Five Years Later By Neal E. Flomenbaum, MD, Editor-in-Chief

In the five years since the destruction of the twin towers of the World Trade Center, emergency physicians have dealt with human suffering caused by disasters such as the Chicago heat wave of 2003 and Hurricane Katrina last year. We have flown to remote parts of the world to help care for victims of war, terrorism, and tsunamis, and we have performed admirably.

But are we any better prepared today for dealing with future catastrophic events?

When I heard the first news reports that a “small plane had crashed into one of the twin towers” on the morning of September 11, 2001, I immediately began calculating time intervals, the distance between the trade center site and our emergency department at New York-Presbyterian Hospital, and the availability of other medical facilities in the city. I concluded that, as the largest regional burn center in the metropolitan area, we would probably begin receiving the most severe burn victims directly from the site within the hour. When later reports described the true size of the plane that hit the north tower, followed by reports of a second plane crashing into the south tower and a similar attack on the Pentagon, I knew that we had entered uncharted territory.

Thirty-four minutes after the north tower was struck, our emergency department received the first of 10 patients with burns over 80% to 100% of their bodies, followed later by an additional seven burn victims from other emergency departments. Cared for by teams of emergency physicians, surgeons, internists, nurses, and technicians, all of the patients were stabilized prior to transfer upstairs to our burn unit.

Later that day, our EMS crews began appearing at our ambulance entrance completely covered by a gray-white powder, which gave an eerie glow to their red-rimmed, bloodshot eyes. The bodies of two of our EMTs remained at the site for months—until all 110 floors of the south tower could be removed from on top of them.

What have we learned since that horrific day?

We have learned that our ability to anticipate and prepare for future disasters will always be limited by the extent to which we can accurately predict human error and capacity for evil. We have learned that changing political and economic circumstances can diminish previously effective resources. We have learned that terrorist attacks disproportionately affect the working population, while natural disasters are particularly devastating to the very young and the elderly. And we have learned that more numerous and more varied forms of communication will help to reduce casualties, as will effective lightweight personal protective equipment, when it becomes available.

It is not at all clear, however, what the chronic effects and long-term sequelae of exposure to the toxic environment created by such disasters will be. Nor is it clear when, if ever, rescue personnel and health care workers from different governmental and nongovernmental agencies will ever figure out how to effectively coordinate their activities in the immediate aftermath of a disaster.

In a 2003 commentary on a critical appraisal of the on-site medical care delivered on September 11, 2001, I wrote that “we did some things wrong, but we did many things right and saved thousands of people who could have perished or been significantly injured,” and I concluded that “a glass may be both half-empty and half-full at the same time.”

Five years after that fateful Tuesday morning, it must be said that the contents of that glass are still some distance from the brim.

Emerg Med 38(9):7, 2006