, it has led to many positive changes, the likes of which even seasoned responders never imagined, including an internalized culture of safety that’s widely accepted and practiced; a newfound respect and cooperation between fire and EMS personnel; and even–gasp–New York City firefighters and police officers taking the first baby steps toward building a foundation of trust.

And in Arlington, Va., Shanksville, Pa., and New Jersey, fire and EMS agencies have developed a new mindset and operating procedures to control and coordinate responding personnel and stop the “self-dispatching” of resources to scenes.

None of these changes would have happened without the cataclysmic event we call 9/11. Ten years later, we look back and remember.

The Way We Were
The primary EMS provider for New York City is the FDNY EMS Division. In addition, more than 30 hospital systems (referred to as “voluntaries”) contract with the city to provide 9-1-1 response units, delivering full-time, professional BLS and ALS service to specific areas of the city. In 2001, there were approximately 950 ambulance tours every day for a city of more than eight million residents and countless tourists.

On 9/11, 24 EMS supervisors were involved in the World Trade Center incident, along with the crews from 29 ALS and 58 BLS units. Assuming each unit had a minimum two-member crew on board, nearly 200 EMTs and paramedics were on site when the towers fell. By evening, an estimated 400 additional EMS personnel had made their way to the World Trade Center.

Arlington
What many people failed to realize on 9/11 is that the Pentagon, while not as tall as the World Trade Center’s Twin Towers, was occupied by more than 23,000 people and is one of the world’s largest office buildings. The 6.5 million square-foot structure has 3.7 million square feet of office space, three times the floor space of the Empire State Building. The Capitol could fit into any one of the five wedge-shaped sections. It has 131 stairways, 19 escalators and 16 parking lots.

Because of the high security around the building that is headquarters to our nation’s Department of Defense, and its expansive security perimeter, which includes 200 acres of lawn, the Pentagon incident appeared to be much smaller than it actually was.

Although the death toll at the Pentagon was less than that at the World Trade Center, the same command and control, firefighting and associated physical and emotional stressors were present in the Arlington, Va., incident.

Edward Plaugher, now assistant executive director of the International Association of Fire Chiefs (IAFC), was a “two-hatter” at the Pentagon incident. He not only wore the hat of the Arlington County fire chief, but he was also the county’s emergency coordinator. Because of all the partners that were going to be there, he knew this particular incident was going to need a senior adviser. So that’s the role he assumed that morning.

Plaugher notes that because of the Pentagon and other government facilities located in the Arlington and the metropolitan Washington, D.C., region, emergency plans for major incidents and terrorist attacks were formulated years before 9/11.

One of the first things Plaugher did when he arrived on scene at the Pentagon was requisition a U.S. Park Police helicopter to do a thorough aerial survey of the damage and determine the true scope of the incident. It was an action that helped him understand the extent of damage that occurred as a result of the attack and helped him formulate a workable incident operation plan with the operations chiefs on scene.

Arlington Fire Rescue crews were also confronted with spectators that simply abandoned their vehicles on the adjacent highways, military personnel and others who self-dispatched to the scene and the rumors and reports of additional planes en route to the Pentagon. These factors forced emergency personnel to rapidly evacuate their patients and crews on more than one occasion during the incident.

Then the Towers Fell
The first EMS crews to arrive at the World Trade Center had established staging areas and began triaging patients, per protocols. They started transporting burned and traumatized patients to nearby hospitals. They dodged the falling bodies of people who elected to jump more than 100 stories to their deaths rather than die in the fires that raged on the upper floors of the north and south towers.

The responders who were there that day, say that the sound of those bodies crashing to the ground will haunt them for the rest of their lives.

Then the towers fell.

Surprised to find that they were still alive, the men and women who were on scene began what could be described as “the long climb to recovery.” Crawling out from under vehicles after what seemed like an hour of entrapment in a suffocating environment and wading through mountains of debris, they entered a new reality–a post-9/11 world. A world of darkness, choking air and “deafening silence.”

“It seemed like a terrible movie,” says FDNY Medical Director Glenn Asaeda, MD. “People just disappeared. I knew that they were gone, but it’s almost like, OK, everybody, come on out now.”

“I remember that first breath,” says Al Kim, executive director of Westchester (N.Y.) EMS. Searing hot and acrid, it could barely be called air.

Kim had been walking toward the lobby of the South Tower when it started to fall. Like many at the scene that day, he mistook the roar of the tumbling building for the third plane that was reportedly heading to New York. He dove under a New York Presbyterian Hospital sport-utility vehicle for protection.

