MMWR. 2002;51(Special Issue):1-5
1 figure, 1 table omitted
Within minutes of the terrorist attacks on September 11, 2001, the Fire
Department of New York City (FDNY) operated a continuous rescue/recovery effort
at the World Trade Center (WTC) site. Medical officers of FDNY Bureau of Health
Services (FDNY-BHS) responded to provide emergency medical services (see sidebar).
The collapse of the WTC towers and several adjacent structures resulted in
a vast, physically dangerous disaster zone. The height of the WTC towers produced
extraordinary forces during their collapse, pulverizing considerable portions
of the buildings' structural components and exposing first responders and
civilians to substantial amounts of airborne particulate matter. Fires burned
continuously under the debris until mid-December 2001. Because of ongoing
fire activity and the large numbers of civilians and rescue workers who were
killed during the attacks, approximately 11,000 FDNY firefighters and many
emergency medical service (EMS) personnel worked on or directly adjacent to
the rubble and incurred substantial exposures. This report describes morbidity
and mortality in FDNY rescue workers during the 11-month period after the
WTC attacks and documents a substantial increase in respiratory and stress-related
illness compared with the time period before the WTC attacks. These findings
demonstrate the need to provide acute and long-term medical monitoring, treatment,
and counseling to FDNY rescue workers exposed to this disaster and to solve
supply, compliance, and supervision problems so that respiratory protection
can be rapidly provided at future disasters.
During the collapse, 343 FDNY rescue workers died and, during the next
24 hours, an additional 240 FDNY rescue workers sought emergency medical treatment.
This report includes all reported injuries/illnesses during the 24 hours following
the attacks. Traumatic injuries are reported for the 3 months after the attacks
because many workers did not report their injuries initially so they could
participate in the rescue effort. Respiratory and stress-related illnesses
are reported for the 11 months after the attacks because onset might be delayed
and/or influenced by repeated exposures. Stress-related illnesses include
post-traumatic stress disorders, depression, anxiety disorders, and bereavement
issues. Incidence rates after the attacks (September 11, 2001–August
22, 2002) are compared with rates for the preceding year (September 11, 2000–August
22, 2001). Cases were identified from the FDNY-BHS computerized medical data
base, which includes data on all FDNY rescue workers who present to hospitals
or treatment centers for emergency medical treatment or to FDNY-BHS for symptom/injury/illness
evaluation, medical leave evaluations, the WTC exposure medical monitoring
program, worker's compensation injury/illness claims, or disability/retirement
evaluations. Typically, case ascertainment is complete because all FDNY rescue
workers must report to FDNY-BHS for regular evaluations if they present to
hospitals or treatment centers while on duty, require on- or off-duty medical
leave, file worker's compensation, or request retirement disability.
The First 24 Hours Following the WTC Attacks
The First 24 Hours Following the WTC Attacks
At the time of the attacks, 11,336 firefighters and 2,908 EMS workers
were employed by FDNY. During the collapse, 343 FDNY rescue workers died (341
firefighters and two paramedics). During the first 24 hours, 240 FDNY rescue
workers (158 firefighters and 82 EMS workers) sought emergency medical treatment.
Most (63%) were for eye irritation, respiratory tract irritation and exposure
(any combination of mild exhaustion, dehydration, and eye and respiratory
tract irritation) not requiring hospital admission. Of 28 FDNY rescue workers
who required hospitalization, 24 had traumatic injuries including 17 with
fractures, four with back trauma, two with knee meniscus tears, and one with
facial burns. One firefighter suffered a cervical spine fracture requiring
surgery for stabilization and recovered without neurologic sequelae. Three
FDNY rescue workers required hospital admission for life-threatening inhalation
injuries. Eight FDNY rescue workers were evaluated for chest pain, and one
EMS worker was admitted for suspected myocardial infarction; after evaluation,
none was found to have coronary artery disease.
