Nurses on Sept 11: 'there were no patients'

No doubt many nurses today are remembering the attacks on the World Trade Center on September 11, 2001. I wasn't a healthcare professional at the time. I had moved back home and was trying to figure out my next move after a web start-up I had been involved with went belly-up. My father was at the university, my mother was gardening, and my brother was at school. I got up and wandered around the house, read the newspaper. For some reason, I turned on the TV to flip through the channels and came across some live coverage.

The towers had already been hit. Not knowing NYC well, I wasn't particularly shocked, mostly just gawking, as you get passing a car accident on the road. I told my mother what was going on, but she wasn't interested enough to stop gardening. So, I road my bike down to the university. My father was teaching a class. Some people in his department office were talking about it casually. But when I went over to the student center, where there was one large projection TV, the students were crowded around and there was a lot distress on faces and in voices. Our university is a popular spot for kids from NYC and Long Island.

In the afternoon, I went to the hospital's blood donation center, but there was already a line snaking out the door and down the sidewalk. I was turned away as they had all the volunteers they could handle and were mostly looking for rare blood type donors.

Like everyone else, I was riveted to news media for days and even weeks afterward. I briefly considered going down to NYC to see if I could help, but realistically there was nothing I could offer. Some people, like this flight attendant, said they went into healthcare following September 11th. I can't say that, although I do enjoy thinking that if something like the attacks ever happened again, I would be able to help out. (I tried going to Haiti, but was unsuccessful.)

Reflections on our response

Unlike most people, I have been unhappy with our response to the devastation. During the initial discussions of what to do with Ground Zero, someone at National Review suggested that we should rebuild the trade towers, only this time with Vulcan cannons on the roof. That about sums up my attitude to the situation: we should have demonstrated that we still had the self-confidence and optimism necessary to rebuild along with the defiance to keep the attacks from happening again; to not rebuild at Ground Zero and move on is a bad omen. I am concerned that our actual response demonstrates our diminishment as a nation. Although many people claim to have felt "united" by the events, I see the widespread focus on negative emotions such as fear and anguish as a socially-directed manifestation of many individuals' obsession with their own problems (as seen across news and entertainment media on a daily basis).
Take the National 9-11 Memorial. Prime real estate in NYC has been given over to two large gaping holes in the ground that serve no purpose other than to act as a reminder of the fact that we were dealt pain and death. The memorial has no meaning in the sense that it does nothing to tie the attacks to the broader cultural conflicts or actual physical conflict that preceded or came after September 11th. It isn't, in fact, a memorial in the sense that it commemorates nothing. Horrified as I was to see the jumpers on TV that day, those who died (rescue workers excepted) simply died.

Compare the 9-11 Memorial with other memorials: they commemorate actions and actors, not victims. For example, the Gettysburg Memorial commemorates those who gave their lives fighting to change the course of history. The 9-11 Memorial is more like a cross and wreath placed beside a highway where someone died: it doesn't turn our thoughts reverently toward a past that was necessary for some to live through so that we today could have better lives, it turns our thoughts inward as a reminder of personal hurt and the pain of others. The 9-11 Memorial is like a wound that won't heal or a trauma that a person can't leave behind. In 100 years, the Gettysburg Memorial will remind our grandchildren that Americans died for freedom; in 100 years, the 9-11 Memorial will remind our grandchildren that people die senselessly because there is evil in the world. The fact that the pools and fountains are not ones in which children and parents can find delight and relief only reinforces the sense of loss, that the whole site is a monument to death and not to, as the Romans put it, agere.

There are those who will say that the 9-11 Memorial commemorates our "unity" on that day. To them, I can say only that it is a sad day when our national monuments in DC are not our symbols of national unity, when people identify with helplessness but not with national aspirations. To a generation that needs to feel fear and anger together to recognize their nationhood, I say it is a sign of your decadence and dysfunction. A generation that scoffs at a "mission accomplished" sign but feels sublimity in empty loss is a sign of the times. In an age of terrorism, what should our cities be? Centers of art and commerce or a pock-marked moonscape of monuments to our enemies' success?

Hermeneutic research on nursing narratives

In the year following 9-11, researchers publishing in the Journal of the New York State Nurses Association conducted interviews with nurses about their experiences of working on that day. They analyzed the narratives using a Heideggerian Hermeneutic approach, looking for thematic commonalities across narratives. The results are interesting in themselves, and also highlight some of the critique of the 9-11 Memorial that I make above.

