Catastrophe

I had already completed her history and examination. My 14-year-old patient was face down on the adjusting table when I finally put the pieces of the puzzle together. The woman sitting in the corner was not the girl's mother. She was her aunt and guardian. The girl was the daughter of a patient whose picture I had placed in a frame overlying a photograph of the World Trade Center. My receptionist had found the patient's picture accompanying a magazine article about the victims of 9/11. Chills ran over my body, and I was overwhelmed with the realization that there is no way to avoid the reminders of the 9/11 attack.

Very few people in the New York City area had any previous experience with such a large, catastrophic attack on their community. Certainly there was no established plan for the manner in which chiropractors should or could respond. Chiropractors, too numerous to name, found creative ways to organize, travel near to the disaster site, and set up temporary relief stations. There was also no plan for how the hospital emergency department's lone chiropractor could or should contribute to the hospital's response to the attack.

As chiropractors make inroads into hospitals and emergency departments, it is important to set up policies and procedures for responding to disasters. In this article, I am dragging up my repressed memories of 9/11, so others can use the experience to prepare for what we all hope will never happen again.

At 3:00 a.m. on the Saturday before September 11, 2001, I treated a patient in the ED. She had been involved in a motor vehicle collision. She was distraught over her car being totaled, her significant back pain, and having to find a taxi so early in the morning. Biting my lip to keep from laughing, I prophetically suggested that sometimes, bad events can lead to good things. I told her that the lower back pain that ended my gymnastics career probably kept me from going on to have more serious injuries at a higher level of competition. She halfheartedly accepted my theory.

The patient missed her follow-up appointment in my office on Monday, September 10. At approximately 9:15 a.m. Tuesday morning, she entered my northern New Jersey office with tears streaming down her face. She had driven to my office while watching the smoke rise from the World Trade Center. With her voice trembling, she explained that she had cancelled a breakfast meeting with six other people that was to have taken place in a restaurant at the top of the WTC. If not for her car accident, she would have been in the building when the plane struck. Her car accident had initiated a course of events that saved seven lives.

As I treated the patient, we listened to the radio. The reports made it sound as if planes were crashing all over the country. It seemed like we were in an all-out war. The ED is just a few miles from the WTC site. My office was about 20 miles away. I didn't call the hospital, as I did not want to tie up the phone line. I attempted to call my own beeper and cell phone. I wanted to know if they were working. My fear was that if they were not working, there would be no way for the hospital to call for back-up personnel. There was no cell phone or beeper service. I headed for the ED, figuring that I could always leave if I wasn't needed. I also thought that if volunteers were needed for other activities, the hospital would be a likely place to gather and organize.

As I drove to the hospital, I could see a portion of the New York City skyline ahead. On a clear day, it is possible to see several buildings, including the WTC, between the trees that line the highway. On this day, there was a rising cloud of smoke filling the sky between the trees. During the ride, my attention was split between the confusing reports on the car radio and the unemotional faces of the other drivers who appeared to have no idea of what was happening. I kept reminding myself to drive slowly - it wouldn't help if I added to the list of the day's causalities.

The ED I work in is part of a small community hospital. There are about eight treatment rooms, with some extra space for overflow patients in the hall. Typically, there is one emergency physician with a staff of approximately six nurses and assistants.

On 9/11, the ED was transformed into a trauma center. The halls were lined with empty stretchers. Dozens of IV poles and boxes of supplies cluttered the spaces between the larger equipment. Numerous physicians, nurses, administrators, and support staff waited in the hallways in and out of the ED. The ED was closed to all except life-threatening emergencies and the anticipated causalities from the WTC.

Before going into the ED, I made my way to the second floor and got in line behind the other people waiting to buy antacids. The hospital volunteer working the cash register was in tears. Her son had left on a flight from Newark Airport that morning. She feared he was on the flight that crashed in Pennsylvania. With stomach acid in check, I headed back down to the ED.

As I entered the department, the nurse administrator of the ED questioned my purpose. I imagine she was preparing herself to organize the handling of hundreds of burned, broken and dying patients. A chiropractor wouldn't be stitching lacerations or starting IVs. She probably saw me as just another person who would just get in the way. The ED director answered the nurse's question: "He is here to help." Without guidance, I took a position near the ambulance entrance and conversed with a local police officer. We knew each other from the times he had brought drunk and injured patients to the ED. Like everyone else, we stood around, speculating about what was unfolding and waiting for the injured.

