10/01/2002, THE MEDICAL ASPECT, BY KERRY J. KELLY, M.D.; DAVID PREZANT, M.D.; and MALACHY CORRIGAN, R.N., M.S.
The Fire Department of New York (FDNY) response to the World Trade Center placed our members at the epicenter within moments after the first plane hit the North Tower. The total departmentwide recall placed every member at the site. The heroic efforts to suppress fire, rescue civilians and firefighters, and recover bodies continued seven days a week, 24 hours a day since that first alarm. A total of 343 firefighters lost their lives that day in a matter of moments. More than 200 members were treated in emergency rooms for physical trauma. Many members required hospitalization and surgical intervention for significant orthopedic injuries. The physical and mental health of members was an immediate concern after this event because of the magnitude of this exposure.
The FDNY Bureau of Health Services (BHS) physicians responded immediately to the event. After the North Tower collapsed, we set up a triage center nearby on Broadway and Vesey streets with our BHS physicians and other physicians who responded to the scene. There were about 40 physicians and nurses staffing the triage center. The catastrophic reality of the losses became apparent when so few injured reported to the triage center, which closed by 9 p.m. that night.
In the immediate aftermath, as the rescue work began, many members complained of eye irritation and cough/congestion conditions. In the first few hours and days after the collapse, the air was filled with particulate matter that covered the skin, irritated the eyes, and caused nasal and respiratory congestion. As the air quality improved, eye irritation symptoms improved, but cough and congestion complaints continued.
Immediate BHS responses were directed at meeting the psychological and physical needs of a department significantly exposed.
In an average year, FDNY experiences three to five line-of-duty deaths, usually caused by burns, smoke inhalation, or cardiac arrest. On Father's Day, June 17, 2001, we lost three firefighters in an explosion and collapse in Astoria, Queens.
Our Counseling Services Unit (CSU), led by Malachy Corrigan, handled members' individual needs when faced with bereavement issues in the past. But the enormous losses of this event were coupled with the significant exposure to this site. Members lost friends and family in this tragedy. They personally witnessed this destruction on that infamous day and in the weeks and months that followed. The round-the-clock rescue and recovery exposed virtually our entire department to this site physically and emotionally.
The CSU immediately mobilized its staff, set up satellite units in the boroughs of Queens and Staten Island, and sent peer counselors to the affected fire stations. International Association of Fire Fighters (IAFF) peer counselors supplemented our own staff. The IAFF counselors came and over the next several weeks continued to visit fire stations. With funding from the National Fallen Firefighter Foundation, additional peer counselors from our ranks were also trained. Given the unique emotional exposure of our members, our CSU was designated a Project Liberty participant to obtain needed Federal Emergency Management Agency (FEMA) resources. In the initial month after this brutal attack, more than 1,000 people sought CSU assistance. Since then, the CSU has helped more than 3,000 members.
Efforts to assist the families of the deceased continue with bereavement groups for spouses, parents, and siblings; "The LINK," a bimonthly counseling newsletter; and other programs and events geared toward the families. We've added additional staff to conduct individual and group therapy. These clinicians see members in our community-based sites and visit the most affected fire stations for ongoing care.
Eye irritation and cough/congestion were among the complaints at the site. (Photo by FDNY Photo Unit.)
In the attack on the WTC, 63 fire units lost members. Clinicians have paired with these houses to offer small group discussions and give members an opportunity to talk. This is an ongoing process as we build a core of clinicians to serve our stations.
Certainly, each individual processes these experiences differently, and no one program can meet every person's needs. All members, at an education day, re-ceived a counseling outreach session. A peer counselor and clinician outlined coping strategies and symptoms of post-traumatic stress.
Recognizing that an event such as this was unparalleled, we sought the advice of experts from the Oklahoma City Bombing and the Gulf War. We have met with nationally known psychologists to develop systems to evaluate and help our members. The behavioral health survey is a tool that can help us assess individual and department needs. This survey will be administered in the summer to evaluate the well-being of the individual members and the department as a whole.
We needed to track the more than 200 members who sought medical assistance on September 11. Members had been sent to a variety of facilities. Some were transported by boat across the Hudson River to Jersey City, New Jersey. We did not, however, track injuries that day. Locating injured members was a difficult process that required telephone calls and personal visits to hospitals.
Medical issue concerns were raised from the beginning. With the cough symptoms that members exhibited early on, questions arose about the exposures that were at the scene. The initial response on days one and two was a departmentwide recall to help in rescue and recovery. In the face of the worst air quality, few respirators were available. It took several days before p100 respirators (which protect healthcare workers against biological agents and fine dust) were available. Members developed cough and congestion symptoms within days of the events. Certainly, it was unclear what exposures members might have experienced with the collapse of two 110-story towers combined with the explosion of two planes and jet fuel. BHS distributed inhaled steroid inhalers (Pulmocort inhalers) to offset the allergic cough symptoms.
