Special Report: "We Are Under Attack"
In the September 2001 issue of Ostomy/Wound Management, Alan J. Cantor, DPM, CWS, FACFAOM, Diplomat of the American Board of Podiatric Orthopedics, was recognized for his passion for learning and teaching, as well as for establishing a humanitarian project in the Caribbean.
He never imagined that he would be asked to share his thoughts again so soon, especially on such devastating events. A decorated volunteer fireman accustomed to responding to many accidents and catastrophic emergencies in his 23 years of service, Dr. Cantor was awarded the Medal of Valor for his role as triage commander at the crash site of Avianca Flight 52 in January 1990 in Cove Neck, NY. The following is Dr. Cantor's account of the attacks on September 11, 2001.
"Tuesday morning was absolutely gorgeous in New York," Dr. Cantor begins. "Perfect weather, clear skies. My wife Alyssa already had left for work, and I was doing the daily routine of sending our children to school. I walked our daughter Brittany to the bus stop, then drove our son Justin to nursery school. En route to my office, I was listening to New York's popular radio show, 'Imus in the Morning.' At 8:48 a.m., sportscaster Warner Wolf called into the show, screaming he had seen a plane crash into one of the Twin Towers. Reports were mixed - some people were saying it looked like a small commuter plane and others that it could have been a 737 commercial jetliner. Warner reported seeing fire and smoke and people waving for help from the upper floors of the building. Initially, like most others, I thought it was a bad accident... until moments later when another aircraft crashed into the second tower. Speeding to work, I looked west to New York City, 20 miles from our hospital and my office. The crystal clear sky was now filled with black smoke spewing from the World Trade Center. I thought, 'We are under attack.'"
When he reached his office, Dr. Cantor's phone was ringing with patients and family members fearful for relatives who worked downtown. Everyone was wrestling with conflicting responsibilities. Dr. Cantor wondered if he should go to his children, go home, go to the hospital, or go into New York City to help at the scene. His experiences with the fire department taught Dr. Cantor that ingress into Manhattan would be virtually impossible, as the city would be paralyzed with traffic and emergency vehicles. Egress from the city also would be compromised - a lesson learned from the Avianca crash, when the crush of vehicles obstructed the roads to and from the site. Knowing that the schools would safely care for his children and enough emergency personnel and medical help would respond to the crash site, Dr. Cantor reported to his hospital.
Nassau University Medical Center, East Meadow, New York, is Long Island's Major Level I Trauma Center and Burn Service. Undoubtedly, this facility would receive victims of the attack. When Dr. Cantor arrived, all of the alarms that previously had announced drills were ringing. As the bells continued to shriek, everyone knew this was no drill. The medical center's disaster plan was implemented - a fluid field of personnel secured the floors, cleared the burn unit of noncritical patients, and tripled and quadrupled patients in room on the floors. "The emergency plan was executed with no panic, no hesitation, and no confusion," Dr. Cantor says. "Medical and administrative meetings were held simultaneously. Team assignments, responsibilities, and scenarios were discussed. All staff were held and additional staff called in - a strategy that was performed in every hospital in our region - and supplies were gathered. Everyone was preparing to receive the victims of this incident, all the while balancing fear, professionalism, and anxiety. Communication was limited. With telephone, cell networks, pagers, and television network broadcasts comprised, we all wondered what was going to happen next, unaware of the other attacks on our nation."
Hospital staff could view the scene in New York City from the upper floors of the hospital, the tallest structure on Long Island. Where the towers once stood facing due west of the hospital, black smoke filled the skyline. "We saw the plume rise when the towers collapsed," Dr. Cantor says. "That sight chilled our veins and left us stunned, silent." Radio reports (some could receive signals) estimated tens of thousands of victims and 1,000 rescuers were lost. Each building was thought to have contained nearly 50,000 occupants.
Dr. Cantor's facility was locked down, secured by armed SWAT teams from the Nassau County Police Department. Bomb trucks arrived. Officers donned "ninja" suits; armed with machine guns, they provided security for the helipad. Taunted and comforted by the sounds of F-16 fighter jets providing air cover, Dr. Cantor says they felt protected, but this activity heightened the realization of the instability of their environment.
