During the great history of the Fire Department of the City of New York (FDNY), no single day has been more devastating than September 11 2001: the day our nation, city and values were attacked by terrorists. The day when World Trade Center (WTC) Towers 1, 2, 3, and 7 burned and collapsed. The day when nearly 3,000 people were murdered, together with 343 first responders including Chief of Department, the First Deputy Fire Commissioner, a FDNY chaplain, paramedics and firefighters. Despite overwhelming losses, the members of the department orchestrated one of the largest successful evacuations of civilians in recorded history – estimated at over 25,000 civilians. For ten months, through the summer of 2002, they continued to work tirelessly in rescue and recovery operations, often while overwhelmed with grief due to the personal loss of loved ones and coworkers. They attended hundreds of funerals and memorial services of fallen friends and colleagues.
A 2016 Pew Research survey of over 2,000 American adults found that roughly 75% include September 11 as one of the 10 events in their lifetime with the greatest impact on the country, a proportion that largely overshadowed other modern events in historical significance.1 More broadly, millennials in a 2009 survey reported the 9/11 terrorist attacks as the most important influence in shaping attitudes and beliefs of their generation.2 Post-9/11 patriotism swept the nation and civic engagement was at an all-time high. Blood banks were overwhelmed with donations;3 an estimated 74%-82% of people displayed the American flag on their homes, cars or selves;4 emergency medical service (EMS) providers, firefighters, police officers and many others from around the country volunteered time, supplies and manpower to the WTC rescue and recovery effort.5 Even for the most seasoned rescue/recovery worker, this was no average task.
After 9/11, our goal as a department was to come together in ways that would make us stronger, smarter, and better prepared for the future: by creating a more resilient department and city. Twenty years after the attacks on the World Trade Center, we realize more than ever that preparedness has the power to differentiate between life and death. In this review, we detail the changes that have taken place over the years, from personnel to communication to healthcare, in order to best meet increasing demands of the FDNY Emergency Medical Services.
Rebuilding a Department, a City
After 9/11, FDNY leadership recognized broad organizational change was necessary for the department to adapt its response operations to unpredictable all-hazards threats.
The Bureau of EMS is responsible for ensuring the timely delivery of quality prehospital healthcare through the New York City 911 system. Key areas of focus include the coordination of medical resources at the scene of assignments, management of EMS operations at mass casualty incidents (MCIs), and timely delivery of patients from the scene of assignments to appropriate 911 receiving facilities: general receiving emergency departments, specialty centers (e.g. trauma, burn, hypothermia, myocardial infarct, stroke, sexual assault, mental health) and most recently, alternative destinations (urgent care centers and clinics specializing in mental health support/treatment).
Additionally, FDNY leadership ushered in an immense number of technological and equipment enhancements creating a safe and robust system for EMS providers and firefighters. The specialized training and equipment employed by EMS providers brings the FDNY to the forefront in cutting-edge prehospital emergency medical care.
Planning: Under the leadership of many talented and dedicated people, the department was able to hire and train thousands of new EMS providers and firefighters, replace its damaged fleet of apparatus, and redefine its mission by training every member in disaster response, terrorism awareness and the Incident Command System (ICS). The department established a tiered response matrix by enhancing the Special Operations Command (SOC), and training/equipping dozens of specialized field units to respond to major emergencies, Haz-mat situations, and MCIs. Working with our hospital partners in the 911 system, we developed a fixed allotment patient allocation system during MCIs. This can be automatically scaled up based on the number of injured patients. The department is currently piloting a program where teams consisting of EMTs and clinical social workers provide specialized on-scene care to patients with mental health emergencies.
Working with our federal partners, we have utilized the Medicare database to identify severely disabled persons who are in need of evacuation during power outages. In the near future, FDNY will work with federal, state and private insurers to provide alternative care options such as telemedicine and transport patients to locations other than emergency departments for those with less severe illness.