When he finally emerged, a thick blanket of gray dust blocked the sun and covered everything within his limited eyesight. The eerie silence was pierced by a single sound–the PASS alarms of hundreds of firefighters. It’s an audible alarm that signals a firefighter is no longer moving. It was a sound he had never heard before–and never wants to hear again.

Physical Toll
The lasting effect of 9/11 is the physical and emotional toll that continues to plague those who responded. New York City’s officials estimate that more than 21,000 people who worked either on a paid or volunteer basis after 9/11 have developed physical and mental disorders as a result of their exposure to toxic substances and traumatic experiences. Most of the responders we spoke to for this article in New York; New Jersey; Arlington, Va.; and Shanksville, Pa., described some degree of physical or mental impairment. For many, the effects cost them their livelihoods and/or relationships.

Since 9/11, many serious health issues, such as chronic respiratory infections and gastrointestinal diseases, have been directly related to the acrid dust and smoke breathed by those on scene. Testing completed by the EPA in the days following the collapse of the towers revealed a complexity of chemical compounds and particulate structures unlike anything ever encountered.

Dust particles, especially those in the air immediately following the collapse of the buildings, were measured at 10 microns or less; particles so small that they are capable of doing damage regardless of the chemical content because of their ability to be inhaled and transferred deep into the lower lungs.

For years, first responders fought for health benefits to help pay for the expensive tests and treatments they required. Gradually, as studies acknowledged that the health issues were due to exposure to toxins as a result of the 9/11 attack, responders began to receive healthcare coverage, but how much and when varied widely.

On Jan. 2, 2010, President Barack Obama signed the “James Zadroga 9/11 Health and Compensation Act,” establishing the World Trade Health Program. It will provide $4.3 billion in federal funding for both treatment and financial compensation to those suffering effects of the attacks. This is a help, but due to the slow-moving wheels of bureaucracy, it comes very late for responders who had already endured years of fiscal, physical and emotional hardship. Some have already died.

Emotional Toll
Even 10 years later, many of the responders are haunted by quirks of fate that day. If a partner hadn’t been late to work, that crew would have been beneath the tower when it fell. If the building had held up for just a few seconds longer, another person wondered if they would have made it into the lobby and certain death. The decision not to take shelter in a subway stairwell or simply to run left instead of right, made the difference between life and death that horrible day. In psychiatric circles, these feelings are called “survivor’s guilt.”

For most of the personnel we interviewed, the initial anxiety has subsided, although several said they’re still uncomfortable above the third floor in high-rise buildings. Some say they have a tendency to hurry their patient out of high rises and into the confines of their ambulance located on the firm ground below.

However, many continue to be plagued by nightmares, especially as the anniversary of 9/11 approaches each year. Some are still being treated for post-traumatic stress disorder. A number of them no longer work in EMS. Some have sought professional counseling. Others wish they had.

“It was extremely difficult because most of us went back to work that day or the next day. We didn’t have any time off to sort of reflect and recover, which I’m not sure now was a good thing or a bad thing in the end,” FDNY EMS Division Chief Janice Olszewski says.

“When I drive past the site–and I do quite frequently–I still get little butterflies in my chest. I mean, all this time later,” she says. “That’s how strong this kind of [exposure to] trauma is.”

Others can’t bring themselves to look at the World Trade Center site. “I drive with my head turned away and hope I don’t hit a car in front of me,” says former FDNY EMT Frank Puma. After 11 years at FDNY, Puma retired following a non-9/11-related injury. “I try not to let it consume my life. I still have my issues with it, you know. Things that will never go away,” he says.

On 9/11, Robert Lahita, MD, PhD, was a physician and EMS medical director for Jersey City Medical Center, which provides ALS to Hudson County and BLS to Jersey City. He’s affectionately known to his EMS friends as Dr. Bob. Today he’s vice-president, chairman of medicine and director of quality at Newark Beth Israel Medical Center (part of the St. Barnabas Health Care system).

“I’m a seasoned physician who had seen death and destruction before, but nothing to this magnitude “¦ nothing like this. It bothered me and many other people for many months.

When you ask what the most vivid memory I have of 9/11 is, what represents the most emotional stress on me and many others that day, it was the smell; the smell of death.

That morning … You know, we’ve all smelled dead bodies; freshly dead bodies. I’m not talking about decomposed bodies [that have a distinctly different smell]. At Ground Zero, there was that smell of blood and death “¦ coupled with the smell of lots of things burning,” says Lahita.