As preparations continued at Dr. Cantor's facility, the two hospitals closest to the Twin Towers, NYU Beekman Downtown and St. Vincent's, were receiving the initial critically injured. Paul Shubinsky, RN, BSN, CCRN, CETN, a nurse at St. Vincent's emergency department, reported that by 1:30 p.m., the majority of cases that were arriving were the "walking wounded." The severely injured had arrived shortly after the first plane crash. Severe lacerations and burn victims were transported by civilians, cabs, and ambulances, all met at the hospital door by teams of clinicians. Street-side triage was established outside the hospital, manned by staff and hundreds of civilian and volunteer physicians and nurses. At NYU Beekman, Dr. Zung Le, Chief Resident of the Podiatric Surgery Program, reported similar scenarios, as hundreds of volunteers came to provide help and expertise. People offered to donate blood, carry supplies, help staff move patients, and relieve staff of unnecessary tasks that would take them away from patient care. Like St. Vincent's, the earliest moments produced the worst cases. One highly publicized case involved a young woman who was carried to Beekman by pedestrians. She had been injured by a falling piece of a jet engine that had severed the posterior aspect of her upper body and inflicted massive lower extremity injuries that included open fractures and massive lacerations. She was exsanguinating when she was brought into an operating room manned by multiple specialists. A decision was made to salvage her legs. Through the heroic efforts of the surgical team, her extremities were saved, blood loss was contained, and she survived.
Sadly, even in the immediate receiving hospitals, the total number of victims was far less than anticipated. St. Vincent's and Beekman received approximately 700 victims, the majority of which had non-life-threatening injuries. Burns were triaged and transferred to New York Cornell and other regional burn centers. The majority of the victims were caught in the collapse of the towers. "The thousands everyone had prepared to treat were not showing up," Dr. Cantor says. "Very few of those admitted to hospital facilities died of their injuries, supporting the fact that most injuries were noncritical."
In the field, triage sites were established early in the operation, along with a command post from the FDNY. Sadly, the command post was lost, along with the department's hierarchy. The Fire Department lost nearly 33% of its command level personnel, including Chief of Department Peter Ganci and Chief Chaplain Father Mychal Judge. Leaders of the Collapse Rescue team and Special Operations and Police Emergency Service Unit personnel were virtually eliminated, leaving an enormous void in tactical experience and leadership. Satellite triage and evacuation sites were established around the World Trade Center in churches and restaurants. A major center was set up at the Chelsea Piers on the Hudson River a few blocks from the towers. Unfortunately, many of these well-equipped triage and treatment centers also were underutilized.
The focus of the rescue efforts turned to finding victims believed to be trapped within crevices and environmentally friendly habitats within the debris field. Emergency teams from around the United States were dispatched to the site - the largest emergency medical/fire/rescue response ever in the United States. The National Medical Emergency Response System was activated. Medical personnel in every conceivable category called publicized phone numbers to acknowledge their availability. By Wednesday morning, the system had received more than 7,000 volunteers. Dr. Cantor, as a podiatric surgeon with expertise in wound salvage, was placed on a high priority list. His group arrived in New York City on Wednesday at noon, escorted by police as part of a convoy of fire and rescue personnel and equipment and dump trucks and garbage trucks needed for debris removal. They were stopped by police at various checkpoints and all personnel and vehicles were subjected to search.
As they entered New York City, Dr. Cantor was first struck by the overpowering odor of burnt wiring, materials, and structures. As they headed south toward the site, they saw the ground color change to white, covered in ash, dust, and debris. "It was odd to hear no horns and see no taxis or pedestrians," says Dr. Cantor. "It was even more shocking to see Army soldiers in Humvees patrolling our streets and to see and hear the steady drone of swirling F-16 and F-15 fighter jets overhead."
The site of Ground Zero was paralyzing and emotionally overwhelming. A virtual mountain range of debris, steel, cement, and carnage encompassed the World Trade Center complex and surrounding streets. The stunned volunteers reported to a command post/triage center where they waited to provide surgical/rescue support. If a victim needing surgical extrication was located, they were prepared with gear and equipment to provide any primary amputation procedure required. Dr. Cantor and his group agonized over this possibility. "We devote our careers to limb salvage, and here we knew the only way to save some lives was to perform battlefield amputations. We did not know what to pray for... we were exhausted, overwhelmed, and cognizant of the fact that our talent and expertise would likely be employed in a manner we never could have imagined."
