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doi: 10.1097/01.ORN.0000403417.74883.1c

Remembering: 9-11

Saver, Cynthia MS, RN; Pritchard, Donna BSN, MA, RN, CNOR, NE-BC; Groah, Linda MSN, RN, CNOR, CNAA, FAAN; Burke, Michelle MSA, RN, CNOR; Jacoby, Zaida MA, MEd, RN; Desnoyers, Mercedes MSN, RN

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Cynthia Saver is president of CLS Development, Inc. in Columbia, Md.

director of perioperative services at Kingsbrook Jewish Medical Center in Brooklyn, N.Y

executive director and CEO for AORN

associate hospital administrator and director of perioperative services at Memorial Sloan Kettering Cancer Center

director of perioperative services at NYU Langone Medical Center in New York City

service group manager in the main OR at Washington (D.C.) Hospital Center

Ten years later, perioperative nurses reflect on how that day changed nursing ... and all of us.

The author has disclosed that she has no financial relationships related to this article.

"9-11 changed everything about the way we live," says Donna Pritchard, BSN, MA, RN, CNOR, NE-BC, who saw the devastation of that day firsthand as she drove to work at New York Downtown Hospital, four blocks from the World Trade Center. "Prior to 9-11 we were aware of terrorism, but it didn't happen here. That day, it became real; it was so close to home. You felt vulnerable."

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Perioperative nursing—and nurses like Pritchard—felt 9-11's effect. Looking back, three trends mark the 10 years since that day: increased emphasis on disaster preparedness, higher security, and a new patient base—those with 9-11-related health problems.

In addition to reviewing those trends, this article features the voices of nurses who agreed to share their experiences from 9-11 and their perspectives today.

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Be prepared

The biggest effect 9-11 has had on healthcare is an increased focus on disaster preparedness, and the OR is no exception.

"After 9-11 it became much clearer that a terrorist act was a real possibility," says Linda Groah, MSN, RN, CNOR, CNAA, FAAN, executive director and CEO for the Association of periOperative Registered Nurses (AORN). "Before then, the OR staff would look at a disaster as a fire in the OR. After 9-11, disaster planning took on a whole new meaning and emphasis in cities, hospitals and the OR increased."

Groah says The Joint Commission now has more detailed disaster standards compared to pre-9-11, and focuses more on those standards when making site visits.

In the first few years after the event, hospitals worked feverishly on disaster plans. However, as the distance from 9-11 has grown, Groah worries that daily operations have eclipsed disaster planning in too many areas.

"We can never get very complacent," she says. "I'm not sure we've maintained our awareness as much as we should."

That awareness includes not only individual hospitals, but also putting a comprehensive plan—tailored to local needs—in place for cities and regions.

Mary Pat Couig, MPH, RN, FAAN, program manager for emergency preparedness for the Office of Nursing Services in the Department of Veterans Affairs, says the National Response Framework, which guides the United States' disaster response, encourages "all-hazards planning—anything that might happen wherever you are. It's not just natural disasters, it's chemical plants, nuclear plants, and intentional disasters such as release of anthrax or someone bringing a firearm into the facility."

For instance, communities with nuclear power plants would put nuclear leaks and terrorism at the top of a list of concerns, whereas those near rivers must be prepared to cope with extensive flooding; other areas would be concerned with tornadoes. "In Denver (where AORN is based), we have to think about what to do with 5 feet of snow," says Groah.

Many of the challenges, however, are common to any situation. "You have to think how people are going to get to the hospital," says Groah. Flooding may have wiped out roads and snow may mean a mass call for four-wheel drive vehicles to transport staff. "You need to have alternative routes."

Michelle Burke, MSA, RN, CNOR, associate hospital administrator and director of perioperative services at Memorial Sloan Kettering Cancer Center in New York City, says that one easily forgotten part of disaster planning is how to manage the many healthcare providers and other people who show up to volunteer.

"What do you do about licensure? What do you do about credentials? Typically disaster plans don't address that." During 9-11, she says, "Hundreds of people lined up to donate blood; they even put themselves in line by blood type." The hospital had to set up a separate station for blood at The New School.

To avoid delays, experts recommend that volunteers sign up ahead of time with an established team so that license and credential information is on file (see Being prepared).

"People who just show up and want to help don't think about the fact that someone has to figure out what to do with this person," Couig says. Volunteers should keep paper copies of their information in case of power losses where they're serving.