From the findings section of the paper:
Seventeen nurses, 2 males and 15 females, comprised the informants. The mean age was 47.7 years (s.d. = 8.4) with a range of 32-64. Ethnicity included 13 white, 2 black, 1 Native American and 1 Asian. Education of the participants included masters (9), baccalaureate (5), associate (2), and diploma (1). Specialty areas included emergency room (4), acute care (2), home care (1), administration (3), pediatric (3), psych/mental health (3), and nursing education (1). The nurses' roles in the disaster included triage (3), coordination (7), care giving and counseling (7). Six themes and one constitutive pattern emerged. The themes are: (a) loss of a symbol, regaining new meaning. (b) disaster without patients. (c) coordinating with and without organizations. (d) rediscovering the pride in nursing. (e) traumatic stress. (f) preparing for the future.
In a more detailed explanation of these themes, their fundamental support of my interpretation of the 9-11 Memorial is given some support. One nurse said, "I usually see the towers ...I looked up 14 Street and there were no towers, absolutely no towers, and my body just shuddered, very fearfully," and another, "on my way home that night I would see the towers, and that night, - not seeing them there - still looking - maybe I am not looking in the right place... you can't believe they're not there ... disbelief ... stunned ... not being able to comprehend."

Nurses experienced ongoing stress from the trauma of the day:
Symptoms of post-traumatic stress were felt by many of the nurses. Some experienced nightmares and flashbacks of victims they cared for. Others described themselves as emotionally fragile and being able "to cry in a New York minute." One nurse has "a lot of pop-up fears that are triggered." Physical symptoms of stress, such as high blood pressure, were reported less but still significantly impacted their lives. One nurse had to change her diet, exercise more, and stop reading the newspaper and listening to the news to help decrease her blood pressure. She realized that "I couldn't leave it alone. It was affecting my health and I had to step back."
This sense of loss and stress is what the 9-11 Memorial will permanentize. And when a generation grows up that never knew the presence of the towers as normality, they will be asked to imagine the loss by visiting the Memorial. Is that a healthy long-term response to loss?

Of the researchers findings, the one probably most salient to all healthcare professionals--at least, it was the most salient for me--is the nurses' frustration at the lack of patients. One said, "We went to Chelsea pier, to the triage center, about 500 doctors and nurses, and they came from all over, we just waited and set up triage, the IVs, the tables and waited for causalities but they just didn't come," and another, "Everything was in place by 10:30 AM. and we got one patient up until 1:30 AM. We got scared then. There was a lot of death. At that point we got the body bags."

Nurses' first-person accounts of September 11

Google searches can turn up quite a few accounts of nursing on September 11th. The best of the first two pages of Google results seems to be the one from the army chief of nurses. Two others, printed in the 2002 Journal of the NY State Nurses Association, I will reproduce here in part. The remainder of these articles can be read on the journal website [PDF].

Nursing at Ground Zero: a life-changing experience. by Maria Gatto, RN

Reluctantly, we have joined past generations for whom history was made through unthinkable events of death and destruction. Our children and grandchildren will ask us where we were on that fateful, tragic day when terrorists destroyed the Twin Towers in New York City, killing thousands of innocent men, women, and children.

As nurses, we all have definitions of ourselves based on our degrees, specialties, educational experiences, and background. In the hours and days that followed the attacks, however, I realized that those really had no bearing at all. A nurse is not what you are, but who you are. In your being is your capacity to heal, help, and comfort. Your presence itself means care. During those days, I didn't have to identify myself with a license or a diploma. I just had to say, "I'm a nurse and I'm here to help." That gave me the right to go into the heart of the disaster site called Ground Zero.

There was no policy, no procedure, no one to report to or "get report from." There was no routine, no schedule, no assignment. It was nursing knowledge and skill the true nursing instinct you find when you're faced with a totally unknown experience. Life hung in the most delicate of balances. Death was everywhere; bodies, minds, and souls were waiting to be resuscitated. The living and the dead needed to be treated with the utmost respect and dignity. No drug book, care-plan, or text could prepare you for this.

Terror on the Television

That fateful day began when I was awakened by my mother. I will never forget the look of sheer terror on her face. She screamed, "We are under attack. A plane just crashed into the Twin Towers!" At first, I thought I didn't hear her correctly. Call it shock, call it denial, but I asked her to repeat what she'd said and then ran downstairs to the television. I sat in disbelief, watching the events unfold. I remember thinking, "This must be just a tragic accident." Then the unimaginable happened as a plane crashed into the second tower. The worst fear was confirmed.

A cold numbness ran through my body. I no longer felt shock and disbelief, but the ultimate in terror. In the moments that followed, I felt a pull in my heart. A message from deep inside came through loud and clear: "You must help. There is a great need and a purpose to be served. You must go there." Confused, but trusting in a faith in God, I prayed for guidance. Where to begin was now the question.

