When Disaster Strikes
To help us gain some perspective on aspects of the physical trauma suffered by victims during and immediately after the World Trade Center disaster, we spoke with Dr. Louis Del Guercio, former Chairman of the Department of Surgery at New York Medical College, Valhalla, New York, and an expert on trauma and shock.
Are the elements of triage any different in this kind of disaster compared with other calamities, such as a plane crash or earthquake?
Triage applies only in battlefield situations where the medical resources are limited and transportation to hospital facilities entails some risk. The triage officer has to decide which patients will benefit the most from transport to major hospital facilities. Triage applies in cases where the medical facilities are limited and you have to decide who are the walking wounded, who don't have to be transported at all, who are hopeless, and who are the ones in the middle who will benefit. But in a situation such as the one that happened here at the Twin Towers, we had more than adequate hospital facilities, and in fact, the Level I trauma centers made beds available and were all prepared. So, there was no need for triage because anyone who was found alive was brought to a Level I trauma center.
The people on the scene were there primarily to give first aid, perhaps begin life support, and get the victims into ambulances to take them to St. Vincent's Hospital, Beth Israel Hospital Downtown, and Bellevue Hospital. There were more than enough facilities. In fact, our hospital in Westchester has a Level I Trauma Center and a Burn Center and we were on the alert. We didn't get a single burn victim -- we didn't get a single trauma patient, because they were all adequately cared for and, unfortunately, because of the high percentage of deaths. Even the Cornell Burn Center had empty beds and they were prepared for everything. The people who were burned in the upper stories, of course, all died.
Would you expect that there could be survivors given the heat, weight, and force of the impact?
There are still hopes that people will be found alive in some of the 6 underground levels, but the building was so high and the forces so great as it came down, that it is unlikely that anybody who came down with the structure survived.
How are patients managed when they are brought to a Level I trauma center?
The first step is to give blood and fluids, evaluate the extent of the injuries, the fractures, and establish breathing, blood pressure and so forth for immediate life support. These are all standardized by the American College of Surgeons and the American Trauma Society (http://www.amtrauma.org/).
Is there a difference in trauma from this sort of disaster compared with other trauma?
Not really, this is blunt trauma, very similar to severe auto accidents and events of that sort.
Would you expect any kind of delayed physical trauma?
Once the initial phases are over, and blood pressure has been restored, a number of other syndromes can develop. Massive blood transfusions themselves can cause a derangement in proper immune responses. The major problem, however, and one that has not been solved in major trauma, is acute respiratory distress syndrome, or ARDS. This is a pulmonary vascular problem with an essentially unknown etiology, aside from major trauma. The lungs don't function properly and these people of course are put on respirators. Probably the best description is hemorrhagic pneumonia. It may be a delayed response to the trauma, the physical trauma causing coagulation problems, and so forth. That is the main unresolved, long-term problem for people who have suffered major trauma.
What is the time frame for developing ARDS?
It usually happens within a week of the event, and it may last for months if the patient survives. Kidney failure, of course, can occur too. But that can be managed relatively easily.
Is ARDS treatable if it's caught early and managed properly?
You are always looking for it, but even when you see it in the early stages, it is frustrating, because although we have many different types of respiratory management, no one has really solved the problem. It doesn't occur in everyone, fortunately. The ultimate disaster for the major trauma patient is multiple organ systems failure, in which one sees a domino effect, the kidneys fail, the lungs, the liver, and so forth. This results from the body's humoral response to the massive trauma. It is a sort of over-response.
We were fortunate to have so many hospitals available. We saw many physicians and nurses standing out on the sidewalks waiting for people to arrive.
Of course, a lot of people were saved because of that. St. Vincent's received over 400 patients, and some with relatively minor injuries.
What were the major types of injuries?
I understand that relatively few severe burn patients survived to reach the hospital. The falling debris injured a number of patients during the collapse -- there were a lot of people on the periphery. Those who were immediately under it, of course, didn't survive.
What about that cloud of debris and dust that poured over everything as the towers collapsed? What kinds of short- or long-term consequences might be expected for people exposed to that?
An article in The New York Times today pointed out that 1 of the buildings was built halfway when they realized that asbestos was a severe danger to people, so they stopped using asbestos. As a result, there was very little asbestos in the debris and dust. The health authorities have pointed out that there is no difference in that dust than the dust that you might get in the desert.
And they've been monitoring it carefully.
Yes, but they're not finding much asbestos there.
Would you expect any delayed effects on those who inhaled this dust?
No, probably not. The healthy lung quickly clears particulate matter. They would be coughing up dirty sputum for a while, but not much in the way of toxic elements are in the dust. Depending on the degree of damage, the effects of smoke inhalation are also temporary.