Burke also advocates including "care for the caregiver. Whether it's the Oklahoma City bombing or flooding in Texas, the plan should include how to help caregivers cope with the situation." That includes holding religious ceremonies and providing counseling.

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Hospital and community mock drills

Education and regular mock drills lay the groundwork for responding to a terror event. "Disaster response is part of staff orientation and management training," says Zaida Jacoby, MA, MEd, RN, director of perioperative services at NYU Langone Medical Center in New York City. "There are several full scale drills the medical center does each year for our disaster preparedness program. During a drill, leadership members of the team across all disciplines meet at a designated command center and obtain a report of what is happening within their areas. In the OR, we do mock training drills for fire with all disciplines on a regular basis."

Staff also can access a website for information about how to prepare for emergencies, staff roles and responsibilities during an emergency, and how the medical center is keeping patients, visitors, staff, and facilities safe and protected.

Regular mock drills keep staff sharp, says Groah. "Staff may know the week when the drill will occur, but they should not know the exact day," she cautions. It's important to make the drill as realistic as possible. At the community level, Groah says, "Most communities do one major drill a year, where 'patients' have moulage to simulate realistic wounds and injuries."

"Disaster drills are so common now," agrees Pritchard, now director of perioperative services at Kingsbrook Jewish Medical Center in Brooklyn, N.Y. "Everything is taken very seriously. Preparation is key."

Hospitals in potential terrorist target areas and military hospitals are particularly dedicated to preparedness. Maj. Vilma Rojas, RN, BSN, logistics coordinator for the OR at Brooke Army Base in San Antonio, Texas, says 9-11, "improved disaster preparedness. We are more prepared and more aware of what could happen." Rojas lived and worked in New York on 9-11; she could smell the destruction from her house in Queens. She advises perioperative nurses to "Be aware that a lot of things can happen and be prepared. Know the plan."

Couig says disaster preparedness "emphasizes communities working together and developing plans, including what are the resources and who might be able to contribute." In Bethesda, Md., for instance, the National Institutes of Health, Suburban Hospital-Johns Hopkins Medicine, and Naval Medical Center are located near each other, so they drill together.

A side benefit of planning may be better management of surge capacity, says Couig. "Planning can help identify ideas for how to manage when hospitals are busier than usual." She cites Salt Lake City's preparation for the Olympics as an example.

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Tight security

9-11 also led to tighter security. "Hospital and OR security have increased dramatically," says Groah. "Everything has been notched up." That includes identifying everyone who goes into the OR, such as vendors.

"People are more cognizant about having strangers without an ID badge around," says Burke. "We are more diligent about making sure people aren't wandering around the OR." The OR policies that cover vendors, healthcare visitors, and students are "more restrictive than they used to be. If you aren't there for a particular purpose, you don't need to be there."

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Health aftermath

Philip Landrigan, MD, MSc, dean for global health, professor and chair of the department of preventive medicine, and professor of pediatrics at Mount Sinai School of Medicine in New York, slots the long-term health effects from 9-11 into three main groups: pulmonary conditions, gastroesophageal reflux disease (GERD), and mental health problems.

Landrigan, who has worked with 9-11 responders for several years, heads the Mount Sinai School of Medicine Clinical Center of Excellence, which monitors and provides treatment services as part of the World Trade Center Health Program, established this year by the James Zadroga 9/11 Health and Compensation Act of 2010.1

Inhaled toxic dust has caused respiratory difficulties such as irritant-induced asthma, chronic nonspecific bronchitis, chronic bronchiolitis and small airway disease, and chronic obstructive pulmonary disease.2 One study found that not only did firefighters' and EMS workers' FEV1 measures decline substantially over the first year after 9-11, but that during the 6-year follow-up period (2002–2008), the study subjects had little or no recovery of average lung function.3 Upper respiratory problems include "horrible, horrible sinusitis," says Landrigan.

Swallowing the toxic dust has led to GERD. Many firefighters and other rescue workers developed a chronic cough from chronic rhinosinusitis, asthma, or bronchitis, often complicated by GERD, a condition known as the "World Trade Center Cough Syndrome."4 The syndrome is associated with posttraumatic stress disorder (PTSD) in firefighters.5

PTSD and depression are the two most common mental problems affecting 9-11 responders and volunteers, according to Landrigan. One study of firefighters found delayed-onset PTSD accounted for about half of total cases of PTSD.6 Another study that followed responders and volunteers over 5 years found a PTSD prevalence of 11.5%, the same as in soldiers returning from Afghanistan, and well above the 3% to 4% range found in the general population.7 Other psychological effects include excessive alcohol use and panic disorder.7

What are the implications of these health problems for OR nurses? Landrigan says restrictive lung disease will likely increase surgical risk in the future, and mental health problems could affect patients' recovery. In addition, OR nurses can play an important role in encouraging eligible people to enroll in the monitoring program.