As part of a generation accustomed to going "on line" for everything, I immediately e-mailed my brother and sister-in-law on Staten Island, where my brother, James Gatto, is a sergeant at the 120th Precinct. I was frantic, wondering if my family was okay and if my brother was on duty in that area. As I waited for a reply, I tried the phone. The lines were down, so I just tried to focus myself and know that I would be led to whatever I was supposed to do.

I hoped that my brother Jim might be able to help me get into the city, because all transportation was being canceled. I phoned him again and finally got through. He told me that if I really wanted to help, there was only one way to get to Manhattan. The Staten Island Ferry was open to emergency medical and rescue personnel only. I would have to take the ferry and then find my way. "Find my way?" I asked. "What do you mean?" He told me that there would be no one to show me where to go or what to do. The entire city was in shock and total chaos. "You'll have to make your own way," he said. "Just follow the smoke, and do what you have to do. If you really need to do this, I will support you 100%. Don't worry, you will know what to do. God will be with you."

I immediately got into my nursing gear, packing a bag with an extra uniform and my nursing identification. I told my mother and father, who accepted my decision without hesitation. I was bolstered by their support and confidence in me.

Ferry to a War Zone

Jim picked me up, and we headed to the 120th Staten Island Precinct. My brother, being a man of very few words but of much quiet strength, was brief but firm in his counsel. "It will be ugly," he explained. "Nothing you have seen before can prepare you for what you will see now. No one will tell you what to do. You must tell them what must be done. The chaos of mass destruction has no rules. Make them up along the way in whatever situation you are in." He opened the car door as we arrived at the precinct. I asked him how could I get back. He smiled and said, "Exactly the way you came."

I made my way into the terminal and down to the ferry. I could feel my heart beating with a sense of urgency, and my steps got faster as I got closer. I explained to some officers that I was a nurse and needed to get on the ferry. They said to hurry and check in because the ferry was about to leave. I ran up to a woman at a small table, introduced myself, and showed her my license and ID. I jumped on the ferry just before it left. That was it. I was given no briefing, report, direction, or instruction.

There were about six other nurses on the ferry. After brief introductions, we talked about what our plans were and where we would go. One group was going to the Ferry Station, where food and supplies were being handled. Another group was going to Liberty Street, where they needed nurses to volunteer at the site. I looked out at the skyline and for the first time saw the dense cloud of rising smoke. I remembered my brother's words - "Just follow the smoke."

We rode the rest of the way in silence.

As the ferry docked, I tried to follow the group of nurses that was going to Liberty Street, but I was distracted by a nurse who tried to talk me into going to help with supplies. I declined, saying that I wanted to go to Liberty Street. We wished each other luck with a hug, and I turned around and followed the smoke.

A Modern-Day Pompeii

I began walking. There were some military officers and police nearby. I went up to a police officer and asked how to get to Liberty Street. He asked for my ID, and then told me to follow the park and make a left. I have never had any sense of direction, and I ended up in the financial district of Wall Street. This was my first introduction to Ground Zero. The story of Pompeii was the first thing that came to my mind. I was the only person walking in streets covered ankle-deep in ash. Papers were everywhere. Buildings, once shining brilliantly in the sun, were now dimmed by thick, choking dust. There was an eerie silence and then the screams of terror-stricken people.

I was directed a few more times and eventually found my way to Liberty Street. Tables were set up like a makeshift but still incomplete MASH unit. There were medical professionals everywhere trying to unload, organize, and care for the rescue workers. I felt out of place, not knowing where to begin.

I heard a familiar voice call out, "Maria?" As I turned around, I saw Angela Appuzzo, one of the clinical lab instructors from New York University. We gave each other a hug, and she asked how I had gotten down here. I told her briefly that I had felt the need to come, hopped the ferry, and walked on down. She gave me a "thumbs up" sign and a big smile. I asked her what I should do. Within two minutes, Angela gave me the basics of setting up triage. I rolled up my sleeves and got started.

All of a sudden, there was an evacuation alert. Rescue personnel and police yelled at us to run. A stampede ensued. That was my last contact with Angela...

Through the eyes of a New Yorker
by Lucille Yip, RN

September 11, 2001

I am surprised when I wake up at 3 a.m., since I had been so tired after coming home from a late dinner. I don't feel right. Somehow I feel the need to go to my living room and look at the New York skyline. It is a spectacular view, full of lights and beautiful skyscrapers. I stand at the window to absorb the peaceful beauty of the city. I return to my bedroom at 5:30 a.m.

A few hours later, I wake up to a sound of an explosion. My apartment is located at the top of a 44-floor high-rise, facing what used to be the most beautiful skyline in the world. I turn on the TV and see the news. Hoping this is a dream, I run out to my living room window in horror and shock. The World Trade Center that I had grown up with is burning out of control.