The collapse of the remaining six stories of one of the towers aroused momentary fear, as the sight of a dust cloud, billowing smoke in an enormous roar, filled the volunteers with worry abut additional injury to the rescuers. Fortunately, the partial collapse claimed no additional victims. But the volunteers were still faced with the horror of standing among streets and sidewalks littered with human remains. "The site was ghastly," Dr. Cantor says. "The smell was sickening. Our eyes were irritated and our throats were sore from coughing and bringing up mucus. Even for the hardened medical/surgical/rescue personnel, these conditions were taxing."
The hardest part was the waiting with no call for a surgical team. One false alarm sent Dr. Cantor's rescue team to a leg that was discovered in the ruins. As rescue workers gently tried to extricate it from the debris, they realized that the leg was the only evidence of a human body. An awareness that the death toll would be incomprehensible and the need for medical services would be minimal grew. Elaborate triage centers and their clinicians were sitting idle, their services devoted to caring for rescuers who were sustaining injuries on the pile and in the pit of the crater: setting leg fractures, suturing lacerations, providing rehydration with IV fluids, irrigating eyes with saline, treating orthopedic injuries sustained when people ran away from unstable buildings, and combatting signs of shock. By now, most of the workers and volunteers had gone without sleep for 36 hours; for many, there would be no rest for many hours to come.
Rescue efforts were hampered on numerous fronts. Of course, the enormity of the devastation was a huge challenge. Missing talent and equipment presented additional obstacles; experienced, knowledgeable fire chiefs and their personnel and rescue workers had been killed or were missing, and trucks were buried in the rubble. The presence of hazardous materials and the precarious setting meant that all excavation had to be manual. Thermal imaging that would have helped locate bodies was ineffective because burning fires and hot steel beams confused the signals. David Marmann, a friend of Dr. Cantor's from FDNY Rescue 1, which lost 11 members, reported that the collapse of the towers created a crater nearly 66 stories beneath ground level. "The knowledge that locating survivors was becoming increasingly unlikely added to our sadness and numbness," says Dr. Cantor. "We had believed we would care for so many."
Triage sites and comfort centers for rescuers and excavation crews remain manned and operational 24 hours a day, 7 days a week and will stay open as long as personnel are working at the site. The work is dangerous; several workers have sustained serious injuries after falls or by being pinned by steel beams and other debris. The main triage site is St. Paul's Church, a few blocks from the World Trade Center complex. Volunteers of all levels of training have come from all over the United States to provide the manhours.
Meanwhile, at his office, Dr. Cantor is back to seeing patients, many of whom were directly involved in the catastrophe. One rescue worker, an NYPD sergeant suffers excruciating heel pain from being on his feet for so long. The wife of a missing member of Rescue 4 needed an ingrown toenail treated, but spent an additional 45 minutes with Dr. Cantor, receiving comfort, friendship, and support. No one waiting in the office complained.
"This experience has changed everyone," Dr. Cantor says. "New York City has been rendered a small town Mayberry. Our lives have taken on a more spiritual tone. We are choosing to be kinder, more caring, and less distracted by minor nuisances. People aren't complaining about their ailments as much, but they also are not taking as good care of themselves. More than ever, wound medicine must be a primary consideration of every clinician. We must be well schooled and well versed in all phases of modern wound management. An atypical wound or lesion may be the first clinical sign of an act of chemical or biological warfare, making the wound expert a key player in recognizing a potentially catastrophic event - the wound the herald of the systemic status of the host's immune system."
Retrospectively, Dr. Cantor asserts that the response to the events of September 11 could not have been executed more heroically or more bravely. "Tens of thousands of civilians were saved by the evacuation performed by the fire and police agencies in New York City. These heroic men and women certainly knew they were endangering their lives, and many had told their crews 'firemen will die this day' as they entered the towers. Professional rescuers and ordinary citizens were lost, performing extraordinary acts of service. For their acts of valor, all of America should be proud.
"The only regret many of us share in the aftermath is that we wished we could have done more for the victims. The empty triage stations forever will haunt many who came to New York City to help."