The biggest unknown is how these health problems will play out in the long term, Landrigan says. For example, "Will (patients with 9-11 health problems) develop cancers in the years ahead?"

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A new era

The decade since 9-11 has been filled with change for nurses, both professionally and personally. Nurses aren't just functioning, but thriving, in this new era by contributing in many areas such as disaster planning.

On 9-11, I was the director of perioperative services at New York Downtown Hospital, a community hospital four blocks from the World Trade Center. I had just left for work and was on the expressway when I saw the first plane hit the tower and then a fireball. It was quite a sight. I continued on my route and saw the collapse of the first tower when I got parallel to lower Manhattan.

The Brooklyn Bridge was closed off. When I told them (officials at the checkpoint) where I worked, they directed me to the Manhattan Bridge. It was closed too, but they let me through. I was the only car on the bridge.

When I got to the hospital, visibility was getting hard because the debris was so heavy. Then the other tower fell. A construction worker helped me into the building. He was my angel.

We got a few fracture patients who went to the OR. Later that morning we lost power and the phone. I couldn't sterilize my instruments so I had to stop surgeries and send the patients to other hospitals in Manhattan. Dust started coming into the hospital and we went on emergency generator. (Surgeries didn't resume until a week later because the hospital was cordoned off by security.)

It was such an emotional experience. You didn't know what was going to go down next. Counselors were brought in to talk with the staff about the experience.

We carpooled to and from work, and that first night we had a police escort over the Brooklyn Bridge. The amount of rubble we had to walk through to get to the hospital was incredible. Lower Manhattan was a little bit like a ghost town. We had to go through checkpoints to get to the hospital and after a while, our supplies started going down. Our materials management department had to fax or e-mail vendors a letter so they could get through the checkpoints.

Later, I realized that the planning we had done to prepare for the millennium came in handy. We had battery-operated lights for surgery and other things ready because we had planned for a loss of power.

9-11 was the most significant event of my career. My critical thinking and decision-making skills were pushed to the max. You had to stay strong for your staff and help them stay calm while you were giving direction in a situation we'd never experienced before.

We had a lot of hospital events at the World Trade Center and we went shopping there; it had so much to offer. There are a lot of memories and now it's gone. Something was taken from us. We all had some component of PTSD.

We did grow in our expertise about disaster management. We were able to learn from 9-11 and apply that to natural disasters. I participated and later chaired an AORN task force that provided resources for OR nurses.

About Osama Bin Laden's death: I was just amazed it had finally happened. All the loss of life, all the children who had to grow up without a mom or dad ... was justice done? But the web continues. He has trained many others, it's succession planning. I'm concerned about the anniversary; it's in my mind and doesn't go away. You live with that. A terrorist attack can affect so many lives in a short period.

On 9-11, I was chief operating officer and CNO of Kaiser Permanente in San Francisco. I was at the gym. The TV was on and I saw it happen. It was pretty incredible. I immediately left the gym and headed home. My brother Joe was stationed at the Pentagon, so I was really concerned something had happened to him. The phone rang ... it was my brother. He said he was okay and then the line went dead. I didn't hear from him for 3 days because he was heading up the effort to bring order to the Pentagon.

(Although they talked several times over the next few days, it would be 3 months before Linda saw Joe in person.)

I got a call and learned San Francisco had been put on alert because the plane that ended up crashing in Pennsylvania was a flight headed to San Francisco. I went right into work. We were put on alert because at the time we didn't know if the plane would be diverted; people thought it would hit the Bank of America building. We stayed on alert even after the plane crashed because the planes hadn't been grounded. When patients' surgery in the OR was completed, we moved them into the postanesthesia care unit and didn't proceed unless there was an emergency surgery. All elective OR cases were cancelled. We kept the disaster center open for 48 hours.

I was in New York City a few weeks after. It was an incredible experience to walk down the street and see the soot and destruction.

Like most people, I was pretty complacent (before 9-11). I didn't think something like that would ever happen. It's forever on my mind. I'm much more tolerant of the security you have to go through at the airport. I'm much more aware and on guard ... not frightened, just aware that terrorism is a possibility. I've become more of an international citizen and more aware of terror attacks in other countries.

