Prepared for the unthinkable: EDs respond to terrorist attacks

Disaster plans were put to the ultimate test — Lessons learned

On Sept. 11, 2001, 33 ED physicians were meeting in New York City less than two miles from the World Trade Center. Among those physicians was Joseph P. Ornato, MD, FACC, FACEP, professor and chairman for the department of emergency medicine at Medical College of Virginia Hospitals in Richmond. When two planes crashed into the World Trade Center towers, the physicians identified themselves to fire department personnel. "They commandeered a bus with a police escort and sent us in," Ornato says. "We were at Ground Zero’ less than an hour after the [first] building collapsed."

The EMS command center was destroyed when the first building collapsed, he reports. Ornato and his team set up a field triage unit, which took about an hour to achieve full functionality. A 40-bed field hospital was set up in a courtyard just off the street. Firefighters went into buildings and hauled out tables from conference rooms to use as beds. The group initially had little equipment, so firefighters radioed with specific requests. Ambulances rushed to the site from nearby hospitals with supplies, including chest tubes, IVs, backboards, cervical collars, dressings, and bandaging equipment.

"It was very helpful that the fire [department] leadership allowed the medical side to dictate what we needed, where we needed it, and how to set it up," says Ornato.

The triage station was prepared to treat hundreds or thousands of patients if needed, but it treated only 19 people, including rescue workers. "The saddest part was that not many survivors came out," Ornato says. At press time, the total number of people missing was 4,979, with 393 confirmed dead. "All the critical patients that were saved, were saved before the towers collapsed," Ornato says.

The disaster response system in New York City was put to an unbelievable challenge, Ornato says. "It was remarkable how rapidly the system was able to continue to function, despite the unthinkable loss of [391 presumed dead emergency response] personnel at the foot of the World Trade Center in the rubble."

The horrific terrorist attacks that occurred at the Pentagon in Washington, DC, and the World Trade Center on Sept. 11 should serve as wake-up call for ED managers nationwide to revamp disaster plans with an "all-hazards" approach, says Thom Mayer, MD, FACEP, chairman of the department of emergency medicine at Fairfax Hospital in Falls Church, VA, and the command center physician at the Pentagon. An "all-hazards" approach ensures that EDs are prepared for all types of disasters, including bioterrorism, he explains.

Mayer suggests using a template of an effective plan instead of starting from scratch. "Then you can individualize the plan for your own situation," he says. (To see Disaster Plan Policy for the Emergency Department, click here. For a list of biological agents and their symptoms and treatments, click here.)

Consider what events occurred at the disaster sites when evaluating your plan:

ED staff used colored tape for identification. All ED staff at New York (City) Presbyterian Hospital, Cornell Campus, including medical residents, clergy, and housekeeping, used colored tape on their shoulders so they could be identified easily, with a different color used for each role. Brian Miluszusky, RN, BSN, director of nursing for the ED, says, "The ED nurses and attending physician wear hats so they can be spotted very easily."

The importance of doing this was identified during a previous drill, says Miluszusky. "A guy was standing there in jeans and sneakers, and I asked him to transport a patient up to OB. It turned out that he was a neurosurgeon," he recalls. "Everyone has a role during a disaster, and that definitely wouldn’t be the best use of his time."

Wearing necklaces with colored IDs didn’t work because they were blocked by protective garments, and colored vests had to be removed after they became contaminated, Miluszusky explains. "We needed something that was cheap and easy to put on. Even if you take off your gown, you can just put the tape back on," he says.

There was a deluge of volunteers. At both the Pentagon and World Trade Center sites, there were few patients to treat and hundreds of people wanting to help, reports Douglas Yoshida, MD, an ED attending physician at Bellevue Hospital Center, two miles from the World Trade Center. "When sick patients did come in, there were so many physicians around the stretcher that care was interfered with," he says.

