As part of the EMS signal 10-40 response (major response to an aircraft crash incident), the EMS patrol supervisor for lower Manhattan responded from the quarters of EMS Battalion 4 on South Street. He intended to establish the preplanned staging area but found that the location was inaccessible: Victims and debris filled the street. Staging was relocated one block west to West and Vesey streets. The lieutenant assumed the role of the EMS operations officer and established the EMS branch of the incident command system at 0853 hours.
Even as the initial responding resources were converging on the 16-acre World Trade Center (WTC) complex, the EMS operations officer was confronted with several critical decisions. On arrival, he found numerous casualties in the street and a massive evacuation of the North Tower in progress. The first-arriving ambulances at West and Vesey streets had patients on- board, and the crews were initiating triage. Based on his size-up, the lieutenant directed all ambulatory patients to run north on West Street, determining that he would conserve his limited assets for nonambulatory patients. By doing so, he was rapidly able to initiate transport for critical patients, including several with life-threatening burns and trauma, to the appropriate treatment centers.
Photos 1 and 2 by John Wheeler.
The crew of the first-arriving ambulance was assigned to set up sectors within the EMS incident command organization, including the staging and communications sectors. As additional units reported to staging, they were assigned to the triage sector, set up in the southbound lanes of West Street (on the undamaged side of the building). Other responding units were arriving and encountering patients on the east side of the WTC complex. They began establishing triage and treatment sectors there.
Conventional EMS doctrine for a high-rise fire or emergency dictates establishing an EMS command post and triage area inside the lobby of the affected structure. This co-locates the EMS and fire command posts, as well as provides a good location for assembling and managing patients as occupants and public safety personnel exit the building. At this incident, the lieutenant's assessment led him to decide to set up all operations outside the building, which was a key element in keeping many EMS personnel out of harm's way.
Within the first 15 minutes, some 36 ambulances were on-scene or en route. The first chief officer assigned to the incident had ordered the mobilization of EMS task forces [eight basic life support (BLS) and two advanced life support (ALS) ambulances under the command of an EMS officer] at each of the bridges and tunnels entering Manhattan. The task forces were to remain uncommitted until their need was determined. In addition, the chief directed activation of the regional EMS mutual-aid plan. Around the city, crews that were changing shifts from the overnight tour were held on duty, and additional ambulances were placed in service. Members heading home turned around and returned to their stations.
The assistant chief of EMS arrived at 0901 hours. He was briefed, assumed command of EMS operations from the lieutenant, and reported to the fire command post inside the lobby of the North Tower.
THE SOUTH TOWER HIT
Operations were proceeding at what likely would have been the biggest mass casualty incident (MCI) in the city's history when a plane struck the South Tower. The concussion of the second aircraft's impact and falling debris injured several EMS members and damaged their emergency vehicles.
EMS personnel used any means available to transport medical equipment through the rubble. (Photos 3, 4, and 5 by Willie Cirone.)
A robust additional response was ordered to support the multitude of victims found and anticipated from the South Tower. Five geographic divisions—each with its own staging, triage, treatment, and transportation sectors—were established to manage the overall incident: South End, Church Street, Vesey Street, Liberty Street, and 7 WTC. All arriving units were committed to patient-care activities.
Arriving chief officers were put in command of each of the EMS divisions, but radio traffic and the multitude of simultaneous events hampered effective radio communications. As a result, the divisions in some cases operated autonomously, using their available resources to manage their assigned areas. The chief of EMS operations arrived from the south and assumed command of the South End division, where numerous evacuees were making their way to the waterfront.
The incident commander had relocated the command post to a driveway on West Street, across from the WTC complex; an EMS liaison was established there. Officers, alert to the hazard of falling debris and bodies, attempted to establish triage and treatment areas inside the lobbies of surrounding buildings or under other cover, where available. At the time, no one anticipated the imminent likelihood of a total structural collapse of the towers.