Traumatic Injuries During the 3 Months After the Attacks (September
11–December 10, 2001)
Traumatic Injuries During the 3 Months After the Attacks (September
11–December 10, 2001)
Data for the first month following the attacks include those injuries
occurring in the first 24 hours that resulted in medical leave. Compared with
monthly mean incidence rates for the 9 months before the attacks, the incidence
of crush injuries, lacerations, and fractures during the month after the attacks
increased by 200% (from three to nine), 35% (from 37 to 50), and 29% (from
21 to 27), respectively, but then returned to levels similar to those observed
before the attacks. Compared with the 9 months before the WTC attacks, monthly
mean incidence decreased for contusions (from 86 to 67 [29%]), sprains and
strains (from 364 to 200 [41%]), other orthopedic injuries (from 96 to 61
[35%]), and burns (from 43 to three [95%]). As of August 28, 2002, a total
of 90 FDNY rescue workers were on medical leave or light duty assignments
because of orthopedic injuries reported during the 3 months of activity at
the WTC site.
Respiratory Illnesses During the 11 Months After the Attacks (September
11, 2001–August 22, 2002)
Respiratory Illnesses During the 11 Months After the Attacks (September
11, 2001–August 22, 2002)
During the 48 hours after the attacks, approximately 90% of 10,116 FDNY
rescue workers evaluated at the WTC site reported an acute cough often accompanied
by nasal congestion, chest tightness, or chest burning; only three FDNY rescue
workers required hospitalization. Compared with numbers of service-connected,
respiratory medical leave incidents (n = 393) during the 11 months preceding
the attacks, the number of respiratory medical leave incidents (n = 1,876)
increased five-fold during the 11 months after the attacks. During February
2002, the incidence of new respiratory illness requiring either medical leave
or light duty began to decrease and during May 2002 began to approach pre-attack
incidence.
Respiratory Illnesses During the 11 Months After the Attacks (September
11, 2001–August 22, 2002)
Respiratory illness with chest radiograph abnormalities
Two weeks after the attacks, one FDNY firefighter was admitted with
acute eosinophilic pneumonia after repeated exposure to WTC dust.1 The firefighter fully recovered after a short course
of corticosteroid treatment. In the 3 months after the attacks, 13 FDNY firefighters
were treated for pneumonia (lobar consolidation with leukocytosis) with complete
resolution following antibiotic therapy. This incidence was similar to that
observed for the same period 1 year earlier. As of August 28, 2002, all 14
firefighters are asymptomatic and have returned to full duties.
Respiratory Illnesses During the 11 Months After the Attacks (September
11, 2001–August 22, 2002)
WTC-related cough
During the 6 months after the attacks, 332 firefighters and one EMS
worker had WTC-related cough severe enough to require ≥4 consecutive weeks
of medical leave.2 Despite treatment of
upper and lower aero-digestive tract irritation (i.e., sinusitis, gastroesophageal
acid reflux, and/or asthma), 173 (52%) of 333 have shown only partial improvement
of WTC-related cough and remain either on medical leave or light duty or are
pending a disability retirement evaluation.
WTC-related cough
As of August 28, 2002, a total of 358 firefighters and five EMS workers
remained on medical leave or light duty assignment because of respiratory
illness that occurred after WTC exposure. On the basis of applications for
respiratory disability retirement benefits during the preceding 6 months,
an estimated 500 FDNY firefighters (4% of the 11,336 total FDNY firefighter
workforce) might eventually qualify for disability retirement because of persistent
respiratory conditions.
Stress-Related Illnesses During the 11 Months After the Attacks (September
11, 2001–August 22, 2002)
Stress-Related Illnesses During the 11 Months After the Attacks (September
11, 2001–August 22, 2002)
During the 11 months after the attacks, 1,277 stress-related incidents
were observed among FDNY rescue workers, a 17-fold increase compared with
the 75 stress-related incidents reported during the 11 months preceding the
attacks. As of August 28, 2002, a total of 250 FDNY rescue workers remain
on leave with service-connected, stress-related problems. Of these, 37 also
have respiratory problems.
Reported by:
G Banauch, MD, M McLaughlin, R Hirschhorn, M Corrigan, K Kelly, MD,
D Prezant, MD, Bur of Health Svcs, New York City Fire Dept.
CDC Editorial Note:
During the 3 months after the WTC attacks, medical leave incidents were
increased for eye irritations, fractures, crush injuries, and lacerations
but decreased for other traumatic injuries. These findings probably resulted
from (1) lack of adequate eye protection against fine airborne particles,
(2) inability of work gloves to reduce injuries while maintaining comfort
and dexterity, (3) effective use of thermal personal protective equipment
despite an extremely hazardous environment, (4) prevention of major injuries
because of safe work practices, and (5) underreporting of minor injuries because
of the dedication of this workforce to remain on the job at the WTC site.
