On the cloudless, blue sky morning of September 11, 2001, I was driving to Chantilly, VA to the National Reconnaissance Office (NRO) to give a presentation to their facility leadership on steps to take to protect workers in the event of a terrorist attack. Drawing upon some of my experiences as a medical team manager for the Fairfax County, Virginia Urban Search and Rescue team, my intent was to focus on some of the simple steps everyone can take to better prepare themselves to respond to a disaster.
It was a beautiful day. Later, I was going to meet my wife at her office at the National Academy of Sciences (right across the street from U.S. Department of State) for lunch. When I got to the NRO at 9:30 am, less than an hour after the attacks began, the gates to the facility were closed and there was a guard standing out front with the biggest machine gun I had ever seen.
He lifted it towards my car. The guard was quite adamant about me turning my vehicle around. I kept asking him why and finally he shouted “because the U.S. is under attack.” I thought I was in a movie.
I pulled my car over, turned off the Grateful Dead and dialed in the radio to WTOP. I also picked up my pager, which was flashing from a dozen missed pages, and heard the first reports of an attack on the Pentagon. Immediately, I made a beeline back to the hospital, knowing I would have to oversee implementation of the hospital emergency operations plan, and thinking I might be activated for search and rescue. This was the first and only time in the three years I had served as the operational medical director of Fairfax County Fire and Rescue Department that I put the “Kojak” light on top of my car. On the way, I spoke with hospital officials to activate the disaster plan.
As I continued my drive towards the Inova Fairfax Hospital with the news on, I heard the report of a bomb at the State Department. It was surreal, it seemed there was chaos everywhere and everyone was in danger. My immediate thought was —that’s exactly where my wife parks her car, directly across the street from the front entrance of State. While I was scared for her safety, and I thought about our little kids in school, I knew there was little I could do about what I had just heard. So I focused on the task at hand. Around noontime I was picked up by a first responder and hurriedly driven down to the fire station where the search and rescue team was assembling. Soon thereafter, we were at the Pentagon and our team members were making entry into a building that was on fire and had already collapsed.
Over the course of the next couple of hours, it became clear that it was going to be a recovery mission…that there wouldn’t be any more survivors. The hardest phone call I ever had to make was to the hospital telling them to stand down the emergency response. I know it was an incredibly hard call to receive.
I didn’t learn until later that afternoon that there hadn’t been a bomb at the State Department. There had been a kitchen fire that morning which prompted a fire department response, and the mistaken news report regarding an explosion. I was also able to make a quick call to my wife, who told me she needed two hours to complete what is normally a 20 minute commute home. It was a great relief to know she was safe.
Over the next few days, we stabilized the Pentagon and shored-up the many support columns that had been wiped out. We worked inside an unbelievably dangerous tangle of debris, metal, fire, smoke and water — it was like Dante’s Inferno. But we made important discoveries. We found the black box and located information on some of the hijackers. We also recovered a number of bodies, helping to bring closure to many families whose lives were tragically upended on that September morning.
I felt incredibly fortunate to have the ability to contribute at a time of utter helplessness. It was important for me to be there and to be able to do something.
On October 2, 2001, Robert L. Stevens was admitted to a hospital in Palm Beach County, Florida after a camping trip to North Carolina. Two days later, he was diagnosed with inhalational anthrax. Shortly thereafter, Health and Human Services Secretary Tommy Thompson said it was an isolated case that he probably contracted while on a camping trip.
I was seeing patients in the emergency department at Inova Fairfax when Secretary Thompson’s news conference was broadcast live on CNN. At the time, I didn’t think this sounded right. When I finished my shift, I put together a one-page primer on anthrax detailing what it is, how it presents clinically, what the initial treatments would be, and what it might look like on a chest x-ray and CT scan. I faxed it to all of the hospitals within the Inova Health System and also to my colleagues at the fire department. I wasn’t taking any chances.
On October 15, a letter containing anthrax was opened in the office of Senator Tom Daschle, located in the Hart Senate Office Building. A few days later, on October 19, the first of what would become hundreds of patients with concerns of anthrax exposure came to our emergency department seeking care. The patient’s chief complaint was that he thought he might have been exposed to anthrax.
The Emergency Department physician on duty that evening, Dr. Cecile Murphy, did what all great clinicians do — she listened to the patient. When he diagnosed himself with anthrax, he did so because he knew his body and something didn’t feel right — his chest felt strange. So Dr. Murphy asked typical questions like “where do you work?”.
The patient said he delivered mail from the Brentwood postal facility. At that time, Brentwood had no special meaning to anyone. Still, Dr. Murphy asked where the bulk of the mail eventually ended up. The patient answered that most of it goes to the Senate. In hindsight it seems pretty apparent what was going on.
However, at that point in time, the Centers for Disease Control and Prevention (CDC) was very clear that unless you were in the Hart Senate Office Building, SE Wing, 5th or 6th floor, between the hours of 9:00 am and 7:00 pm on October15, you had nothing to worry about.