Despite the scale of the incident, the emergency medical activities underway were being carried out in a relatively organized, controlled fashion. At the front lines, victims were either self-evacuating or being brought to EMS triage areas established at various locations around the complex, where EMTs and paramedics assessed and categorized the patients. Some EMS crews were inside the towers or other complex buildings treating patients or assisting in the evacuation. Arriving ambulances, including 9-1-1 units from around the city and mutual-aid responders from the greater metropolitan area, activated through the preexisting regional mutual-aid response plan or having self-dispatched when they learned of the incident, were transporting patients to numerous hospitals around the city. Many other patients were self-referring or making their own way to hospitals for care. Despite communications challenges, the command structure was in place, and measures were being taken to reinforce command and control as additional EMS officers arrived at the scene.
THE SOUTH TOWER COLLAPSES
In the midst of the massive efforts to manage patients while evacuations were underway, conditions inside the towers were deteriorating rapidly. At 0958 hours the first-arriving patrol supervisor, now operating on the east side of the complex, reported hearing "the biggest roar in the world," and the South Tower collapsed in a huge cloud of dust, ashes, and debris.
Thousands of civilians fled Manhattan using every form of transportation.
The tower's collapse immediately disrupted all operations at the scene. The fire and EMS command post, in the mouth of a driveway leading to an underground garage across the street from the WTC complex, was destroyed. Some members of the command post staff were able to escape into the underground garage and make their way out on the waterfront side. Other members, caught on the street, ran through the raining debris and escaped.
Communications at the scene were lost along with the EMS command post. The minutes that followed the collapse were surprisingly quiet, as members regrouped, assessed the impact, assisted in rescues, reestablished triage areas, and cared for the injured. Unlike the rest of America watching on television, many at the scene were unaware of what had actually taken place. The view from street level was essentially a large cloud of smoke and debris, which obscured perspective of the tower that no longer stood.
A number of EMS providers who had been operating in or around the WTC complex were trapped or injured from the initial collapse. Other crew members were separated from their partners or teams. Many of the patients now being encountered were public safety personnel being pulled from the debris or brought out of the scene, some with serious injuries. A quantity of EMS vehicles and equipment had been lost, and additional resources were ordered to the staging areas. By 1000 hours, 53 BLS and 36 ALS ambulances, with 18 officers, were assigned, along with an unknown number of additional mutual-aid and self-dispatched units from outside the city. Other EMS task forces were being assembled in the outlying boroughs. Members who had been in refresher or other training at the EMS Academy staffed ambulances or boarded buses for response to the scene.
THE NORTH TOWER COLLAPSES
As EMS divisions and sectors were pulled back from the scene and reestablished, a group of EMS chief officers converged at a triage area on Vesey Street and North End Avenue, one block west of the complex. Led by the assistant chief of EMS, they attempted to assess the situation, reestablish command and control, and develop a strategy. Because of the loss of effective communication on all media, including department radios (400 and 800 MHz), pagers, cellular telephones, and landline telephones, these objectives were daunting. As the group assembled, one of the aides heard a rumbling sound. Personnel on the street took cover inside the Embassy Suites hotel as the North Tower disintegrated.
Photo by Steve Spak
Already staggered by the first collapse, operating forces were now devastated by the abrupt fall of the North Tower. This second impact interrupted rescue activities underway from the South Tower, totally disrupted communications to and from the scene, crushed or rendered inoperable numerous EMS vehicles, trapped and injured many EMS members, and exacted the most devastating toll on the Fire Department of New York. The department lost 343 members, including Paramedics Ricardo Quinn of Battalion 57 and Carlos Lillo of Battalion 49. Six other mutual-aid EMS providers were also killed.
The EMS chiefs conducted a hasty strategy session in the rear of the Embassy Suites lobby. Realizing that the city was under attack and not knowing the extent of the current situation or what to expect next, immediate priorities were quickly identified:
- Force protection for our remaining resources;
- Reestablish EMS and interagency command and control capabilities;
- Conduct accountability checks to determine who was missing;
- Regroup to manage the WTC operation and any potential additional attacks;
- Mobilize the largest mutual-aid response in recorded history; and
- Maintain 9-1-1 coverage for the rest of the city.
The assistant chief of EMS established two mobilization points, sufficiently clear of the incident zone, that would serve as locations for safe withdrawal as well as collection points for incoming units. These locations, at Chelsea Piers to the north and the Staten Island Ferry Terminal to the south, were communicated to the incident dispatchers, who made appropriate notifications as communications were gradually restored. The chiefs at the Embassy Suites were variously assigned to establish command at the mobilization points or reestablish command at the WTC site. As they were leaving, police Emergency Services Unit officers ordered an emergency evacuation of the Embassy Suites triage and treatment areas be-cause of a ruptured natural gas main and the risk of explosion. Once again, EMS personnel were forced to remove their patients and retreat from the scene.
