Reflections on 9/11 — Medical Care in the Chaos

by Michael M. Karch, MD (M’95, R’02)

Does it seem that the flags are always flying at half-staff these days?

With the recent upward trend in large-scale, violencerelated injury patterns from Orlando to Nice, the ability to organize, manage, and treat mass casualty victims, whether in man-made or natural disaster, should now be paramount in every physician’s mind.

For Americans, this “awakening” occurred on the morning of September 11, 2001. Something fundamentally changed in all of us. On that day, we realized both individually and as a nation that we were vulnerable. On that day, those of us who practice medicine realized that we had much to learn about the emerging field of civilian mass casualty medicine. On that day, I was chief resident on the Georgetown Orthopaedic Surgery Service, in my PGY-7 year of surgical training and full of confidence, and knowledge... or so I thought. On that day, within minutes of the explosion at the Pentagon, we were told to be prepared to receive 200 patients in the next five minutes.

It was a high-voltage moment.

In reality we received only one, a man with severe burns who was transferred to Washington Hospital Center’s Burn Center. The others couldn’t get to us from Virginia. Bridges into Washington, D.C. were quickly shut down as part of the preestablished disaster plan to protect the inner core of the nation’s capital.

It made sense, at least on paper.

However, when a disaster occurs on the other side of the river, as in the case of the Pentagon, Georgetown and virtually all of the city’s major trauma centers were immediately out of reach.

Like everyone in medicine that day, I felt empty, paralyzed, and incredibly frustrated. It was as if we had trained for that specific moment our entire lives, and when it did occur, we couldn’t help.

My high-voltage electricity had been shut down.

I then did something very impulsive... out of character and irrational in every sense of the word.

I left the hospital and went home.

I stuffed a backpack full of dressings and sutures, food, a water purifier, a headlamp, and a sleeping bag. I took a cab to Baltimore since the Washington train station was closed, and jumped on a train headed to New York City.

Within hours, I was in the heart of it.

My thought was that in some way I could help the surgeons there, possibly rotate them out when they were tired.

The city was in chaos. Hot fire, eye-burning smoke, and choking dust everywhere. It was impossible to see. Deafening wails, of sirens and of people, made it impossible to hear. Clear senses became quickly fogged. Water from fire hoses made dangerously slick mud out of the ash, and gas and electrical lines tempted one’s fate along a hopscotched path through debris. It was hot when it should have been September cool and dark when it should have been afternoon light. There were thousands of papers floating through the financial district—life savings, mortgage statements, stock portfolios just drifting aimlessly in the wind. And shoes—hundreds of shoes everywhere. And bodies. So many bodies in the street, with no shoes on at all. I was told that the greatest immediate need was to organize the growing pile of bodies; for most, it was too late for my surgical skills.

I assigned myself to an ice skating rink nearby, where we set up to triage live patients if they came, but also to unload bodies and body parts onto the ice for later preservation and identification.

Ground Zero was austere in more ways than the destruction, with no precedent, no assigned leaders, no chain of command, no sign-ins, no registration and, most importantly, no directions. We had to take the initiative. We had to make things happen on our own. An ice rink-turned-morgue seemed strangely logical.

At one point in the early evening, I went to the bathroom and noticed a set of fireman’s clothes on a hockey bench. When I got back to my job, there was an announcement that there had been a request for doctors to go up to the front in order to establish a triage unit; there was new hope of finding injured survivors. The only requirement was that physicians would need to secure fire gear, as it was dangerously hot in “The Pit.”

Up to this point in my life, I had never stolen anything. Within seconds, I was wearing someone else’s fire gear from that hockey bench. I became one of the first physicians on site at Ground Zero and spent the next 48 hours directing a selfmade, onsite MASH unit performing search and rescue, body recovery, and damage control mass casualty medicine.

This was an “into the frying pan” moment.

To say that I was prepared for this experience would be a gross misstatement. I was humbled and then humbled again many times over. I walked away from that experience admitting to myself that I knew nothing. Knowing what I know now after 15 years of studying, practicing, and teaching disaster and mass casualty medicine, I must have made errors upon errors in the simple act of trying to help.

Did I do no harm?

At that time virtually no one received formal training in civilian mass casualty medicine. A decade-long course in late night, home research and self-directed study helped me understand how to do it better the next time. The prolific writings of our military colleagues serving in Iraq and Afghanistan provided volumes of material to learn from over the coming years.

Could their knowledge be translated into civilian mass casualty events?

The 9/11 experience put me on a different career and life trajectory than expected, allowing me to respond to, practice, and instruct civilian mass casualty medicine in the far corners of the world. And through this privilege, I have seen both the best and the worst of humanity.

I continue to be humbled by the destructive power of a super-typhoon or an earthquake or a bomb or bullet—or for that matter, the rejuvenating energy of an innocent baby that is randomly born into the chaos of it all. But also, I am inspired by the force multiplier effect—the impact that those who “march toward the sound of gunfire” have on others who are in need. The simple act of helping, or just being there, lifts people up and allows them to stand again.

At the core, far deeper than the DRGs and the CPTs and the EMRs, I believe these selfless acts remind us of why we went into medicine in the first place.

Is it truly our responsibility to care for our communities? Is it our role to be leaders? If being prepared is what we naturally do as physicians, regardless of our specialty, then, in this changing world, it is our obligation to learn about civilian mass casualty medicine.

People depend on us to do so.