Training: One truism came to the forefront in the wake of 9/11–preparedness starts with training. In addition to EMS merging with Fire Operations in 1996, FDNY now is a major player in our homeland’s defense against disasters – both natural and human-made. Post 9/11, the EMS Academy had to refine and restart their training programs to reflect the new world in which we were living. In addition to the core EMS competencies (CFR, BLS, ALS), the EMS Academy integrated interdisciplinary training within the department as well as interagency training with other municipal agencies (i.e. New York Police Department and New York City Emergency Management), federal agencies, and other 911 stakeholders, including hospitals. The EMS Academy annually trains over 14,000 FDNY personnel and over 28,000 New Yorkers through community outreach programs (i.e. FDNY’s Mobile CPR Training Unit). After 9/11 several other initiatives include: advanced simulation training (driving simulators and high-fidelity mannequins); mental performance initiatives (training educating personnel in performing during intensive situations); cadaver labs for teaching paramedics advanced medical skills; creation of an EMS Academy audio/visual production unit; frequent interagency drills throughout the city; and use of an internal web-based library for members to access training videos, articles, books and other materials.
Additionally, FDNY developed an enhanced leadership training program for newly promoted officers. The program improves competency in areas such as on-scene command and control, management of MCIs, performance as a medical branch officer, administrative tasks and communication skills. These aims strengthen their interactions with coworkers, firefighters, civilians, and other agencies in need of assistance. Through coordination of both medical care and fire suppression, FDNY operations are safer and more effective. With natural and human-made disasters providing unique dangers to our members on-scene, EMS members are trained in situational awareness and caution at all incidents.
Communication: Communication is a critical component during any incident. On 9/11, many of the traditional communication methods were compromised. This deficit created additional challenges. Since 9/11, communication is one of the most dramatically improved elements in the department. High-rise buildings and underground tunnels present significant transmission difficulties. In addition to increasing the number of repeater sites, FDNY members utilize the self-contained and self-powered command post radio system. The post radio is carried by each battalion and division response vehicle.
Additionally, command post radios can be deployed to any location where communications historically prove problematic. The issuance of fire ground radios to EMS members and the increased number of channels for administrative and special operations use has further improved the interoperability between Fire and EMS. Recently, all EMS members have been issued personal smart phones to provide an additional means of communication. When coupled with UHF-band handie-talkies, smart phones, vehicle repeaters, and pre-established interoperability frequencies, EMS and Fire Commanders now have the tools to manage an incident via planned and reliable communications.
Fleet and Technical Services: The initial response to the post – 9/11 environment was to stabilize and rebuild the fleet. Dozens of pieces of fire and EMS apparatus were damaged and/or destroyed so fleet and technical services’ first action was to provide adequate equipment to support the department’s field operations. In the months and years following 9/11, the department believed it was important to live by the lessons learned from the incident. FDNY had to build a fleet that was viable not only for day-to-day operations but also be sustainable during times of crisis. The department began to focus on the inter-operability/commonality of components and parts platforms and most importantly member safety.
In the 20 years since 9/11, the fleet of EMS vehicles has evolved dramatically. The department has moved to a heavier duty chassis and introduced four-wheel drive on all ambulances. For the comfort and safety of the EMTs and paramedics, extended cab four door chassis were introduced. All the ambulances are now equipped with idle reduction systems, brake-lock anti-theft systems, collision avoidance, GPS locators and wi-fi. Fleet Services developed new suspension systems, four-point restraints in the patient care area and are now piloting devices to reduce carcinogens and viral/bacterial transmission. All vehicles have GPS tracking that integrates with the computer assisted dispatch (CAD) system to provide accurate estimated times of arrival to the scene and unit location in case of an emergency.
The department’s ambulances have grown a little larger to provide the necessary landscape for additional compartmentation and safety gear. In that light, EMS officer vehicles now utilize a walk-around mini-squad on a ¾ ton pickup chassis. This enhancement provides much better storage of emergency equipment in a maneuverable platform.
All these enhancements were born out of a desire to provide the safest, most efficient mode of transportation for the largest and busiest municipal EMS system in the United States. The department’s experience from 9/11 was used to design equipment that works during extreme crises as well as routine daily emergencies.
Medical Special Operations: Post 9/11 highlighted the need for local specialized medical resources that could operate during disasters in the austere environment. Based on new national standards and an emerging body of knowledge of medical management in the austere environment, the FDNY established its Medical Special Operations. For EMS, this organization consists of HazTac (EMTs and paramedics) and rescue paramedics. These members operate and provide medical care in HazMat situations and other technical rescue environments (i.e. collapsed structures/confined space, high-angle, trench).