The good news is that most patients don’t read textbooks and many doctors don’t read CDC alerts. What we knew of anthrax, we heard on WTOP. Thankfully, our doctors also convinced us that we couldn’t believe everything published in the Morbidity and Mortality Weekly Report because, based on what CDC had provided as guidance, our patients wouldn’t have been in the high risk group.
So Dr. Murphy pursued the case further. She did an x-ray which just didn’t look right, and then followed that up with a chest CT Scan that was demonstrable for the telltale sign of inhalational anthrax — a widened mediastinum. Sure enough, it was clear as day that the patient was suffering from inhalation anthrax.
The first call Dr. Murphy made was to the D.C. Department of Health, because she was watching the news and knew D.C. was dealing with this.
At the time, there was limited guidance on the management of a bioterrorist attack. Treatment protocols for anthrax were tucked away in journal articles sitting in the hospital library. And no effective means for managing the multitudinous information that was beginning to ripple across the healthcare community was in place.
Later that same night, another of our emergency department physicians, Dr. Denis Pauze, took care of another postal worker from Brentwood. He came in because he had the worst headache of his life — which, in the ER, triggers an automatic workup for a leaking aneurysm. He had a normal Head CT scan and a normal spinal tap. Still, he didn’t look right, so Dr. Pauze did a chest X-ray which was borderline abnormal. He followed this up with a chest CT scan, given that the patient told him he was a postal worker from Brentwood (and, by that time, the words ‘anthrax’ and ‘Brentwood’ were echoing throughout our large, suburban emergency department like a rifle volley on a firing range). The scan was abnormal, just like the previous case, and all of a sudden, Inova Fairfax had two diagnosed cases of inhalation anthrax sitting in our emergency department. In short, we were inventing the wheel. This wasn’t reinventing the wheel, because virtually no clinicians in the United States had faced this before.
We realized there was no cavalry coming to sort things out, and that we would have to manage most of this ourselves. Part of what contributed to the difficulty in coordinating our efforts was due to what we sometimes call the ‘Potomac Ocean’ effect — even though the three surviving cases were in Northern Virginia (we helped contribute to the diagnosis of the third case of inhalational anthrax in a postal worker from the Federal mail facility in Sterling, VA), all the media attention was essentially focused on D.C. Indeed, even the 9/11 attacks took place in northern Virginia, not D.C.
We created our own treatment protocols and put together an ad-hoc communication information management system that reached all Northern Virginia hospitals. It was very important that we coordinate these emerging protocols with our public health colleagues in the Fairfax County Health Department. Late nights on the phone with Dr. Carol Sharrett and Dr. Gloria Addo-Ayensu produced templates for screening patients, offering prophylaxis countermeasures, and suggesting basic risk communication statements for our regional hospitals to use. We did this under the joint imprimatur of Fairfax County and Inova Health System. And like many in the region, we participated in the gazillion conference calls held to discuss and share information about the emerging and rapidly evolving event, and passed this information along to the rest of the hospitals in our region.
We made clinical decisions on the management of the anthrax cases by committee and involved infectious disease and intensive care doctors. While I helped to contribute to a number of these early discussions, I turned my attention to creating the systems needed to manage the ongoing bioresponse event — essentially to invent the wheel. Along with colleagues in emergency medicine from across northern Virginia, we created the Northern Virginia Emergency Response Coalition (NVERC), one of the first healthcare coalitions in the country, and the model for much of what HHS/ASPR has encouraged in the years since these awful attacks. In October 2002, the NVERC was formally re-established as the Northern Virginia Hospital Alliance, governed by the CEOs of the northern Virginia hospitals who comprise its Board of Directors. In the 10 years since the attacks, this group has never failed to have a quorum of participants, which demonstrates the absolute commitment to emergency preparedness by the healthcare system leadership in our community.
We have evolved these efforts into a much stronger community of emergency responders in the decade since the attacks, coordinating closely with, not only our public health colleagues, but those in public safety and emergency management.
September and October 2001 was a frenzied and chaotic time in the history of our country. These successive attacks stretched thin all aspects of the public health system.
As an emergency physician who was deep in the trenches in the fall of 2001, I can tell you that the entire public health community was dealing with a world that was turned upside down. It was clear to me that emergency physicians and nurses were now on the frontlines of the public health response in this new age of catastrophe, terror and fear.
In short, emergency physicians and nurses have become the operational lynchpin of our new focus on public health emergency preparedness. While the emergency department has long comprised a significant portion of the public health safety net, providing equal access to all who seek care, we now find ourselves in the added role of community protector. And it doesn’t stop at the emergency room threshold. In fact, hospital staff have become the ‘new first responders’ or what has now been termed ‘first receivers.’ We are all essential personnel in the continued struggle to keep our communities safe and healthy.
Dan Hanfling, MD, Special Advisor on Emergency Preparedness and Disaster Response to the Inova HealthSystem; Board Certified Emergency Physician