After a short time, I worked my way back to the treatment room where I typically see patients. This was the only room with a television. It was there that I had the opportunity to treat hospital personnel for their stress-related symptoms and to watch the story unfolding on the TV, along with the many staff members who crowded the room. When the flight number of the jet that crashed in Pennsylvania was announced, I ran up the stairs to the second floor. After taking a long, deep breath, I told the hospital volunteer her son was not on the flight that crashed in Pennsylvania. A little while later, I was asked to go back upstairs to escort a man to see his pregnant wife, who had escaped before the Trade Center collapsed. There was no other good news for me to relay that day.

Unfortunately, only a handful of patients from the WTC came in. The ED staff treated their relatively minor injuries and released them. Later, I heard from a surgeon who had responded early to the disaster site. He reported passing hundreds of medical personnel who just stood by the road with nothing to do. Unfortunately, in our hospital there was other work to do. It had nothing to do with patient treatment. It would begin hours later, after nightfall.

Periodically, the hospital would shake as a low-flying military jet flew by. The New Jersey Turnpike was visible from the north side of the hospital. What must have been hundreds of ambulances lined the turnpike. Their movement was halted by a police investigation of a suspicious van. Over the trees, to the southeast, the smoke from the smoldering Trade Center stained the crystal blue sky. Throughout the hospital, stories were exchanged about loved ones either unaccounted for or fortunately late or absent from work in New York City that morning. Ambulance crews stopped in from time to time with stories of ambulances being bombed in the city. Fortunately, these stories turned out to be untrue. We also heard stories from the various political and emergency management leaders. Many, if not most of these stories also turned out to be untrue. I never expected how difficult it would be to obtain reliable information during a disaster. People in responsible positions were apparently unknowing conveyors of misinformation.

The injured did not have the types of problems the ED physicians would refer for chiropractic evaluation and treatment. They suffered from minor burns, abrasions, respiratory difficulties, and anxiety. During the long wait, the chiropractic care I provided was restricted to members of the hospital staff. I treated staff members with neck pain and headaches obviously related to stress. It was fortunate to be able to afford some measure of relief without the risk that medication might affect judgment, cause sleepiness, or irritate the already-tense stomachs of people with critical roles.

Evening came. Due to the few numbers of injured and lack of hope of survivors, most of the staff were dismissed. Some of us who stayed a little longer were told that we would not be able to get home until later, because many roads were closed due to police activity. The ED had an unusually small number of patients. As night fell, the quiet was broken by the progressively more frequent ringing of the phones. People began calling to find out if a loved one or co-worker had been brought to our hospital. For hours, the phone rang at least once every 30 seconds. The caller would give a name. Hopelessly, we would look down the list of those who had been treated and released. We would then give the caller the names and numbers of other local hospitals so they could also call there in vain. Some of the callers would insist on describing their missing loved one. They would talk of their desperation or describe what made their missing child, spouse or co-worker a good person. Each one of us took frequent pauses to breathe deeply, wipe away a tear, and get ready to answer the next call. In effect, we spent the night and early morning hours telling hundreds and hundreds of people that their loved ones were dead. Chiropractic college didn't teach me how to handle these types of phone calls. It also wasn't a part of my job description as a chiropractor in the ED.

My 9/11 experience taught me that the hospital is a good place to gather and organize a response to a catastrophe. With post-9/11 security measures in effect, you will not have access to the hospital unless you are on staff. The staff chiropractors need to have an established policy for response that fulfills the needs of the hospital and medical staff. You cannot depend on a call from the hospital to tell you that you are needed. The role of the chiropractor should be flexible. You need to use your chiropractic skills to help workers avoid the possible side-effects of medication. You also may be needed to assist with human skills to allow those trained in emergency response to focus on more critical life-saving issues. The chiropractor needs to display a good balance of being able to stay out of the way and being immediately available to help.

Make yourself familiar with the hospital's emergency response plan. Work with the hospital staff to integrate the chiropractor's role. Disasters are unpredictable and you will need to be prepared to be creative and do what is required, regardless of previously established protocols and procedures. Be wary of unsubstantiated reports from the disaster site. When emotions run high, focus on the job at hand, take long, slow breaths, and remember that there will be plenty of time to reflect and cry later.

John Cerf, DC
Jersey City, New Jersey