HazTac consists of 39 BLS and ALS units specially trained and equipped to operate at the HazMat medical technician level. Their specific mission is to provide medical management to patients contaminated with hazardous materials or who are affected by weapons of mass destruction (WMD). HazTac members are trained to operate in all levels of respiratory protection and chemical protective clothing (CPC), and are able to provide patient care in all zones of a HazMat incident. Given this high level of training, it was only natural for these units to form the backbone of our operational response to extremely contagious diseases such as Ebola.
The Rescue Paramedic program was established in 2005 and was structured around the FEMA National Urban Search and Rescue (US&R) System’s criteria and standards. As such, specialized equipment, management/coordination, communications, and training was adopted by FDNY EMS. The Rescue Paramedic program was designed to train paramedics and physicians to integrate and enhance SOC operations. These members bring medical care to the patient wherever that may be. Rescue Paramedics and the Office of Medical Affairs (OMA) Response Physicians work together in difficult environments using specialty equipment, medications and protocols to treat patients for various conditions (i.e. crush syndrome). While a federal response to a disaster may take up to 24 hours, the FDNY is capable of addressing the medical needs for a major disaster almost immediately after the incident takes place.
Rescue Task Force
In a response to an increase in violent situations, the department established the Mass Causality Rescue Task Force (RTF). This task force consists of EMTs, paramedics, firefighters and law enforcement. RTF works as a cohesive unit to provide triage, emergency medical care and patient removal from warm zone environments of aggressive deadly behavior incidents.
Since 9/11, the FDNY modernized and significantly increased its capabilities on the water. Marine Operations provides a multifaceted response to firefighting, medical evacuation and treatment, hazardous materials mitigation and decontamination. The marine fleet has over 21 boats ranging from 31 to 140-foot high-performance fireboats. Seven marine units are state-designated ambulances and are staffed by rescue paramedics for marine-based patient encounters (i.e. cruise ship escorts or large-scale special events). Two boats, the 343 and its sister ship, Firefighter II, have components made from WTC steel and are considered two of the largest and most advanced fireboats in the world.
Technology: FDNY 911 medical call receivers are EMTs who are specially trained in the use of our computerized triage application (CTA). CTA utilizes advanced algorithms to assist EMTs in assigning the appropriate call type so dispatch is prioritized based on medical severity. When on-scene, FDNY EMS providers use an electronic patientcare record (ePCR) to document prehospital care, assessment and treatment. FDNY EMS providers routinely wirelessly transmit this data prior to arriving at a receiving hospital. All EMS providers are personally issued ruggedized smart phones for potential incorporation of telemedicine video conferencing and communication with physician-based on-line medical control. These cell phones are linked with department-issued email, selective outside applications (i.e., GPS, selective news networks for situational awareness), and access to the department training videos/training related materials.
For mass-causality incidents (MCI), the department has custom-made an incident command system (ICS) application. This application allows the on-scene incident commanders to have a digital overview of the units operating on-scene and their status (i.e., staging, triage). The incident commander and officers can review data pertaining to a building (i.e. pictures, diagrams and specifications) from the Department of Buildings. The ICS application is able to seamlessly incorporate patient tracking information, triage tag designations and hospital transport destinations in near real time.
Healthcare for our members: A healthy response requires a healthy workforce. Healthcare for FDNY members, those exposed to the WTC and those unexposed, has been vastly expanded by what was learned after 9/11. The WTC Health Program provides no-cost medical monitoring for all enrolled members.6 Additionally, no-cost treatment for those with certified WTC-related and associated health conditions are also included. A certified condition is an illness or health condition the federal government has agreed that exposure to 9/11-related airborne toxins, hazards, or other adverse conditions was likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition. The FDNY WTC Health Program streamlines this process by obtaining appropriate medical diagnostic tests and submits certification documentation for any member who meets the criteria for a WTC covered or associated health condition.
Physical health: As of March 2021, approximately 791 FDNY EMS providers and 9,019 FDNY firefighters have at least one physical health certification. Currently, the most common certified physical health conditions are GERD, lower respiratory diseases, and upper respiratory diseases, affecting more than more than 19% of WTC-exposed EMS providers and 40% of WTC-exposed firefighters.
