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Advance For Nurses: A New Era: Life after 9/11 - 9/04/06

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September 4-11, 2006

By Lyn A.E. McCafferty & Craig Causer

Sept. 11, 2001 began like most other days for Mary Lyke, BSN, RN. As nurse manager for the emergency department at New York Downtown Hospital, she started work at 7:30 a.m. in the small community hospital in downtown Manhattan.

One of the night nurses had argued with her fiance that morning, so Lyke walked her out to talk to her privately.

That's when they heard a plane flying very low and very close.

"We were talking and couldn't finish our conversation — the plane was that loud," Lyke said. "We knew something was going to happen. Then we heard the crash. All the birds flew away in the trees; car alarms went off everywhere around us. We immediately went back inside the ED."

As they rushed in, a paramedic was exiting the building. "Did you hear? A plane crashed into the World Trade Center," he said.

Eye of the Storm

Over the next 24 hours, Lyke and her colleagues at New York Downtown Hospital pulled together to triage and treat victims of the terrorist attack. They worked in conditions that were far from ideal: the ED was covered in a cloud of dust; there were no computers, no phones and no water to sterilize equipment; and the only power available came from a back-up generator.

In the hours and days ahead, the hospital would serve not only as a place to treat the injured, but also as a clearing house and information center. Local residents came to the hospital seeking news about lost loved ones or friends. They sought refuge and comfort — to be with other people while their world was literally crumbling around them.

But in fact, very little could be learned in the hub of the storm. While located only four blocks away from the World Trade Center, hospital nurses, doctors and support staff had very few resources available for answers.

"We didn't even know if we were safe," said Peter Fromm, MPH, RN, CHE, NREMT-P, director of emergency services at New York Downtown. "Without power, we couldn't see the news, and rumors were flying at the facility. We had no reliable source of information."

Changing World

In the 5 years since 9/11, a lot has changed in the world, in New York City and at New York Downtown Hospital.

"I still wonder 'What if?'" said Fromm, who oversees emergency preparedness at New York Downtown. "If you'd asked me on Sept. 10, 2001, what's the worst thing that could happen in Lower Manhattan, it would not have been this."

Since then, Fromm and other healthcare leaders have taken the lessons they learned from 9/11 and recast a more formalized disaster and emergency preparedness plan. Every employee — from the medical director to housekeeping — is trained in what to do if or when another crisis occurs. Lines of communication have been drawn, both internally and externally with neighboring facilities, city, state and federal agencies.

Despite the planning, the training, the drills and even the opening of a new expanded ED at New York Downtown on Sept. 7, there's one overriding theme these healthcare leaders have learned from 9/11.

"You can't plan for every contingency," Fromm said. "But good people will find a way to make the right things happen if given the right framework to work in."

Disaster Plan

New York Downtown Hospital has had an emergency management and disaster plan since 2000 — more than a year before 9/11. Fromm worked with a consultant to create a three-tiered emergency system.

"We developed the plan in 2000 to keep our staff safe," Fromm said. "It was a commitment on behalf of the hospital and hospital leadership. This is lower Manhattan and anything can happen. We knew we needed a plan. We needed to be prepared.

"Our nurses and personnel are our most precious resources and we need to keep them safe," Fromm said.

Beginning in 2000, every new employee received 4 hours of training in the Incident Command System and Emergency Management Plan, Fromm said.

"I can't think of any other hospital that does this for every employee — from doctors to nurses, to unit clerks and housekeepers," Fromm said. "Our goal with this training is that people become familiar with it and know how to react when the time comes."

Under Code Yellow — which represents a disaster — nursing staff must immediately go to their stations, call the nursing office and receive an assignment.

Code Yellow

Lyke activated a Code Yellow on 9/11, alerting staff a level III disaster was at hand.

"I don't even remember doing it," Lyke said. "I was on automatic pilot. I knew what I had to do and I did it."

Other nurses looking at Lyke knew this was no drill. This was the real thing. And they rose to the occasion. Nurses, doctors, technicians and unit clerks broke the ED into different sections according to the hospital's disaster plan, which was formalized the year before.

In the red section were the critical patients, yellow was for acute patients, green was for the walking wounded and black was for the dead. Lyke and two doctors oversaw the red, yellow and green areas.

"Because we were so close to the WTC, we knew we'd get a lot of walking wounded," Lyke said. "We took over the cafeteria and made that our 'green' area. A five-bed chest pain section of the ED and one trauma room became the 'red' area for critical patients, and the rest of the ED — about 17 other beds — was set up for acute patients."

Through the Doors

The first patient arrived by ambulance. She'd been hit by a piece of plane.

"She was de-gloved," Lyke said. "She'd lost skin on her back, half of her buttock, the back of her legs and her heels.

"Another patient came in already intubated, but when he was moved from the EMS stretcher to our stretcher, brain matter came out," Lyke continued. "We knew there was very little we could do for him, so we put him on a vent and walked away. In crisis situations like this, you have to make hard decisions about who you can save and who you can't."