“And there were trees that had no leaves. Pieces of clothing, like dresses and shoes and stuff. I would look up–there was catastrophe. I would look down–there was catastrophe. Everywhere I looked, things were burning. It was like something I’ve never seen. And I hope I never see it again. It came back to me recently when I saw images of Joplin, Mo. It was similar to that, but worse because at Ground Zero, there was also a sea of dust mixed in with all the wreckage!

One of the firemen I was working with a few days after 9/11 made an observation that’s still unfathomable to me and many others who were at Ground Zero. After the collapse, you did not see any contents of the towers that were intact or in their original composition; no chairs or desks or file cabinets, or windows or computers “¦ Just a lot of dust.

It was like everything was totally vaporized. And I mean that. There was nothing that was recognizable. Everything was literally vaporized,” Lahita says.

After 9/11, many say it was hard not to bring those emotions to work. Or worse yet, they bring them home.

Sean Boyle, a Bayonne (N.J.) firefighter and per diem EMT with Jersey City Medical Center, part of LibertyHealth in Jersey City, says that, since 9/11, he and many of his colleagues in EMS, fire and law enforcement no longer sit with their backs to the door when in a restaurant or other public place. He says, “Most responders today have the mindset that they have to walk around with their head on a constant swivel.”

Families
Relationships, marriages and family cohesiveness have also been significantly strained and broken in the aftermath of 9/11. Although there’s no official record, unofficial reports suggest that the divorce rate is high among 9/11 responders. It’s unclear whether the struggle just became too much for some relationships or, like some have suggested, surviving this country’s worst terrorist attack gave those responders a new sense of purpose and perspective.

“I think if you really take to heart that life is short and you should appreciate everything you have “¦ [and] not worry about the small stuff, then, that could take a toll on those around you; or it could be beneficial,” Kim says.

Part of the problem may have been that spouses were left out of the counseling loop. Although counseling was offered to the responders through work and to many of their children through their school, there was no organized effort to assist the wives, husbands and significant others who inherited the emotional victims who suddenly became quiet, silent or different inside.

Getting Help
“We were very fortunate in that we had a peer counseling program set up before 9/11,” says Jack Delaney, retired director of New York Presbyterian EMS. The problem, he says, is that some of our paramedics wouldn’t go for any kind of counseling because doing so could eliminate any chance of getting hired by the fire department. To work around that, New York Presbyterian established a peer counseling program.

“One of the most important aspects of our department before 9/11 was our focus on behavior health. Working with our Employee Assistance Program, we develop trusted relationships with their counselors that contributed to our overall wellbeing during and after the tragedy,” says Arlington County Fire Chief Jim Schwartz.

Responders like former FDNY Deputy Chief of EMS Charles R. Wells, who have taken advantage of the counseling, found it to be of significant benefit. “There’ve been setbacks along the way. You get nightmares. You get times where you have these feeling of impending doom. Thank God for the counseling unit … because they’ve been miracle workers, with me anyway,” he says.

In many cases, the relationships that allowed couples to share their love for EMS and their love for their partner seemed to cave under the excessive emotional pressure and attention the rescuers paid to the job or recovery efforts after 9/11.

To find closure, some responders needed to bring the event full circle. For Olszewski, it meant retracing that day’s steps. Initially it was hard to get her bearings, she says. The landscape is so dramatically different. One day, she returned to the front of the Millennium Hotel, where she was standing when the north tower fell. She walked past the church on the corner, the subway stairwell she nearly ran down into and finally onto Broadway Avenue and safety. “I felt better when I did that,” she reports.

Puma says it helps him to talk about it, but, like many others, he’ll only talk to people who were there that day. “In the beginning I didn’t want to talk about it to anybody,” he says. Eventually, his wife convinced him to open up a bit and participate. She reminded him that someday his baby boy is going to have questions about 9/11 and his father’s role on that terrible day. “Whether you like it or not, you’re a part of history,” she told him.

A few responders, like New York Downtown Hospital paramedic Juana Lomi, emerged from 9/11 feeling affirmed. At first, she says she spent days locked up in her room crying. But she was able to gain perspective by writing a personal journal about her experience and her feelings afterward.

“I think the whole incident “¦ was like a defining day, but it was also a day of confirmation of what I, we, live life to do,” she says. “I made it out of this one, so I better do something better. Keep doing what I’m doing, because it must have been “¦ God’s will that I be there and I should keep myself [in EMS] until I can’t do the job anymore,” she says.