CDC Editorial Note:
Although approximately 90% of FDNY rescue workers reported a new or
worsening cough during the 48 hours after the attacks, only three FDNY rescue
workers required hospitalization for acute inhalation injury, and no FDNY
rescue worker with chest pain had coronary artery disease. These findings
are related to FDNY medical policy that does not allow firefighters to perform
fire-fighting duties unless cardiopulmonary function is normal. During the
11 months after the WTC attacks, the number of medical leave incidents for
respiratory illnesses increased, and approximately 500 FDNY firefighters might
qualify for retirement disability benefits for new onset asthma and other
reactive airway diseases. Increased bronchial responsiveness also has been
found in firefighters with WTC-related cough. These findings might reflect
delayed or progressive inflammation of the respiratory tract with or without
repeated exposures and the synergistic inflammatory effects of sinusitis and/or
gastroesophageal reflux.
CDC Editorial Note:
The high incidence of respiratory problems and related medical leave
among FDNY rescue workers demonstrates the need for adequate respiratory protection.
During the collapse, 52% of workers did not wear respirators, and 38% did
not wear respirators for the rest of the first day.3 In
addition, most of those reporting the use of a respirator during the first
day used only a disposable paper dust mask that was neither NIOSH-certified
nor fit-tested. However, despite widespread acknowledgment that rescue workers
at future disasters be provided with respiratory protection as soon as possible,
such plans will be successful only if barriers to use, such as supply, heat
stress and discomfort, communications, training, compliance, and supervision,
are resolved.
CDC Editorial Note:
The increase in stress-related medical leave did not occur in large
numbers until months after the attacks. Repeated exposures at the site and
the increasing number of funerals and memorial services that firefighters
attended during the next 11 months might have contributed to stress-related
problems. In July 2002, new cases began to decline, but previous incidents
of terrorism suggest that cases might increase after the 1-year anniversary
of the attacks. Especially for stress-related problems, these numbers do not
reflect the full volume of health evaluations and treatment activity because
many workers report symptoms and seek treatment while remaining on full duty.
CDC Editorial Note:
The findings in this report are subject to at least one limitation.
Because of disaster conditions after the attacks, some rescue workers who
presented to hospitals or treatment centers for emergency medical treatment
and were treated and released without admission and never required medical
leave might have remained unreported. This limitation would only apply to
minor injuries.
CDC Editorial Note:
One year after the WTC attacks, FDNY rescue workers continue to recover
from orthopedic, respiratory, and stress-related problems. The findings in
this report demonstrate the need to provide improved personal protective equipment
(especially eye, hand, and respiratory protection) and continued medical monitoring,
treatment, and counseling for all rescue workers exposed to disasters.
Recollections of 9/11—Medical Officers of the New York City Fire Department
Recollections of 9/11—Medical Officers of the New York City Fire Department
These personal recollections describe the conditions
faced by persons responding to the World Trade Center attacks and the circumstances
of the injuries and illnesses among New York City Fire Department (FDNY) rescue
workers. These remarks were recorded in August 2002.
Recollections of 9/11—Medical Officers of the New York City Fire Department
Drs. Kerry Kelly and David Prezant are the Chief and Deputy Chief Medical
Officers, respectively, of FDNY. Approaching from different directions, they
arrived on the scene shortly after the second plane hit the South Tower of
the World Trade Center (WTC).
Recollections of 9/11—Medical Officers of the New York City Fire Department
Dr. Kelly: As I made my way toward the nearest
firehouse (Ladder 10/Engine 10 on Liberty Street) in lower Manhattan, I saw
people and debris raining from the towers. A group of FDNY firefighters called
for me to help a firefighter who had just been hit by a civilian falling from
the tower. The injury appeared fatal. We attempted to resuscitate him and
then placed him in a nearby ambulance. A captain then escorted me across West
Street towards the command center.