After the second plane crashes, I call my sister, who works at the Federal building [six blocks from the World Trade Center]. "I'm leaving," she says, and I don't hear from her for six hours after that. I later learn she was on the train when the power shut down and smoke began to enter the car, but she was able to get home safely.

I witness the collapse of Tower 1 and then Tower 2. They both fall like a deck of cards. My "backyard" now resembles a war zone. Shortly after the collapse, I am told to evacuate the building. Hundreds of people from the Wall Street area are walking through my neighborhood in Chinatown. People are painted with thick, white soot. Cell phones are down and long lines begin to form at the payphones. There are no subways, no buses. The sounds of sirens fill the air and New Yorkers gather around car radios to listen to the news. It is total chaos.

I need to get to the ER [at St. Vincents Catholic Medical Center] and help, but I have no way of getting there. I decide to hitchhike, something I never would have thought about doing in New York before today. I find a sanitation worker who is willing to take me.

I arrive in the ER to what appears to be controlled chaos. I am assigned to triage patients. I see patients with severe burns, smoke inhalation, and open fractures. The ER is prepared for any victims that may have survived. The trauma team, anesthesia team, nurses and doctors are situated inside and outside. Stretchers, wheelchairs, and oxygen tanks line the sidewalks. The news media have stationed their cameras across the street, hoping to catch a glimpse of any survivors.

The ER is overstaffed because volunteer nurses and doctors have come in from Long Island, Queens, Manhattan, and as far away as Maryland. Doctors and nurses I have not seen in years come to the ER, hoping to help. The camaraderie is uplifting.

The staff is informed that we can't leave the hospital until further notice. We don't know if the night staff will be able to enter the city. I am physically and emotionally tired. Late in the afternoon, Starbucks donates fresh coffee and water. It sure hits the spot. The Starbucks on Greenwich Avenue has closed its doors to the public in order to cater to our needs. The local restaurants donate sandwiches, hot food, and gallons of water. Residents from Greenwich Village came in, wanting to help and donate blood. I am moved to hear that an elderly woman brought over one plate of spaghetti for anyone who might be hungry. I am so touched to see the outpouring of support from my fellow New Yorkers.

The ER is busy, but also painfully quiet. We do not receive any survivors from the collapse. The silence after the initial rush of patients is deafening. The night shift arrives, and the staff is able to leave. I have to ask a police officer for a lift home, since there is no public transportation south of 14"' Street. I manage to squeeze into a police van filled with officers and they drop me off at Varick and Canal Streets.

As I walk through the streets of lower Manhattan, I feel like someone had sucked my spirit out of me and ripped it into pieces. The streets are empty, there are barricades on every block, stores and restaurants are closed, police and state troopers are standing on every corner, and people are wearing face masks. I am consumed by the silence, smoke, and emptiness in my neighborhood. Is this my New York?

A passerby looks at me. We share the same pain but say nothing. Near my apartment, I am stopped by a police officer standing in front of several barricades. "Where are you going?" he asks. I show him my ID and tell him I'm going home. He allows me to go through the barricades and comments, "Get some rest. We're in this together."

My husband has not been able to get home. The apartment smells of smoke. I turn on my TV for the latest news. My neighbor knocks on my door to see if I'm all right. She offers some of her dinner to me, knowing that I haven't eaten anything. I'm touched by her kindness.

I can't sleep and watch the news until 2 a.m. The sound of the explosion still echoes in my head. I need to rest - tomorrow will be another long day. September 12, 2001

I wake up after sleeping only three hours. The phone lines are still down and I am unable to reach my husband. I know he is safe at his restaurant and hope to call him later.

My street is blocked off to all traffic except official cars. I will have to hitchhike to work again. I flag down a patrol car, which drops me off in front of the ER. The street has been blocked off to pedestrians, except hospital personnel. There is a crowd of reporters, cameras, and onlookers across the street.

I am assigned to triage again, which means I have to see every patient who enters the ER. A 38-year-old fireman comes in with a crushing chest injury caused by falling debris. Surprisingly, he is sitting up, talking, and coherent. Despite his ashen color and his concave chest, in my heart I hope he will survive his injuries. In my head I know that his chances of surviving are slim. Nevertheless, I am shocked when I'm told later that he died on the operating table...

  1. Dickerson, Jezewski, Nelson-Tuttle, Shipkey, Wilk, & Crandall (2002). Nursing at Ground Zero: Experiences During and After September 11 Word Trade Center Attack Journal of the New York State Nurses Association, 33 (1), 26-33

  2. Gatto, M. (2002). Nursing at Ground Zero: A Life-Changing Experience Journal of the New York State Nurses Association, 33 (1), 4-8

  3. Yip, L. (2002). Through the Eyes of a New Yorker Journal of the New York State Nurses Association, 33 (1), 9-15