Lomi is the only employee left at New York Downtown who responded to 9/11.

Lessons Learned
“Our system of regional automatic and mutual aid, developed over several decades, was a significant advantage. Units from our neighboring jurisdictions, with whom we work every day, fit into the response as if we were one organization.

Terrorism had been an area of focus for us before 9/11, and one of our most important partners was the FBI. They established a liaison with the Fire and EMS departments in the region in 1999 and were training with us on the morning of September 11,” says Schwartz.

Since 9/11, FDNY approaches EMS and fire operations differently. “We all talk about our careers as before September 11th and after September 11th, and it’s been totally different,” says FDNY Fire Commissioner Salvatore J. Cassano. “It certainly has changed the way we do business. It’s changed the way we think about our job in that we don’t just fight fires anymore. We have so many other responsibilities.”

The first order of business for FDNY was to assign new leaders for the fire department. When the towers fell, the FDNY lost Chief of Department Peter J. Ganci, First Deputy Commissioner William Feehan and 21 other chiefs. Lost with them was significant experience, institutional memory and decades of succession planning.

Those who were left had to step up. On the morning of 9/11, Cassano was a citywide tour commander. Within 24 hours, he was named acting chief of operations, second only to the chief of the department. The formal promotion came just days later. He vowed to institute changes that would guarantee this type of catastrophic leadership void would never happen again.

To that end, FDNY embraced the National Incident Management System (NIMS), putting its own twist on it and dubbing it Citywide Incident Management System. With the help of a NIMS team from the Southwest IMT, FDNY has learned how to better staff and manage long-term incidents, sending only those who need to be at the scene directly to the incident site.

A state-of-the-art fire operations center at FDNY headquarters in Brooklyn was created after 9/11 and now uses live video feeds from police helicopters and Department of Transportation cameras, digital photography, and multiple maps and displays to give ranking officers a global view of an incident and avoid the need to have all command officers on scene to direct operations.

To groom future leaders, the department began an aggressive leadership training program. “We send our staff chiefs to all kinds of management schools,” Cassano says.

In 2002, the fire department established the FDNY Fire Officer’s Management Institute (FOMI), an executive program to provide fire and EMS chiefs with leadership and management training.

In 2004, then EMS Chief Peruggia became the first member of the FDNY to complete the National Fire Academy’s Executive Fire Officer Program, a four-year course aimed to develop leaders in the field of fire service. Since then, six more officers have participated in the program, including Olszewski.

A New Culture of Safety
EMS and fire personnel have a new perspective on safety since 9/11. Looking at the risk/reward through a different lens, the safety of the EMS providers is paramount. “We’re the ones who are going to have to treat the patients, so it’s better to take a safer approach,” says FDNY EMS Command Chief Abdo Nahmod. “We have learned to work smarter and safer.”

New “recall packages” deploy personnel depending on the type and size of an incident. A recall may now involve only 25% of personnel, leaving 50% to relieve the other 50%. Or, if the incident warrants it, only special operations command personnel may be recalled.

The Arlington County Fire Department now uses a special ID and reporting system, as well as a color code that tells their personnel to call what off-duty staff is being requested to respond.

According to Cassano, FDNY has quadrupled training since 9/11. “We got fanatical about training, and between training and safety, we’ve been pushing each incredibly hard since then,” Olszewski says.

FDNY’s Certified First Responder Program is helping to improve the relationship between FDNY firefighters and EMS personnel. The program is also part of the curriculum for all probationary firefighters. “It just becomes part of their job vs. something that’s thrust upon them that they didn’t bargain for,” Olszewski says.

Other joint training efforts include firefighter Mayday drills that involve EMS crews. Previously, firefighters would run right past EMS crews with an injured firefighter, not knowing exactly where to take them. Today, Olszewski says the emphasis is, “Bring them to me. I care. I want to help him. I think that’s a big deal,” she says. FDNY also now offers a formal rehab process for its members at all major incidents.

Nahmod and his colleagues in Virginia, and Pennsylvania say that all agencies have learned an important lesson about collaboration since 9/11. “No one agency can handle an incident like this,” he says. “It’s the dialogue that makes it happen, not the technology. You have to figure out a way to collaborate.” FDNY does close to 100 drills with various agencies. It has also established inter-agency liaisons with police and fire to address issues before they become unmanageable. Nahmod admits that there are no Kumbaya sessions yet, but it’s a start.