Recollections of 9/11—Medical Officers of the New York City Fire Department
Dr. Prezant: Every street had been closed off
by police, only allowing entry to a steady stream of ambulances, fire trucks,
and emergency vehicles. The chief-in-charge directed me to set up an EMS medical
triage area directly in front of the South Tower. I was joined there by about
20 EMS workers.
Recollections of 9/11—Medical Officers of the New York City Fire Department
Dr. Kelly: All of a sudden, the captain shouted,
"Hurry up, the South Tower is falling!" We ran across the street, and he pushed
me against a building, covering my body with his. The sound was deafening
as debris pounded down. It was hard to breathe. The air was thick and choking.
Then there was silence. It looked as though black snow had fallen, covering
everything. Everyone was covered with gray powder; their features were indistinguishable.
Recollections of 9/11—Medical Officers of the New York City Fire Department
Dr. Prezant: As the EMS workers and I began
to set up a mini-triage area in the middle of West Street, there was a soft
rumbling that sounded like a freight train. Everyone started to run across
the street away from the tower. I had nearly reached the cover of a pedestrian
bridge when I was blown off my feet and completely buried under debris. I
knew I was going to die but it seemed to be taking forever. I pushed myself
up to my knees and tried to maintain a position that could trap enough air
to breathe. Several sheets of construction materials covered me and I was
able to wedge myself out. I was surprised that I could stand up. It was as
dark as a tunnel and the air was as thick as soup. Despite repeatedly scooping
chunks of dust and debris from my mouth and nostrils, I inhaled and swallowed
large quantities. I heard screams to my left and I began to walk toward them
and met several firefighters. Together, we helped several civilians out of
the debris. After walking one or two blocks, the sky lightened to a grayish
color, and it became obvious that I had been trapped in a massive dust cloud.
We were coughing continuously, and it was hard to see. I do not remember hearing
the second tower collapse.
Recollections of 9/11—Medical Officers of the New York City Fire Department
Dr. Kelly: Other FDNY rescue workers and I
found two injured firefighters and brought them into a nearby parking garage.
While we were looking for medical supplies, the second tower collapsed. A
firefighter pushed me into a revolving door as the debris swooshed down the
street. The gray turned to black once again. Afterwards we carried the two
firefighters to an ambulance and later helped transfer them to a police transport
boat. I walked south to the tip of Manhattan—the Battery.
Recollections of 9/11—Medical Officers of the New York City Fire Department
Dr. Prezant: I saw Dr. Kelly for the first
time. We grouped up with some other firefighters and headed back toward the
collapse zone. We were then directed to a new staging area on Broadway and
Vesey, several blocks from the collapse site. Together with physicians and
nurses from FDNY, we opened a triage center in a pharmacy. Additional supplies
came from local hospitals. Medical personnel responding to the WTC attacks
were directed to this triage area.
Recollections of 9/11—Medical Officers of the New York City Fire Department
Dr. Kelly: We started to hear rumors that WTC
Tower 7 was going to collapse, and we all felt our triage area was too close
for comfort and moved it across the street to Pace University. This location
gave us greater space for anticipated trauma and eye/respiratory treatments.
Unfortunately, the extra space was not needed, because many firefighters had
died, and those left alive had been transported to hospitals or were hurriedly
working at the site to rescue others. As the day wore on, most visits to the
triage center were for eye/ respiratory irritation requiring eyewashes and/or
bronchodilators. The triage center was closed around 9:00 p.m. and we headed
back to FDNY headquarters.
Recollections of 9/11—Medical Officers of the New York City Fire Department
Dr. Prezant: We finally got back to headquarters.
It took an hour to wash off the dust, which by now had become like a layer
of concrete. I sat down to call my wife and tell her I was still alive. The
phone line was difficult to hear through, and I thought she said that the
TV showed pictures of both towers fully collapsed. I couldn't believe what
she had said. Amazing—I had nearly been killed, and then worked there
all day and I never knew or imagined that the entire WTC had collapsed.
Recollections of 9/11—Medical Officers of the New York City Fire Department
Drs. Kelly and Prezant: Over the next days
and weeks, there has been little time to grieve. Together with our staff at
the Bureau of Health Services, FDNY members, retirees, and others, we have
tried to meet the physical and mental health care needs of FDNY rescue workers.
Each day we are thankful for being alive.
Recollections of 9/11—Medical Officers of the New York City Fire Department
David Prezant, M.D.
Kerry Kelly, M.D.
References
Rom WM, Weiden M, Garcia R.
et al. Acute eosinophilic pneumonia in a New York City firefighter exposed
to WTC dust. Am J Respir Crit Care Med.2002(in press).