Which clears itself after some time?
That's right. People suffering from carbon monoxide poisoning are generally taken care of in hyperbaric chambers until the carbon monoxide is cleared from their systems.
Do all the trauma centers have hyperbaric chambers?
No, not even all the burn units. The major hyperbaric chamber is at Jacobi Hospital in the Bronx. Usually the firefighters know that and when victims are suffering from severe carbon monoxide poisoning, they are all transported there. I don't know whether any of the people from the World Trade Center were taken there or not. I hadn't heard anything about it, and wouldn't expect that this would have been an issue at the World Trade Center site, because the people in the upper stories, those who would have suffered smoke inhalation injuries, died.
Do you feel that in terms of the medical response, New York was prepared for this?
Absolutely. Everyone was prepared right away. New York City has 3 Level I trauma centers, which was more than adequate to care for those survivors. Even if there had been more survivors throughout the metropolitan area, it would have been possible to care for all of them. The University of Medicine and Dentistry of New Jersey has very good trauma and burn centers as well.
Should we have done anything differently?
Clearly, someone made a big mistake in putting the command centers so close to that site. Many people died because of that. But who would have imagined that those buildings were going to collapse? Nonetheless, someone should have moved those people out of there. In fact, Mayor Giuliani missed being killed by about 10 minutes. He was at that command center 10 minutes before the collapse. Everyone who stayed was either severely wounded or died.
What other issues for the future do we need to think about or prepare for?
This happened in a major metropolitan area with plenty of hospital beds, plenty of Level I trauma centers. There are other areas around the country where you would have to go 300 miles to find an adequate trauma center. I think the military is going to have to take this into consideration. The Army mobile hospitals are going to have to be activated or prepared to activate. The Navy is going to have to remobilize the hospital ships and making them available in case something happens. There are smaller cities where the hospitals themselves may be destroyed if there is a major disaster, whether chemical or biological warfare, and the country is going to have to be prepared.
Do you think we are prepared for a chemical or biological threat?
Well, yes, as much as possible. People who work in the area of trauma are well aware of the various chemical problems; during the Persian Gulf war everyone was well aware of it. I had volunteered during the Persian Gulf and we had special decontamination procedures, and vaccinations for germ warfare. We had special masks and chemically impervious uniforms, among other things. These probably are still stockpiled somewhere.
To help us gain some perspective on aspects of the physical trauma suffered by victims during and immediately after the World Trade Center disaster, we spoke with Dr. Louis Del Guercio, former Chairman of the Department of Surgery at New York Medical College, Valhalla, New York, and an expert on trauma and shock.
Are the elements of triage any different in this kind of disaster compared with other calamities, such as a plane crash or earthquake?
Triage applies only in battlefield situations where the medical resources are limited and transportation to hospital facilities entails some risk. The triage officer has to decide which patients will benefit the most from transport to major hospital facilities. Triage applies in cases where the medical facilities are limited and you have to decide who are the walking wounded, who don't have to be transported at all, who are hopeless, and who are the ones in the middle who will benefit. But in a situation such as the one that happened here at the Twin Towers, we had more than adequate hospital facilities, and in fact, the Level I trauma centers made beds available and were all prepared. So, there was no need for triage because anyone who was found alive was brought to a Level I trauma center.
The people on the scene were there primarily to give first aid, perhaps begin life support, and get the victims into ambulances to take them to St. Vincent's Hospital, Beth Israel Hospital Downtown, and Bellevue Hospital. There were more than enough facilities. In fact, our hospital in Westchester has a Level I Trauma Center and a Burn Center and we were on the alert. We didn't get a single burn victim -- we didn't get a single trauma patient, because they were all adequately cared for and, unfortunately, because of the high percentage of deaths. Even the Cornell Burn Center had empty beds and they were prepared for everything. The people who were burned in the upper stories, of course, all died.
Would you expect that there could be survivors given the heat, weight, and force of the impact?
There are still hopes that people will be found alive in some of the 6 underground levels, but the building was so high and the forces so great as it came down, that it is unlikely that anybody who came down with the structure survived.
How are patients managed when they are brought to a Level I trauma center?
The first step is to give blood and fluids, evaluate the extent of the injuries, the fractures, and establish breathing, blood pressure and so forth for immediate life support. These are all standardized by the American College of Surgeons and the American Trauma Society (http://www.amtrauma.org/).
Is there a difference in trauma from this sort of disaster compared with other trauma?
Not really, this is blunt trauma, very similar to severe auto accidents and events of that sort.
Would you expect any kind of delayed physical trauma?