BHS partnered with the National Institute for Occupational Safety and Health (NIOSH) and the Centers for Disease Control (CDC) to develop a medical monitoring program to evaluate our exposed firefighters. An initial 400 members with stratified exposures were evaluated in early October. But it was clear that, given the extent of exposure, we needed to test the remaining members. BHS undertook testing of the remaining 10,000 members with a seven-day-a-week, three-shift-a-day schedule, seeing 180 members daily. From October 31 until the end of January 2002, we saw 10,000 firefighters, fire officers, EMTs, and paramedics.
Medical monitoring included ECGs, pulmonary function tests, chest X-rays, hearing evaluations, and blood testing (consisting of CBCs, chemistries, liver functions, lipid profile, lead, beryllium, PCBs, and urine mercury and urinalysis testing). In addition, the CDC lab tested for the presence of dioxins and hydrocarbons on the initial group of 400. Blood was banked for testing at a later time if the need arose. Since our members take a complete candidate entrance medical exam and an annual examination, BHS had baseline bloods, PFTS, EKGs, and other tests for every member.
We have shared the results of these tests with our members. In general, the blood tests have not indicated any significantly elevated levels of toxic metals or abnormal chemistries or blood counts. Some members have had continued cough complaints with shortness of breath on exertion. The pulmonary function tests have shown a decline that matches this complaint. In most cases, this change has not affected overall functional capacity, but some members remain off the line with active symptoms. It remains to be seen how members recover from this event.
The events of September 11 were catastrophic. In a matter of moments, our members became participant in a battlefield. The FDNY response was outstanding when we review the numbers of civilians saved and we measure the heroic efforts of so many individuals. Our losses are deep felt with the deaths of members from every rank and every branch of our service. Our memories are filled with the experiences of that day and the many days that followed. Both physically and emotionally, we have reacted to this event. The rebuilding of our department has begun. The medical monitoring is the first evaluation of our members after this event. In the months and years to come, the annual examination will allow us to continue to monitor the medical well-being of our members.
Future planning should focus on following up with members after they retire. As the most exposed group to an event of this magnitude, it is essential that we continue to monitor this group.
Walter Kowalczyk, the senior Emergency Medical Services officer on duty that day, recalled driving up West Street and seeing body parts and debris. "My mouth went dry," he said. "I had the sensation that I had a job to do; I had to ensure the safety of the EMS workforce. But how do I do this if I can't talk?"—"Before the Towers Fell, Fire Department Fought Chaos," Jim Sawyer, The New York Times, Jan. 30, 2002
"I've actually had guys saying, 'Gee, I feel kind of guilty.' I say, 'No, you shouldn't feel guilty. They're thanking you for things you've always done, even though it took something so terrible to make people actually realize what you've been doing.' "—Tom Pandola, Los Angeles City battalion chief, in "Wave of Support for Local Firemen," Erica Werner, AP writer, The New York Times, Sept. 20, 2001
"You have 100 floors of computers, all of which have gone to the basement and been raised to 2,000 degrees Fahrenheit and boiled away whatever they have in them. That's what we're worried about," Tom Cahill, a researcher at UC Davis, said. He led a group of team scientists who studied five weeks worth of ground zero air to determine exactly how harmful the atmosphere of the WTC was.—"Attack Site Air to Be Tested by UC Davis," KCRA, The KCRAChannel.com, 11/5/01
"He still imagines loud noises at night, and his dreams are haunted by images of people leaping from the burning Trade Center. He said he sees pieces of bodies on the sidewalk and cannot fall back to sleep. 'I lost a lot of friends. I lost a lot of guys. It's killing me just thinking about that. I never want to be that vulnerable again.'"—Firefighter Vinny Picciano, "FDNY Personnel Have Stress Ailments," Michael Weissenstein, AP writer, Feb. 28, 2002
Dr. Robert Lahita, 55, rheumatology chief at St. Vincent's Hospital in Manhattan, was in Jersey City, where he's a director for Hudson County's Emergency Medical Service. "It [New Jersey triage] was a nasty scene. One guy had an open skull fracture. You could see his brain." Lahita tried to radio for more help, but the transmitter, atop the World Trade Center, had been destroyed. Bandages and other supplies were fast running out. Fortunately, workers from nearby offices pitched in with first-aid kits, chairs to use as stretchers, and Venetian blinds to serve as splints.—"Precious Mettle," People, Oct. 1, 2001
KERRY J. KELLY, M.D., has been the Fire Department of New York (FDNY) medical officer for 13 years and chief medical officer for seven years. She received a bachelor's degree from Vassar College and a medical degree from Brown University Medical School. She is a family physician and did her residency at Downstate Medical Center in Brooklyn, New York.
DAVID PREZANT, M.D., has been FDNY's medical officer for nine years and deputy chief medical officer for seven years. He has a bachelor's degree from Columbia University and a medical degree from Albert Einstein Medical School. He is a pulmonary medicine, internist, and critical care specialist at Montefiore Hospital.
MALACHY CORRIGAN, R.N., M.S., has been director of FDNY's Counseling Services Unit for 20 years. He is a graduate of Hunter-Bellevue School of Nursing and does psychiatric nursing.