The horror of the next few hours at the incident site was punctuated by three notable sets of activities. Members of New York's EMS—working alongside FDNY and the NYPD, members of other agencies, and civilians—performed Herculean acts of heroism to rescue survivors reachable through the rubble. Numerous independent and impromptu aid stations were established as EMS officers struggled to regroup members and tend to the casualties in a multitude of locations across lower Manhattan. Simultaneously, EMS command leadership went about the massive missions of reestablishing command and control while implementing unprecedented mobilization plans in the stricken city.
EMS dispatchers could not make radio contact with officers at the scene after the North Tower's collapse. Who was in command was unclear; various efforts to conduct radio roll calls were not successful. Additional sectors and divisions were established independently; units encountered patients in the surrounding areas of Manhattan and in Staten Island, where boatloads of evacuees were being discharged, and on the Brooklyn side of the Brooklyn Bridge, where thousands of evacuees were streaming on foot over the bridge. After some time without contact from the scene, the EMS chief in command of the Brooklyn Bridge division was preparing to bring his task force over the bridge and assume command of the incident. Just then, at approximately 1100 hours, the chief of planning reestablished EMS operations at a new command post located at West and Chambers streets, four blocks north of the WTC complex.
From 1100 hours on, operations at the scene and around lower Manhattan continued, with resource demand peaking by 1300 hours. By that time, 106 ambulances (69 BLS, 37 ALS) and 24 officers from the 9-1-1 system were operating, supported by a still undetermined number of mutual-aid and self-dispatched units. Operations continued through the afternoon, as did rescue activities.
CITYWIDE AND REGIONAL MOBILIZATION
The city's Emergency Operations Center (EOC), managed by the Mayor's Office of Emergency Management, was located on the 23rd floor of 7 WTC, on the north side of the complex. Evacuated at the outset of the incident, the building had been struck by debris and set on fire when the North Tower collapsed. The assistant chief of EMS, one deputy chief, and their aides relocated across Manhattan to police headquarters, site of the former EOC, in anticipation of reestablishing interagency coordination from there.
By noon, information and communications were still very limited at the ad hoc EOC. Telephone contact was sporadic; radio and television reception were poor. There was no contact with the incident scene. Based on the known information, thousands of injured casualties were anticipated over the course of several days. Plans were developed to establish three large casualty collection points (CCPs) to manage these patients. These CCPs, to be set up at the Javits Convention Center in Midtown Manhattan, the Brooklyn Navy Yard, and the minor league Staten Island Yankee Stadium, were to be staffed and resourced by medical personnel, equipment, and supplies from city hospitals, so that the EMS system would not be further burdened. The CCP concept of operations was to immediately transport patients with life-threatening injuries to hospitals and process nonacute patients at a CCP, where they could be treated and discharged home or transported to hospitals when resources permitted. The plan was to activate the first CCP by 1800 hours on September 11. Sadly, it became apparent by 1600 hours that the small number of injured survivors would not tax the existing medical infrastructure. Two of the three planned CCPs were demobilized; the third was secured at 1800 hours.
EOC representatives from the University of Medicine and Dentistry of New Jersey (UMDNJ), the EMS regional mutual-aid coordinator for New Jersey, provided a critical point of contact with that state's resources. It reported that it was treating and decontaminating 1,000 patients on Ellis Island, 200 patients at the Port Authority Trans-Hudson (PATH) light rail station in Hoboken, 60 patients in Jersey City, and 150 patients who had arrived by boat in Monmouth County (in southern New Jersey).
During the late morning and early afternoon, media outlets broadcast messages for a total recall of off-duty public safety and EMS personnel. This was unprecedented and created a series of challenges ranging from personnel accountability to sufficiency of vehicles and equipment to support such a recall. Many recalled personnel staffed spare or reserve apparatus while others responded directly to the incident scene.