Once the initial phases are over, and blood pressure has been restored, a number of other syndromes can develop. Massive blood transfusions themselves can cause a derangement in proper immune responses. The major problem, however, and one that has not been solved in major trauma, is acute respiratory distress syndrome, or ARDS. This is a pulmonary vascular problem with an essentially unknown etiology, aside from major trauma. The lungs don't function properly and these people of course are put on respirators. Probably the best description is hemorrhagic pneumonia. It may be a delayed response to the trauma, the physical trauma causing coagulation problems, and so forth. That is the main unresolved, long-term problem for people who have suffered major trauma.
What is the time frame for developing ARDS?
It usually happens within a week of the event, and it may last for months if the patient survives. Kidney failure, of course, can occur too. But that can be managed relatively easily.
Is ARDS treatable if it's caught early and managed properly?
You are always looking for it, but even when you see it in the early stages, it is frustrating, because although we have many different types of respiratory management, no one has really solved the problem. It doesn't occur in everyone, fortunately. The ultimate disaster for the major trauma patient is multiple organ systems failure, in which one sees a domino effect, the kidneys fail, the lungs, the liver, and so forth. This results from the body's humoral response to the massive trauma. It is a sort of over-response.
We were fortunate to have so many hospitals available. We saw many physicians and nurses standing out on the sidewalks waiting for people to arrive.
Of course, a lot of people were saved because of that. St. Vincent's received over 400 patients, and some with relatively minor injuries.
What were the major types of injuries?
I understand that relatively few severe burn patients survived to reach the hospital. The falling debris injured a number of patients during the collapse -- there were a lot of people on the periphery. Those who were immediately under it, of course, didn't survive.
What about that cloud of debris and dust that poured over everything as the towers collapsed? What kinds of short- or long-term consequences might be expected for people exposed to that?
An article in The New York Times today pointed out that 1 of the buildings was built halfway when they realized that asbestos was a severe danger to people, so they stopped using asbestos. As a result, there was very little asbestos in the debris and dust. The health authorities have pointed out that there is no difference in that dust than the dust that you might get in the desert.
And they've been monitoring it carefully.
Yes, but they're not finding much asbestos there.
Would you expect any delayed effects on those who inhaled this dust?
No, probably not. The healthy lung quickly clears particulate matter. They would be coughing up dirty sputum for a while, but not much in the way of toxic elements are in the dust. Depending on the degree of damage, the effects of smoke inhalation are also temporary.
Which clears itself after some time?
That's right. People suffering from carbon monoxide poisoning are generally taken care of in hyperbaric chambers until the carbon monoxide is cleared from their systems.
Do all the trauma centers have hyperbaric chambers?
No, not even all the burn units. The major hyperbaric chamber is at Jacobi Hospital in the Bronx. Usually the firefighters know that and when victims are suffering from severe carbon monoxide poisoning, they are all transported there. I don't know whether any of the people from the World Trade Center were taken there or not. I hadn't heard anything about it, and wouldn't expect that this would have been an issue at the World Trade Center site, because the people in the upper stories, those who would have suffered smoke inhalation injuries, died.
Do you feel that in terms of the medical response, New York was prepared for this?
Absolutely. Everyone was prepared right away. New York City has 3 Level I trauma centers, which was more than adequate to care for those survivors. Even if there had been more survivors throughout the metropolitan area, it would have been possible to care for all of them. The University of Medicine and Dentistry of New Jersey has very good trauma and burn centers as well.
Should we have done anything differently?
Clearly, someone made a big mistake in putting the command centers so close to that site. Many people died because of that. But who would have imagined that those buildings were going to collapse? Nonetheless, someone should have moved those people out of there. In fact, Mayor Giuliani missed being killed by about 10 minutes. He was at that command center 10 minutes before the collapse. Everyone who stayed was either severely wounded or died.
What other issues for the future do we need to think about or prepare for?
This happened in a major metropolitan area with plenty of hospital beds, plenty of Level I trauma centers. There are other areas around the country where you would have to go 300 miles to find an adequate trauma center. I think the military is going to have to take this into consideration. The Army mobile hospitals are going to have to be activated or prepared to activate. The Navy is going to have to remobilize the hospital ships and making them available in case something happens. There are smaller cities where the hospitals themselves may be destroyed if there is a major disaster, whether chemical or biological warfare, and the country is going to have to be prepared.
Do you think we are prepared for a chemical or biological threat?
Well, yes, as much as possible. People who work in the area of trauma are well aware of the various chemical problems; during the Persian Gulf war everyone was well aware of it. I had volunteered during the Persian Gulf and we had special decontamination procedures, and vaccinations for germ warfare. We had special masks and chemically impervious uniforms, among other things. These probably are still stockpiled somewhere.