Hospital staff thought a third patient was a black male, but when they were able to cut through the patient's clothes, they discovered a white female instead. "She was so badly burned, we couldn't tell initially," Lyke said.

Patients with less serious injuries came streaming in as well, and help arrived from every quarter. Staff members who were on their way home returned to see if they could help. Clinicians from other departments came to the ED to help. A group of physicians who were in town at a nearby trauma conference showed up offering their help.

"The ED started to get flooded with a lot of additional staff members," Lyke said.

"Everyone was coming to me, asking 'what can I do?' I kept telling them to go to the staging area because that's where I'd go when I needed something — runners to relay messages, patients to be transferred, tests to be run."

Pitching In

As then-director of EMS at New York Downtown, Fromm was headed upstate to a meeting when his secretary called to tell him about the plane crash. He turned around immediately and arrived back in the city as the first tower fell.

It was chaos on the streets of Manhattan. Police officers were stopping everyone. No cars were allowed into lower Manhattan, from Canal Street south. He was forced to abandon his car near the FDR Drive and began walking to the hospital.

"I was buried in a dust cloud. I had no idea where I was but I headed toward the World Trade Center because the hospital was nearby," Fromm said. "I asked a cop if the hospital was still there and he said he had no idea — I'd have to find out for myself."

Fromm eventually found one of the hospital's paramedics with an ambulance and got a ride back to the hospital. They picked up three injured firefighters on the way back to the hospital.

When he arrived at the hospital, he saw nurses and doctors doing triage outside the ED. Inside, he found Antonio J. Dajer, MD, interim chief of the ED, working with patients and Lyke organizing supplies and staff in the ED.

"I started working with them immediately, doing whatever I could," Fromm said. "We tried to evacuate as many patients as possible to safe areas but we had patients too unstable to transfer so we had to stay and run the hospital.

"We kept hoping to see more survivors."

Walk to Remember

Veronica Blakely-Ewart, RN, heard about the terrorists' attacks as she was visiting a friend. A nurse at Downtown Hospital since 1983 and a veteran of the bombing of the World Trade Center in 1993, she knew the hospital would be a hub of activity. So she began to walk from 20th Street to Lower Manhattan.

During the trek she noticed an element of "humanness about everyone." Everyone was walking together. Restaurants placed tables on the street and had televisions outside to keep people abreast of events as they unfolded. Water and telephones were provided to the masses evacuating the area.

"When I first got to Williamsburg [in Brooklyn], that's when I started noticing all of the ash and soot that came from the World Trade Center," Blakely-Ewart explained. "I said a prayer because I knew I was walking back into it."

She was able to reach her son on the phone and he told her "'Mommy, they're telling people to go home.' I told him that I'm trained for this type of thing. I said a prayer and I thought, I think it's safe enough for me to go back in."

Blakely-Ewart stopped at One Police Plaza to get a mask so she could continue her trek into the dust-filled area. She spotted a New York Downtown ambulance and got a ride back to the hospital.

"When I got there I was almost in a state of shock because there was ash everywhere," Blakely-Ewart said. "I always tell people that it looked like a war zone. I'm into sci-fi and it looked like a disaster where Godzilla attacked. I went inside and every room was packed. If a room usually fit two patients, there were three patients there.

"One of the nurses told me that she was holding someone's head and brain matter was coming out," she said. "The hardest thing about triage in that situation is you have to work your hardest on that patient but you have to save those that are viable."

Filled to Capacity

By 11 a.m., the ED was completely filled. Many of the incoming patients had suffered traumas, chest pains and eye injuries.

"We had 350 patients come in the first 2 hours, not counting the hundreds that came into the hospital to get out of the smoke," Dajer said.

Patients that were critical but stable were transferred to other hospitals.

"It was dark, gray and smoky, and everybody was coughing," said Josie Golivit, RN, a night-shift triage nurse in the ED. "It was scary. At one point I thought about my family and wondered if I was going to be able to get out."

Despite her personal concerns, she worked throughout the morning, afternoon and evening to triage and admit patients. She cannot forget the first patient she saw that day — the woman who'd lost part of her back from flying shrapnel. The patient was so badly burned that physicians initially wanted to amputate her legs, Lyke said. Ultimately, clinicians decided to try to save the woman's legs. They were successful and more than 6 months after she was first admitted, the woman was transferred to a rehab facility.

The day was a seemingly endless stream of patients. While many New Yorkers were heading home to their families, Golivit and others stayed.

"I didn't go home at all that day and worked until about 1 a.m.," she said. "We had an area at the hospital where we could rest and that's where I stayed for the night.

"I didn't see my family until the next day. But I was able to talk to my son and tell him I was OK."

All in the Family

Golivit was not the only one worried about her family. Amidst organizing the ED, Lyke was also doing a mental checklist of her loved ones. Her sister worked for the federal government, her parents were on election duty in Staten Island. She'd heard from her parents that a brother in Las Vegas was OK, and her sister was fine.

But no one had heard from another brother — a New York City police officer.

"Then my brother John came in to check on me" at the hospital," Lyke said. "We just hugged each other for a few minutes."