Yoshida notes that dozens of medical students and physicians rushed to Ground Zero, even after reports that it was extremely dangerous and there was nothing to do. "A number of our residents almost got trampled on day 3 when a building threatened to collapse," he adds.

Yoshida notes that there were enough EMS workers at the site, and transport times were short. "The only things that I conceive that a physician could have done at the site would be to treat hyperkalemia, give ketamine for a field amputation, and perform the amputation if so trained," he says. Other procedures could have been performed by EMS personnel or waited until the patient arrived at the hospital, because the patient already would have survived many hours or days, he argues.

At the Pentagon site, dozens of volunteer doctors, nurses, and paramedics contacted Mayer. "I can’t tell you how many people showed up and said, "Put me to work, I’ll do anything you want,’" he reports. Scores of visiting physicians, nurses, and paramedics offered help, but they ultimately were not needed, he adds.

However, the scenario underscores the need for a system to verify credentials of volunteer physicians, nurses, and paramedics, advises Yoshida. "Your hospital disaster plan should include an effective plan for this, such as the volunteer having to present a hospital ID or license to an administrator," he says. (See "Warning: Sites report problems with security," in this issue.) He suggests having pre-made ID badges that say "Volunteer Emergency MD," Volunteer Surgeon," or "Volunteer OR Nurse." "The volunteer then can report to the appropriate attending or charge nurse with the understanding that they are under their direction," he explains.

Communication from the disaster sites was difficult. The World Trade Center disaster site was "chaos," according to Yoshida. "There was no functioning incident command system, and we had no idea of how many patients to expect," he says. "Our preparedness for patients was basically rumor-driven from what we could gather from the TV and police radios." Cell phones and land lines often did not work, he adds. "We were able to be in contact with the other city-run hospitals, but there needs to be an inter-hospital radio system with direct communication with the on-site command center," he recommends.

Mayer reports a similar problem at the Pentagon. "One of the most difficult things was standing by on high alert hour after hour, not seeing anybody and not knowing what was happening," he says.

Patients went to the closest hospital. Initially, most of the World Trade Center victims went to St. Vincents Manhattan, a small Level One trauma center, and New York University (NYU) Downtown Hospital, which is not a trauma center, says Yoshida. "Several seriously burned patients and patients with head trauma were brought to NYU Downtown, which was quickly overwhelmed. The patients were later transferred," he adds.

Both disasters showed that most patients show up at the closest hospital, not the most appropriate hospital, says Yoshida. "There was little or no field triage, and most patients arrived without tags," he notes. In the hysteria of a mass disaster, there is no way to prevent patients from coming to the closest hospital, says Yoshida. "The EMS system can try to educate EMTs to bring them to the appropriate hospital, but a number of patients will be brought by police or private vehicle," he says. "Therefore, every hospital must be prepared to handle trauma — and biological, chemical, and nuclear terrorism — and this should be included in your disaster plan."


For more information about the response to the terrorist attacks, contact:

Thom Mayer, MD, FACEP, Inova Fairfax Hospital, Department of Emergency Medicine, 3300 Gallows Road, Falls Church, VA 22042-3300. Telephone: (703) 698-3195. Fax: (703) 698-2893. E-mail:

Brian Miluszusky, RN, BSN, Emergency Department, New York Presbyterian Hospital, Cornell Campus, 525 E. 68th St., New York, NY 10021. Telephone: (212) 746-0721. Fax: (212) 746-4883. E-mail:

Joseph P. Ornato, MD, FACC, FACEP, Department of Emergency Medicine, Medical College of Virginia Hospitals, 401 N. 12th St., P.O. Box 980525, Richmond, VA 23298-0525. Telephone: (804) 828-5250. Fax: (804) 828-8597. E-mail:

Douglas Yoshida, MD, Emergency Department, Bellevue Hospital Center, First Avenue and 27th Street, A-345, New York, NY 10016. Fax: (212) 562-3001. E-mail: