A Decade of Hope

by Dennis Smith

  Let me fast-forward to about 11:00 P.M. that night, after having survived and then having worked the entire day there. Around 11:00 at night I was finally able to call my wife. I said, “I’m okay,” and she said, “Thank goodness.” She said the towers collapsed, there are no more towers, and I kept telling her about my day, and we kept going back and forth until I interrupted her and asked, “Wait a minute, honey, what did you just say? The towers are gone? What are you talking about?” Because to that moment, I thought that the only things that had fallen were from where the planes had hit. I did not know that the entire tower had collapsed. I wasn’t watching TV, so I didn’t have any visual images of this. I was very busy thereafter and was looking in the opposite way from the towers. This was a complete revelation to me. And I ask myself how someone could have been down there the whole day and not realized that the whole towers had collapsed. I realized that tower 7 had collapsed, because they asked me to move our triage area, and we had been on Broadway, right in the shadow of tower 7. I don’t remember the North Tower collapsing. It might have collapsed while I was still under all of the debris.

  Getting back to that morning: When I got out from under the debris I was all alone, but I saw one or two firefighters and fire marshals on the street with me. We started walking away from the dust cloud toward the Staten Island Ferry. I got all the way to the ferry, and that’s where I met Dr. Kelly for the first time, and Chief Nigro, as well. Dr. Kelly told me how she had been rescued on two occasions by two different firefighters: one pushed her through a revolving door and another under an overhang, away from the onslaught, which shielded her from the dust clouds. I still did not realize there were collapses, thinking it to be debris from the airplane destruction. She’d actually treated one of our firefighters, who had been severely injured, and helped evacuate him to an ambulance. So she had been able to actually accomplish something.

  The three of us walked a little east and up Broadway. When we got close to Vesey Street, Chief Nigro went off on his own to command the event, and Dr. Kelly and I decided to set up our triage center there. So with the help of several firefighters, we broke into one of the buildings on Broadway, where there was a Duane Reade, so that we could get supplies from its pharmacy. We had the firefighters break down two separate entrances, so we would have an ingress and an egress for the wounded. We had anticipated that we would have many injuries, and the two of us would do the best that we could.

  Police officers must have known that we were there and directed people to us. We wound up being a magnet for many other health-care professionals who wanted to help, including a surgeon friend of mine whom I didn’t know was down there, along with Dr. Ira Feirstein, the psychiatrist from the Fire Department. We built a minitriage area where we could treat the wounded, give them psychological counseling, do eyewashes, albuterol treatments for people who had irritant injuries, and we actually even had a little surgical center in case somebody needed emergency treatment before we could get him to a hospital. We had no major injuries but were treating a lot of eye and nose irritation, giving them nebulizer treatments with albuterol, and a lot of walking wounded as well.

  And then, late in the afternoon, a chief came in and said we were in the shadow of tower 7, which could collapse right on top of us, and we had to move our triage area. I was a little upset about this, because we had really organized it very nicely, but we moved to Pace University, across the street from city hall, which turned out to be a better place for us, with a lot more room. When tower 7 fell the dust from the collapse came all the way up the stairs of Pace University, so we just missed the very periphery of that dust cloud. We stayed in our new location, again treating the same types of problems: no life-threatening injuries, just wounded people, eye irritation, and pulmonary irritation. I was helping a lot of people.

  I didn’t know until the next day that Chief Ganci was gone. I was too busy. I had no idea that 343 firefighters had died. I had no idea how many deaths there were. I had no idea that Father [Mychal] Judge [chaplain of the New York City Fire Department], with whom I was very friendly, had died. I had immense respect for him—immense. And I loved him. When I had been involved previously with some protective equipment research, he was really very helpful to me.

  I knew there must have been deaths in the collapse, but my feeling was very strong that my role was to work at and command the triage center. My expertise was not in packaging patients but rather in treating them. “Packaging” is not a negative term but an EMS term for immobilizing people and making [them] ready for transport. There were many people who were doing that, and I needed to be taking care of those people who walked or stumbled out and needed assistance. There were a lot of patients, and we were helping a lot of people, so I felt fulfilled. It was the right decision.

  We remained at Pace until about 9:00 P.M. One interesting event occurred then that shows we are all human and can all make serious mistakes. As we were leaving, exhausted, a young woman Rollerbladed up to the Pace center in hospital scrub and said, “I’m here to help.”

  I realized how much people wanted to help, and I presumed she was a nurse or physician. And she could have been helpful, but I had to disappoint her. I know it sounds strange to say “disappoint,” because it’s a good thing to not have patients, but I knew I was going to disappoint her. And so I said, “I’m sorry, but there are no patients anymore, and we’re closing up our shop, but you might want to go to a local emergency room to see if you can be of any help.”

  She replied, “No, you don’t get it. I’m a veterinarian.”

  Now she could see in my face complete surprise and a little disgust. I told her, in what I guess was a chauvinistic way, “Give me a break. We’ve been attacked; there have been hundreds of deaths.” I didn’t know then that there were actually thousands. This was not the time for a veterinarian to be here to rescue the parakeets and the kittens. We’re not going to risk lives to save some parakeets and some kittens.

  She now no longer presented the nice personality that she had had a moment before. Her facial expression changed, and she put me in my place, as she should have, and retorted something like, “Listen, buddy, I am a veterinarian, and one of the official veterinarians for rescue dogs in any New York City disaster. You either direct me to where the rescue dogs are or under federal regulation I am closing this site for all rescue dog activities.”

  And so there I was, now completely realizing that due to my own stupidity I could have stopped rescue activities. Luckily she had the strength of will to get assertive, and I then directed her to where I thought the rescue dogs were. So that was a good thing. And yes, she was probably more of an asset at that time than I was.

  After leaving Pace we went to visit one or two local hospitals: Downtown Beekman [near Pace University], and then another hospital right over the Brooklyn Bridge. We then went to headquarters [FDNY headquarters in Brooklyn], because we thought we might be needed throughout the night, though it turned out we were not. We slept at headquarters that night, and the next day we started figuring out what to do in terms of building for the future.

  After 9/11 Dr. Kelly and I went to Fire Commissioner Von Essen, who was a very prohealth and prosafety fire commissioner, and in my opinion did more for health and safety than anyone serving before him [Thomas Von Essen was also a former president of the Uniformed Firefighters’ Association, the union that represents the firefighters.]. We told him this had been a unique exposure, the only time we had been attacked on our own soil. Forget about the political aspects: From a medical perspective, this had been a unique exposure.

  The cloud that day was very thick and did not fully dissipate: 9/11 dust is a very heterogeneous mixture. What we at the ground level were exposed to is called sedimentary dust. By definition it consists of the largest, heaviest particles, the particles that fell closest to Ground Zero. As you go farther out, if you draw concentric circles, the dust that people on the street level are exposed to is by definition smaller, so many think
that the greatest exposure to bad stuff is right at the epicenter of the event. Actually, in terms of inhalation exposure, that’s not always true, because we are able to breathe in the smaller particles deeper than we can breathe in larger particles. And sometimes you get more cardiopulmonary and toxic exposures distant from the epicenter, because that dust is coated with all the chemicals of combustion and pyrolysis that have been occurring.

  What was different about the World Trade Center is that, against common teaching, the people at the epicenter inhaled deeply a ton of stuff. Common teaching holds that those large particles at the epicenter would just have caused sinus and upper airway irritation. Because the density was so high, however, we actually inhaled large particles into our lower airways, so the World Trade Center is actually the opposite of a typical disaster, and you got greater inhalation injury at the epicenter.

  Right around Ground Zero you could not see your hand, but as you walked toward the Staten Island Ferry it became gray. What struck me was the sheer grayness of it. I love old movies, and Ground Zero on 9/11 really did look like the movies that were made about the cold war and the A bomb, the H bomb. There was no color. Everything was black and white. It was very, very cloudy, very dusty, nobody around, and very quiet. Total quiet. It could have been in an old end-of-the-world movie.

  I realized that there would be pulmonary consequences that same day, which is why we set up the triage center. But I thought they were going to be the standard smoke-inhalation injury, which is a few days of coughing up stuff and, in certain rare cases, a few months of problems. It was only the next day that my thoughts settled and, after processing what different firefighters had been saying—that the fire smelled different and tasted different—and the fact that there had been much more coughing going on than at a typical fire, that I realized that this could have really catastrophic impacts on people’s health.

  From a health perspective, we needed to investigate the health consequences of 9/11. We would not be stopped by people saying that if we found problems we were going to open up Pandora’s box. The example that we gave Commissioner Von Essen was the historic telephone company fire on Thirteenth Street and Second Avenue in the 1970s. Every firefighter who was there had large PCB [polychlorinated biphenyl] exposure, and all over the world firefighters believe that those who worked at that fire died of cancer. We don’t know whether that’s true or not. We did not provide medical services; we did not study it. We did not prevent people from thinking that 100 percent of those firefighters died from cancer. If we had been there, do you really think we would have found 100 percent dying of cancer? Even if we found conclusively 90 percent dying of cancer, it would have been better than believing it wrongly.... Von Essen agreed instantly. And we then began to fight a battle, which continues today, with the federal government to get the funding necessary to do this right—from a medical perspective and from a science perspective.

  FEMA had money for rebuilding New York after the terrorist attack. I think they had $20 billion in emergency funding, and we successfully received a grant of $4.8 million for the first two years. That allowed us to demonstrate to the federal government what I’ve always believed, which is that you cannot provide a short-term or a long-term medical monitoring or treatment program after a disaster if you’re not able to partner with credible local people. And then we had to convince people that our program was state of the art.

  We started our 9/11 program before any other 9/11 program in New York City, a year before Mount Sinai started theirs. We have consistently provided top-notch, state-of-the-art medical care and monitoring, and we have provided services that no one else can match, because our dollars go further. We don’t have indirect overhead costs that many institutions have for federal funding, and we don’t have to advertise to find people. We don’t have to search them out, since we know every one of our firefighters and EMS workers. We maintain the retirees in the group, and we keep in touch with them so that we don’t have longitudinal dropout, which screws up any long-term medical monitoring and treatment program. It is bad for science and creates barriers for providing medical care to those most in need. The sick people are lost to follow-up, and there is the false impression that everyone is well. The primary goal was clinical service. But again, just like the unions and management know, just like I know, and now just like our patients know: If you’re not able to show credibly that there’s a need for a program, just asking for it is not enough. This program exists here, and at Mount Sinai for non-FDNY workers, because our scientific studies are credible.

  We wanted a sustainable medical program. And so we do clinical service, and we study that service, because in studying it we get to be better by learning what’s working and what’s not, keeping the program at its freshest level for our firefighters. For example, we did some blood and urine heavy-metal studies right from the beginning, with the first three hundred people, and then, to a lesser extent, with the first ten thousand people we saw. Those studies, showing that heavy metals like lead and mercury were not elevated, indirectly kept the World Trade Center site open when people wanted to close it due to a [misplaced] concern about high mercury levels [and the potential of ongoing exposure to it]. We were able not only to keep the site open but to redirect our dollars into much more useful things, like pulmonary function tests and CAT scans, mental health therapy, things that the group really needed rather than chelation therapy for mercury. So this is a fundamental value of our World Trade Center Medical Monitoring and Treatment Program.

  We then made certain decisions that were very helpful. The key decision that we made was advocating right from that day for a monitoring and treatment program. We were capable of doing monitoring, but not in a large-scale concept. We advocated for getting funding so we could do more than what we normally do, like all the heavy-metal tests. We advocated that we would control it—that it would not be outsourced to anyone—because we felt it was a matter of our credibility, and [it was] our responsibility to do it right. And we felt that it would be more sustainable if it was done internally. We also had pre-9/11 data to compare it to, so we would have the objective ability to keep this sustainable. With Von Essen’s help we already had built an infrastructure that could be expanded to do this.

  Another key decision was in trying to bring in specific, focused resources that would help us. We identified certain things that we were lacking, that we needed. The first thing was to increase radically the counseling involved. We already had a good program in place, which probably provided the best alcohol treatment program in the world and phenomenal counseling services for the one to three firefighter service–connected deaths that we averaged per year. But it was not large enough to handle the activities we needed now.

  Remember, we have 12,000 firefighters and 3,000 EMTs and paramedics in our Fire Department, and several thousand civilians: 343 firefighters and 2 paramedics died that day, so we would need to provide counseling services for all 15,000 in the FDNY, and also specific counseling services for the families of the 343 people who died. In the Fire Department, in many of those families, there were additional active or retired firefighters, which compound the impact of a disaster like this. We had learned, even before this, that when a firefighter dies in the line of duty you make a serious mistake if you provide counseling only to his firehouse. Because that firefighter is actually associated with several firehouses—one that he is currently assigned to, one that he served in previously perhaps, one where he was a probationary, and all of those firehouses where he had been detailed to during certain tours. So three to five firehouses may need to be counseled, and if you leave one out of the loop, they feel that they are not getting adequate services. Multiply that by 343, and you’ve got a massive problem.

  So we partnered with the International Association of Fire Fighters [the national parent union of the city’s Uniformed Firefighters Association] and other local city institutions to bring in counselors. That was another key decision, and a very important and go
od one, working with Vinnie Bollen and Rich Duffy in the IAFF. We also advocated strongly with the federal government to provide funds for us to get these services. It was a huge battle, because they wanted to take control of the whole thing. We had the CDC [Centers for Disease Control] come in and draw the blood and urine samples on the first three hundred firefighters we saw, when medical monitoring began on October 1, 2001. The reason we had the CDC get involved was because they have capabilities that no one else has. On a single tube of blood or urine they can process about three hundred chemical analyses for PCBs, dioxins, heavy metals, and various other chemicals of combustion and pyrolysis. The CDC in Atlanta is also considered to be the finest laboratory in terms of quality control.

  Here—and this is so cool—was our first sense of how everyone in America wanted to help the 9/11 effort. Our plan was to draw the blood ourselves and then put it on ice and send it to them. Once the CDC agreed to do this for us, however, they sent in their own team to draw the blood. Three guys showed up at the FDNY Bureau of Health Services on the second floor of the MetroTech building in Brooklyn and said, We’ll draw the blood for you, package it, and send it off every night. We started talking to them and found out that they were one of the teams that goes to Africa when there’s an Ebola crisis. They said they loved being able to help, and it was great for them being able to draw blood when they weren’t in a level-A HazMat suit. These guys were real professionals, so it was a great partnership.