New Programs
“We in EMS here in New York City have learned to adapt to the ever-changing threat landscape,” Peruggia says. “We are doing great things to serve the people we protect.” In the fall of 2011, the EMS Division will deploy a new, triage tag with an orange triage level to identify patients who develop a major medical issue as a result of the incident, not because of it.

“Initially those kind of chest pain or difficulty breathing patients were tagged green because they would be the walking wounded,” Asaeda says. But even with diligent re-triaging, these patients can get lost in a mass-casualty incident. The orange tag category now allows EMS personnel to identify these patients early as a medical triage and get them the treatment they need.

Increased Awareness
There are fewer and fewer of the first-to-arrive 9/11 responders left working in New York City and Arlington. Those who are still on the job are different. They’ve seen the face of evil, and it has changed the way they work and train. “We realized now “¦ it has affected many, many people, and we just don’t know to what extent,” Asaeda says.

Olszewski says she knows from her firsthand experience on 9/11 that she may again need to deploy the new protective equipment, such as the compact respirator assigned to each member. For others, it may be just another piece of equipment to leave on the ambulance. “But having been through 9/11, I take it with me. And I encourage those under my command to do the same,” she says.

Orlando Martinez was promoted to lieutenant this past February. As a FDNY EMS officer, he finds that his experience 10 years ago as a responder on 9/11 gives him a valuable perspective. “I’m definitely more aware,” he says. He’s also very protective about the younger personnel working the job. “I’m there for their safety,” he says. “And I’m very emphatic in my orders for the crews to wear the protective gear issued to them.”

For Martinez and his colleagues who responded to the Pentagon, their hyperawareness doesn’t end when their shifts are over. The responders are now aware of all the exits when they are in public places. “It’s always in the back of my mind,” says Martinez. The negative aspect of this new “watch your back” thought process is that it has subtly added extra stress to the lives of responders and their families when they’re supposed to be “off duty.”

What’s Next?
Everyone has their own ideas about what the next attack would look like. Cassano says it doesn’t really matter. It may not be a terrorist attack; it could be a tornado. Rather than focus solely on terrorist attacks, FDNY takes an all-hazards approach to major incidents, something Cassano says all emergency providers, no matter where they live, should consider.

The key is to provide for the safety of emergency workers so they can provide for the safety of the public they serve.

Cassano says that the personnel at FDNY feel a profound gratitude for all the assistance they received following the attacks and they want to give back. “We’d love to share what we’ve learned,” he says.

“We needed a lot of help to recover after September 11th, and we got it from a lot of different departments throughout the city “¦ state, the country, the world. Whether you’re the smallest department in the country or whether the FDNY, we’re all in this battle together,” he says.

Conclusion
As the 10th anniversary of 9/11 approaches, many of the responders we spoke with said they choose not to participate and, in fact, many who can, plan to leave town during the event.

The reality is that the responders to each 9/11 attack site will never be able to forget what they heard, felt, saw and struggled with that awful day. Each responder realizes that they must move on with some semblance of normalcy in their lives. And each agency involved in the 9/11 incidents has learned much from their experiences, struggles and stresses. They’ve instituted new processes to better manage incidents in the future. JEMS

Flight 93
Jill Miller, manager of the Somerset Area (Pa.) Ambulance Association on 9/11, responded to the crash of United Airlines Flight 93 in Shanksville, Pa., as a paramedic on the second-arriving ambulance. She then assumed the position of on-site EMS coordinator.

“What I remember most about that day is the utter shock that there was actually a plane that had crashed. The plane crashed into unsettled Earth, which was then thrust into the air and completely covered in the ground. There was very little debris and even fewer pieces that appeared to be from a plane.

Several days after the incident, when I was made aware that the plane was actually beneath the ground where we first parked and walked, I could not fathom the possibility of it all. I remember that it was one of the most beautiful fall days I could ever recall. The sky was bright blue, and the sun was shining. I pay more attention to those kinds of days now,” she says.

Christian Boyd, a full-time EMT with Somerset Ambulance that day, realized that in less than five minutes, there were no survivors, and there would be few intact bodies to be recovered.

Boyd says that no matter how he tries to forget the crash of Flight 93, he still has vivid memories and subtle reminders of the incident. And, like other responders from New York City and Arlington, Va., after that day, he initially refrained from returning to the crash site. It wasn’t until November 2002 that Boyd drove past the site.

This article originally appeared in September 2011 JEMS as “10 Years Later: Living in a post-9/11 world.”