As the day progressed, EOC representatives from various entities arrived and began to coordinate activities. At the request of EMS, the regional emergency preparedness coordinator from the New York State Department of Health established a separate, co-located Emergency Support Function 8 (Health and Medical)1 EOC, with the mission of bringing together all the participants representing health and medical support entities to optimize coordination of the medical response.
Representatives included city, state, and surrounding county health departments, EMS provider agencies, the New York City Health and Hospitals Corporation, the Office of the Chief Medical Examiner, the Greater New York Hospital Association, the Nassau-Suffolk Hospital Council, the American Red Cross, the Federal Emergency Management Agency, and the U.S. Public Health Service, among others. This provided an effective medium for coordinating information flow and resource management among all the participants.
Additional resources for EMS assets were requested through the State Emergency Management Office (SEMO). Consistent with the regional mutual-aid plan, 10 task forces of 10 ambulances each (eight BLS, two ALS, and an officer in command of the task force) were requested, with five from upstate New York to mobilize at the Fire Academy on Randall's Island, and five from Long Island's Nassau and Suffolk Counties to mobilize at Shea Stadium in Queens. These task forces were deployed later in the day, providing relief for FDNY EMS assets and enabling FDNY to maintain effective deployment throughout the city. Immediate requests were placed through SEMO for the deployment of federal Disaster Medical Assistance Teams (DMATs), Disaster Mortuary Operational Response Teams (DMORTs), and four Urban Search and Rescue (USAR) teams (see sidebar on page 110).
The outpouring of assistance from medical personnel and suppliers created a significant challenge. Many calls were received offering supplies; in some cases, the EOC was merely informed that shipments were en route. Efforts focused on coordinating the flow and destination of resources, attempting to collect all the resources at the Fire Academy. Coordination with law enforcement was needed to have arriving delivery vehicles inspected for contraband or secondary devices, as well as to establish security and safeguard the products. Had the CCPs been activated, these shipments would have been redirected to them.
Many people called the EOC and the EMS communications center identifying themselves as medical professionals and offering assistance. While there was no immediate need for their services, a logging process was established to document their capabilities and note their contact information in case assistance was needed in staffing the CCPs. All individuals would have had to be credentialed to establish the validity of their certification or licensure before being assigned to work—a massive undertaking.
The police department was asked to help with patient tracking; this task could not be carried out effectively from the scene because of the volume and dispersal of patients. Police officers were sent to every medical facility in the tri-state area of New York, New Jersey, and Connecticut to identify and pedigree patients who presented from this event.
This mission took weeks to complete, as the Greater New York Hospital Association, hospitals, EMS, and law enforcement agencies throughout the region compiled and reported data.
ONGOING RESCUE OPERATIONS
As afternoon turned to evening, most of the survivors were cleared from the scene. At 1700 hours, the chief of EMS Operations conducted a strategy meeting at which short- and long-term mutual-aid plans were developed and implemented. EMS operations were reorganized into North and South Divisions, with one or more staging, triage, and treatment sectors in each division. A morgue sector was established for fatality management. Logistics, safety, staffing, communications, and liaison sectors were established to support the operation. Chelsea Piers, a 30-acre sports and entertainment complex encompassing four piers on the Hudson River waterfront, became a major mobilization point. Incoming ambulance resources were assembled, credentialed, briefed, and deployed from here. The piers also were set up as a CCP. The ice skating rink was set up as a temporary morgue, although these facilities were not used.
On the night of 9-11, the EMS incident command organization was expanded to include planning and logistics sections. Organizational planning was developed to enable effective deployment of resources for the days to come. Functions included the following:
- Integration of mutual-aid assets;
- Release of some New York City 9-1-1 units for duty in other parts of the city;
- Rest and rehabilitation for personnel who had operated during the day;
- Creation of organizational charts and establishment of a long-term scene management strategy;
- Shifting departmental leadership to a 12-hour/7-day schedule; and
- Initiation of formal incident action plans and documentation.
During the afternoon, EMS brought in 10 ATVs: six-wheel covered off-road utility vehicles equipped for emergency medical evacuation. The vehicles, used by EMS for special event coverage in parks and on beaches, proved outstanding for navigating the devastated terrain and debris found at the site. They were used to move patients or remains from the closest accessible recovery point to an ambulance, appropriate aid station, or morgue facility.