Prezant D, Weiden M, Banauch G.
et al. Cough and bronchial responsiveness in firefighters exposed at the World
Trade Center site. N Engl J Med.2002 Sep 12;347(11):806-815.
CDC. Use of respiratory protection among responders at the World Trade Center
site—New York City, September 2001. MMWR.2002;51(Special issue):6-8.
MMWR. 2002;51(Special Issue):18-19
Classification of the deaths and injuries that occurred as the result
of the events of September 11, 2001, presented CDC's National Center for Health
Statistics (NCHS) with a dilemma. Under the current classification systems
for mortality and morbidity, the World Health Organization's International Classification of Diseases, Tenth Revision (ICD-10) and
the United States' International Classification of Diseases,
Ninth Revision, Clinical Modification (ICD-9-CM), deaths and injuries
associated with acts of terrorism could not be identified uniquely.
To evaluate the adequacy of the classification systems for characterizing
terrorism-related deaths and injuries and in response to requests from the
affected states for guidance in classifying these events, NCHS formed an Ad
Hoc Workgroup on the Classification of Death and Injury Resulting from Terrorism.
The recommendations of the workgroup and consultations with other federal
and nonfederal partners resulted in the development by NCHS of a new set of
codes within the framework of ICD-10 and ICD-9-CM and a set of guidelines
that will allow the classification of deaths and injuries associated with
terrorism.1
For mortality, the codes developed include *U01-*U02 for terrorism involving
an assault (homicide) and *U03 for terrorism involving intentional self-harm
(suicide). Additional information about the structure of the mortality codes
and inclusion terms is available at
http://www.cdc.gov/nchs/about/otheract/icd9/appendix1.htm. The asterisk preceding each code indicates that the code was introduced
by the United States but is not officially part of the ICD. Codes from the
"U" Chapter of ICD-10 were selected because this chapter was reserved specifically
for "future additions and changes and for possible interim classifications
to solve difficulties arising at the national and international levels between
revisions."2 To maintain international comparability
in reporting homicide and suicide rates, deaths coded to *U01-*U02 will be
included in general tabulations with other homicides (X85-Y09 and Y87.1),
and deaths coded to *U03 will be included with other suicides (X60-X84 and
Y87.0). Implementation of the codes developed for mortality classification
is effective with 2001 mortality data.
For injuries associated with terrorism not resulting in death, the codes
developed include E979 and E999.1. E979 was unused previously in ICD-9-CM;
E999, which was used previously to denote the late effects of war operations,
was modified to include late effects of terrorism. E999.0 was created to classify
the late effects of war operations, and E999.1 was created for late effects
of terrorism. Additional information about the structure of the morbidity
codes and inclusion terms is available at
http://www.cdc.gov/nchs/about/otheract/icd9/appendix1.htm.
For statistical purposes, codes E979 and E999.1 will be tabulated
with other assaults (E960-E969). No plans exist to create a parallel category
for self-inflicted injury. Implementation of the codes developed for morbidity
will be effective October 1, 2002.
For the new terrorism codes to be used for the classification of deaths
and injuries, the incident in question must be designated as a terrorist act
by the U.S. Federal Bureau of Investigation (FBI), which has jurisdiction
over the investigation and tracking of terrorism in the United States. The
FBI defines a terrorism-related injury as one resulting from the ". . . unlawful
use of force or violence against persons or property to intimidate or coerce
a government, the civilian population, or any segment thereof, in furtherance
of political or social objectives."3 This
precludes individual judgments made by medical examiners, coroners, medical
coders, nosologists, or hospital staff. If the incident is labeled as a terrorist
act before the completion of the death certificate or the filing of the medical
record, it may be so described on the certificate or discharge record. When
the incident is labeled as terrorism after the death certificate has been
filed, the certificate can be recoded. Updating and recoding of the medical
record after it is completed and submitted for reimbursement is more complicated
and is unlikely to occur.
The standardized classification systems described here address the need
to identify deaths and injuries resulting from terrorism and will allow a
better assessment of the public health impact of terrorism in the United States.
References
World Health Organization. International Statistical Classification of Diseases and Related Health
Problems, Tenth Revision. Vol. 1. Geneva, Switzerland: World Health Organization, 1992.