A recent report found that WTC-exposed cancer patients enrolled in a WTC Health Program (in either FDNY’s program or the General Responder Cohort Program) had longer survival times compared with other New York State cancer patients.7 This is likely due to early detection, access to a full battery of no-cost treatment options at some of the finest medical centers in the nation, comprehensive case management, and social support from family and fellow responders through our Family Assistance Unit (FAU). FAU has a contingency of volunteers to provide transportation for doctor visits so that no member has to worry about how they will get to and from medical care.
Mental health: FDNY rescue/recovery workers with the highest amount of WTC exposure had the greatest risk for adverse physical health effects. The same relationship with WTC exposure has been found for mental health effects.8,9 WTC-related mental health services are also at no-cost to the members. As of March 11, 2021, approximately 400 FDNY EMS providers and 3,900 FDNY firefighters have at least one mental health certification, though members can be certified for more than one condition. These conditions are often made worse by stressful situations such as adjustment to retirement or the development of physical health problems (such as cancers or serious respiratory illness).8 Our members, those with and without WTC exposures, are continually encouraged to take advantage of counseling services provided by the FDNY WTC Health Program to address these and other mental health conditions when needed. These efforts have been expanded even further to meet the need of our members to deal with the unique stress that occurred during the FDNY’s response to the COVID-19 pandemic.
The dramatic evolution of the FDNY over the past 20 years was a direct result of the staggering impact of the World Trade Center attacks. By establishing focused, realistic objectives, the FDNY was able to rebuild into a stronger and more resilient department. Enhanced training, improved communication, expanded planning, personnel initiatives, and a robust healthcare system have allowed the FDNY to meet the needs of EMS providers past and present, as well as those they serve.
Every year on the anniversary of 9/11 the following roll call is recited by the company officers at firehouses and EMS stations throughout the city a few moments before the 8:46 a.m. moment of silence on September 11:
“Today, we remember the bravery of the 343 members of this great department, who made the supreme sacrifice twenty years ago today, so that others could be saved.
Twenty years ago today, members gathered in their firehouses and EMS Stations to begin another day of service to the people of this city not knowing what the day would bring. This can be said about every day in the life of career first responders.
On September 11, 2001, the department lost not simply 343 Members, but we lost one member 343 times. Today, we come together to remember each of these individuals. We also come as a fire department family to give strength and support to each other.
We continue to honor the memory of our 343 fallen members and their contribution to the department, the city and the country. We will never forget.”
1. Deane C, Duggan M, Morin R. Americans Name the 10 Most Significant Historic Events of Their Lifetimes. Pew Research Center;2016.
2. Halpin J, Agne K. The Political Ideology of the Millennial Generation: A National Study of Political Values and Beliefs Among 18- to 29-Year-Old Adults. Center for American Progress;2009.
3. Korcok M. Blood donations dwindle in US after post-Sept. 11 wastage publicized. CMAJ. 2002;167(8):907.
4. Skitka LJ. Patriotism or Nationalism? Understanding Post-September 11, 2001, Flag-Display Behavior1. 2005;35(10):1995-2011.
5. Lowe S, Fothergill A. A Need to Help: Emergent Volunteer Behavior after September 11th. Beyond September 11th: An Account of Post-Disaster Research. 2003.
6. Centers for Disease Control. 9/11 World Trade Center Health Program https://www.cdc.gov/wtc/about.html. Accessed on Sep 7, 2021.
7. Goldfarb DG, Zeig-Owens R, Kristjansson D, et al. Cancer survival among World Trade Center rescue and recovery workers: A collaborative cohort study. American journal of industrial medicine. 2021.
8. Webber MP, Glaser MS, Weakley J, et al. Physician-diagnosed respiratory conditions and mental health symptoms 7-9 years following the World Trade Center disaster. American journal of industrial medicine. 2011;54(9):661-671.
9. Yip J, Zeig-Owens R, Webber MP, et al. World Trade Center-related physical and mental health burden among New York City Fire Department emergency medical service workers. Occup Environ Med. 2016;73(1):13-20.