To operate a response of this scale and maintain 9-1-1 coverage, a massive amount of outside assistance was needed. Mutual-aid ambulances, as well as a host of specialized vehicles and units, responded from all over the tri-state area to augment EMS operations. A command post vehicle from Union County, New Jersey, served as the EMS operations post for an extended period.
Federal agencies provided additional vital support, including DMAT, DMORT, and USAR teams, veterinary medical assistance teams, and incident support teams to provide overall leadership and organization for the federal assets. Federal assets continued to operate for months; the DMAT operation continued until January 2002.
From the outset, there were two primary EMS objectives. The first was clearly to manage patients—those generated from the primary events and those who presented in the course of rescue and recovery operations. The second was to support fatality management activities, including documentation of all remains and transportation of deceased public safety personnel with dignity and honor.
The medical concept of operations put in place on the first night continued until the incident was concluded on May 30, 2002. Patients who sustained minor or moderate injuries and not likely to require hospitalization were brought to one of the treatment areas, where they were assessed and treated by DMAT personnel (later in the incident, a private occupational medicine contractor was hired to provide these services on-site). Patients who were seriously injured were brought directly to ambulances for transport off-site to an appropriate hospital destination. EMS ATV teams, deployed around the site, transported patients as needed.
FROM MASS CASUALTIES TO MASS FATALITIES
Before September 11, New York City, fortunately, had relatively little experience with mass fatality incidents (MFI), certainly nothing near this scale. Doctrine dictated that once the deceased were pronounced dead by EMS personnel, removal and management of the remains were the purview of the Office of the Chief Medical Examiner (OCME). However, because of the nature of this incident and the fact that so many of the deceased were public safety personnel, FDNY EMS members took on the fatality management role as well.
A temporary morgue was established at the scene, on Vesey Street. As bodies or remains were recovered, an effort was made to determine whether they were civilians or public safety personnel. All remains were brought to the temporary morgue, where they were examined and logged in. Civilian remains were loaded onto refrigerated trucks and were periodically transferred to the OCME office on First Avenue. Public safety members were given ceremonial honors by an interagency honor guard and any other uniformed personnel in the area, placed onto FDNY ambulances, and transported immediately to the OCME office with police escort.
Morgue operations were augmented by the arrival of a FEMA DMORT on the evening of September 12. The DMORT operation provided tremendous support to the weary OCME personnel; however, the mission of recovering, packaging, and removing the remains continued as a public safety task until site operations were concluded.
FROM RESCUE TO RECOVERY: WITH RESPECT AND HONOR
On September 30, incident operations shifted from a rescue mode to a recovery mode. EMS operations were phased out gradually as site operations were scaled back. An appropriate level of prehospital care and field treatment activities was maintained for the eight months of recovery operations at the site.
Emergency support functions (ESF) refer to the functional resource groupings of the Federal Response Plan. ESF 8 is the grouping for health and medical services responsible for providing assistance for public health and medical care needs.
Thanks to the following, who assisted in the preparation of this article: Chiefs Robert A. McCracken and Jerry Z. Gombo; Division Chiefs Walter M. Kowalczyk and Joel A. Friedman; Deputy Chiefs Robert Browne, Toni Lanotte, and James P. Martin; Lieutenants Christine Bastedenbeck, Rene Davila, Christopher Eccleston, and Amy Monroe; and Chief's Aide/EMT Mary Merced.
ZACHARY GOLDFARB, BS, CEM, EMT-P is an EMS deputy chief with the FDNY Emergency Medical Service Command. During his 24-year career with FDNY (and the New York City Emergency Medical Service, prior to their 1996 merger), he has served as Bronx borough commander, deputy chief of operations, emergency management coordinator, and commanding officer of the Special Operations Division. He is the author of the New York City Emergency Medical Action (disaster) Plan. He served as an EMS commander at both the 1993 bombing and the 2001 terrorist attacks on the World Trade Center. Goldfarb is validated by the U.S. Department of Defense as a medical nuclear, biological, and chemical subject matter expert instructor and is a consultant member of the federal Domestic Preparedness Training Team. He has an associate's degree in paramedic science and a bachelor's degree in public administration and management from the City University of New York. He is a member of the editorial advisory board of Fire Engineering.