She later learned his story: When the first tower fell, he was on West Street — bordering the World Trade Center — with his boss. They were a block away when the building fell. They ran in the opposite direction and got a block before the dust cloud caught up with them.

"He said he had to go back to the site but told me to call Mom and Dad when I got a phone to let them know he was OK," Lyke said. "And then he told me to 'stay safe' and headed back."

Controlled Chaos

Despite the controlled chaos, close to 1,200 people were treated within the first 24 hours — in an ED that usually treats 90-100 patients a day.

"We used every square foot we had," Dajer said. "We expanded into the cafeteria. Then, as people continued to come in, we expanded up into the floors of the hospital. The fourth floor became the next staging area, and when that filled up, we went to the fifth floor."

Lyke added: "We treated patients from 2-5 minutes after the plane crash until about 2 p.m. in the afternoon. And then, all the sudden it just stopped.

"That was worst," she said. "That's when it hit home with staff that everybody was dead. Everybody who could get out did."

Command Center

It wasn't until the afternoon that Fromm was able to go to the command post on the first floor of the hospital. It was there a core group of hospital leaders from different disciplines gathered to ascertain the condition of the hospital, what resources and supplies were available and what else was needed, as well as plan how they could best ensure the staff's safety.

"I discovered many, many problems with our plan that day but there was no way to plan for every contingency," Fromm said.

On Sept. 11, established communication systems didn't work. Land-line phones were destroyed — the wires were routed under the World Trade Center. Cell phones were sporadic at best — cellular towers had collapsed and others were clogged with the millions of city workers trying to call loved ones.

"We eventually used old-fashioned runners," Fromm said. "We wrote down messages and had people deliver them in the hospital. It seemed medieval but it worked."

In fact, one of things clinicians learned from 9/11 was technology isn't always the answer because, Fromm said, "those systems can disappear."

"You have to plan for almost any contingency but sometimes you can't even imagine what will happen next," Fromm said. "Part of planning is establishing the human chains of commands and being flexible as situations develop. You need to be able to say, 'OK, that's not working, let's try this.'"

Planning for Disaster

Along with learning where things could be improved with the hospital's disaster plan, clinicians also saw first-hand what worked. New York Downtown was more prepared than other hospitals might have been simply because it had one disaster plan that was communicated to everyone in the facility.

"We have check lists for departments and specific roles but the plan is only as good as the people carrying it out," Fromm said.

What Fromm and others discovered on 9/11 is that the hospital, its staff and patients can rely on the good judgment of the people who work there.

"I don't know if anyone told the engineers to close off the vents on the roof when the clouds of dust were surrounding us, but they did and it kept a lot of people safe," he said.

There were countless other examples of individuals and departments rising to the occasion on Sept. 11 and in the days and weeks that followed.

Moving Ahead

The nurses, doctors and other staff at New York Downtown Hospital got through 9/11 in a way that brought honor to the hospital and the city. But they also knew they wanted to be more prepared for the next disaster.

In addition to conducting disaster drills more frequently, fine-tuning its 2000 disaster and emergency plan and continuing to train every hospital employee on disaster preparedness, hospital leaders decided to go through with its plan to expand the hospital's ED. The expansion was something that was on the drawing board before 9/11 but became a real goal in its aftermath.

On Sept. 7, the new Lehman Brothers Emergency Center will be unveiled. The new center will include a significant decontamination facility, an enlarged trauma room, a new chest pain emergency unit and individual asthma treatment stations, among other features.

The center's square footage has doubled. Every cubicle, although set up for a single patient, can be expanded to hold two patients. While the number of beds has increased by five to a total of 31, the expansion will allow the capacity to be raised to more than 60 patients in the case of an emergency or disaster, Dajer said.

On 9/11, the walking wounded were triaged and treated in the hospital's cafeteria. Knowing the cafeteria is an expansion area in the case of an emergency, the expansion project also beefed up medical resources available there as well.

The new decontamination facility is a huge improvement over the small shower that was available on 9/11. Today, the facility has high-volume, high-pressure showers installed over the ambulance bay, Dajer said. The fully integrated decontamination unit is designed to respond to biological and chemical attacks and other emergency situations.

The enhancements will allow New York Downtown to better serve its neighbors in the Financial District, Battery Park City, Chinatown, Tribeca, Little Italy and the Lower East Side.

"9/11 really provided the impetus to do a lot of the things that we've done including increasing size, surge capacity and facilities including accommodations for extra guests, connections and clinical monitoring," Dajer said.

"It's a significant step and we've already hired additional staff for the new center."

Ready or Not?

So, with all the improvements, renovations, communication and planning, is New York Downtown ready for the next big emergency?

"It's something we think about all the time," Fromm said. "We got through 9/11 in a way that I think brought honor to the hospital and to the city, but are we ready for it to happen again? I just don't know. We can't plan for every contingency.

"All we can do is put a good system into place and rely on our staff to react appropriately to situations as they come," Fromm added.

"We didn't execute perfectly on Sept. 11, but we kept everybody safe. We kept our staff safe and we kept our patients safe.

"And, when you think about it, that's what our whole job in healthcare is about."

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