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Lessons Learned: New York Downtown Hospital and 9/11

By Tony Dajer, M.D., for HealthLeaders News, October 5, 2006
New York Downtown Hospital, founded two years after the Broad Street bombing of 1920, sits just four blocks from the northeast corner of what was the World Trade Center. On a typical day, the hospital's emergency department handles five patients per hour, which can rise to 10 patients per hour during peak times. On Sept. 11, 2001, our small community hospital treated 1,500 patients, including 350 in two hours--35 times the usual number of patients.

While this was an amazing feat, the faculty and staff of Downtown Hospital did not remain complacent after the fact--nor have we focused strictly on recovery. Instead, we've worked to find innovative solutions to the problems faced by most EDs. Although many of our disaster policies and spur-of-the-moment decisions worked as well as could be expected on that day, the events of 9/11 shed light on potential areas for improvement to make emergency response better in the future.

Looking back

Summoned to the ED by an overhead page at 8:55 a.m., it didn't fully register with me when the charge nurse rounded a corner exclaiming that an American Airlines plane had hit the World Trade Center. Our chief nurse was quick to start organizing the staff after she heard the blast. Nurses assembled at their stations as the chief nurse called central supply for extra materials. I gathered chest tubes, instrument trays and intubation sets out of our one and only trauma room and dumped them on a table in the main ER.

Doctors and nurses poured down from the upper floors and whisked the dozen overnight admissions we had up to the patient floors so we could make room and prepare. Our Level 2 trauma center doesn’t routinely see the victims of gunshots, stabbings or high-speed motor-vehicle accidents. When pushed to the limits, it could accommodate 30 stretchers.

After the first plane crash, the situation wasn't too out of control. But as ambulance sirens began to announce their arrival with multiple victims, things changed. Quick-thinking staff members implemented an impromptu visual triage system that helped them attend to the most critical patients first. We darted from ambulance to ambulance tying triage tags on patients as the medics and dozens of staff members helped them into the hospital. Green tags meant minor, yellow was serious, red was critical. One medic announced that the second tower had been hit before he dashed away to bring more people from the scene.

Soon, ambulances began pulling up four at a time. Staff members were running to keep up. Patients--walking, in wheelchairs or hobbling between friends--poured in through every entry to the hospital. The severity of the injuries multiplied quickly. A surgeon tried to intubate a badly burned woman while our chief pulmonologist and a cardiologist looked on. She had third-degree burns over 90 percent of her body--an unsurvivable injury. Morphine was the most we could offer her.

Police cars barreled up and men and women wearing red scrubs clambered out. They were surgeons from Bellevue Hospital Center who, despite our jammed phone lines, had guessed where patients were being taken. One physician, sporting a red backpack stuffed with supplies, roared up on his motorcycle and hustled into the ER with his comrades.

Suddenly, a surreal 10-story-high maelstrom of smoke and ashes roared between the tightly packed buildings on Gold Street and poured over us. We braced ourselves as the sun vanished behind a thick cloud of orange, black and gray. Everyone ducked inside, but only for a second as the choking mess didn’t stop the ambulances.

Relaying information from the frontlines, someone shouted that the impossible had happened: One tower had collapsed. Scores of people seeking shelter pounded on the windows of the main lobby, leaving powdery handprints. Two construction workers rigged the interior double doors to stay closed so people could step in, close the outer bay doors, and then open the inner doors forming an instant airlock. The ER had no airlock, so we all donned surgical masks.

Events seemed to be happening in slow motion as ambulances kept arriving out of the acrid blizzard. Soon the second tower was gone, and the cloud of dust again doused the sun.

Moving forward

The experience in the ED at Downtown Hospital on 9/11 illuminates what can happen in an emergency room when tragedy strikes on a grand scale. More importantly, it shows how--although no hospital can ever fully prepare for something of that magnitude--superior organization and teamwork can help staff members perform lifesaving miracles under the most dire of circumstances. In the five years since the attacks, Downtown Hospital has been fortunate to stay open despite several recovery challenges. Coming full circle, we've been able to implement changes as a result of the many lessons learned from that day--and the days following--as we've looked ahead to the future of care and emergency response in our city:


  • Designing for emergencies
    Downtown Hospital treated hundreds of members of the financial community on 9/11. Five years later, the Wall Street community continues to give back to the hospital, most notably by helping us build a new $25 million emergency department, which opened on Sept. 7, 2006. Ours is now the only ER in New York specifically built to respond to terror attacks and other major disasters. The ED features one of the largest and best-equipped decontamination facilities in the city. It also has a larger trauma room outfitted to perform a wider range of procedures. A newly-enhanced cafeteria can serve as an expanded ER in the event of a large-scale emergency. In addition, a new pediatric emergency suite, chest pain emergency unit and asthma treatment center have increased our ability to care for patients presenting with a wider variety of health issues.


  • Throughput during emergencies
    Emergency departments in the U.S. continue to fall under scrutiny for long wait times, ambulance diversions and other throughput-related issues. Downtown Hospital has taken an innovative approach to address these issues since 9/11 by designing our new ED with surge capacity in mind. The new facility is twice the size of the old one, and the hospital has increased clinical staff by one-third. Gas pipes have been extended into the cafeteria, so it's always equipped to serve as expanded emergency space in the event of another disaster. To handle day-to-day capacity more efficiently, we added electronic medical record capabilities and patient tracking systems.


  • Educating for emergencies
    In the hope of helping hospitals around the world develop better preparedness strategies, Downtown Hospital is sharing its experience and lessons learned on 9/11 by spearheading an annual international emergency-preparedness symposium focusing on the topics of readiness and response to large-scale emergencies such as natural disasters and terrorist attacks. It is the hospital’s hope that doing so will enable hospitals to serve patients quickly, efficiently and effectively in the event of a major disaster.






Tony Dajer, M.D., is interim chief of the emergency department at New York Downtown Hospital. He may be contacted at Antonio.Dajer@downtownhospital.org.