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Being prepared

Linda Groah reminds OR nurses that "as healthcare professionals, we need to have a disaster plan not just at work but for our families, too." That includes disaster preparedness, plans on how to communicate (keeping in mind that cell phones likely won't be working), and preparing your family to be without you because "it's all hands on deck" at hospitals when a disaster occurs. Groah says a great holiday gift is a disaster-preparedness gift such as a hand-cranked radio.

If you're willing to volunteer, register with an organization now, before something happens. Options include:

* The Emergency System for Advance Registration of Volunteer Health Professions, a federal program administered on the state level. Registering lets states verify healthcare professionals' identification and credentials in advance, which saves time in an emergency. The registration process varies from state to state. Read more at http://www.phe.gov/esarvhp/pages/registration.aspx.

* Medical Reserve Corp., which identifies qualified, credentialed personnel available and ready to respond to emergencies. Read more at http://www.medicalreservecorps.gov/QuestionsAnswers/Overview.

* American Red Cross, which operates through local organizations. Find yours at http://www.redcross.org/en/volunteer.

Some other resources include:

* National Response Framework at http://www.fema.gov/emergency/nrf.

* Citizen Corps at http://www.citizencorps.gov.

* Disaster Preparedness—What Can Your Ambulatory Surgery Center Do? a digital slide presentation by Marilyn Christian, RN, BSN, CNOR, CASC. Available through AORN at http://www.aorn.org/docs/assets/334F0CAF-1871-EBA3–884BD940DCD0D78E/Christian_AMB_4812_Disaster%20Preparedness.pdf. "The program focuses on the ambulatory surgery center, but the principles are all-inclusive," says Groah.

* World Trade Center Health Program (http://www.cdc.gov/niosh/topics/wtc/default.html), which provides health monitoring and treatment benefits to eligible emergency responders; recovery and cleanup workers; and residents, building occupants, and area workers in New York City affected by 9-11. The program includes responders to the Pentagon attack in Arlington, Va., and to the Flight 93 crash site near Shanksville, Pa. The Department of Health and Human Services administers program enrollment and benefits, while the National Institute for Occupational Safety and Health administers all other parts of the program.

I was working at St. Vincent's Hospital (in New York City; the hospital, which received victims from the World Trade Center bombing in 1993, has since closed) in 2001, but on 9-11, I was in Washington, D.C., representing AORN at a meeting of more than 100 organizations involved in the Johnson & Johnson Nursing Agenda for Change. We had broken up into small groups when my son called me after the first plane hit the World Trade Center. My reaction was, "You've got to be kidding me." When he called to tell me about the second plane, I knew it wasn't an accident. By the time he called me about the plane hitting the Pentagon, he was frantic. I went to the hotel lobby and saw my city in flames.

I tried to find my niece, who worked in that area, and finally got through to her. My job was trying to find me because they knew I was in Washington.

The next day, Amtrak was running, so I took a train to New York. I jumped into a cab and went right to work. Police had blocked off the streets at 14th; the hospital was at 7th Avenue and 11th Street, but I showed my ID and was able to get through.

We were the closest trauma center to the World Trade Center. We canceled surgery and waited for patients. We got a few first responders, and then the towers collapsed; we had nurses with family members in the towers. We were there 3 or 4 days, waiting for people to come. It was hard not getting anyone to rescue. All the restaurants that were closed cooked for us. OR staff drove across country to offer their help.

It was a tense, difficult time. We resumed surgery Thursday or Friday (the attack happened on Tuesday), but the next couple of weeks were particularly hard. You could walk the streets and feel the dust on your face. You'd look to your left and the towers weren't there. Outside the hospital was a wall with photos of loved ones posted by people looking for family. It was hard to walk by. I arranged bereavement counseling for my staff and we had religious ceremonies.

We got a lot of love. A grade-school class sent us coffee mugs with candy and teddy bears. Sheila Allen, who was president of AORN at the time, came to New York and met with the staff. ORs around the country sent us messages. One OR sent us 100 American flags shaped into OR caps. All the OR staff got a cap, including housekeeping.

9-11 changed me as a nurse and as a person. I'm not as fearful; I don't let the small stuff get to me. It's made me more attentive to patients and families. It still hurts. I still have difficulties going into high buildings. It's still difficult to see (9-11 footage) on TV.

About Osama Bin Laden's death: Right after 9-11, I wanted retaliation, like most people. When Osama Bin Laden was killed, my first thought was "finally," and then there was incredible sadness; it's sad to wish for somebody's death. For a moment I was fearful again, but I realized it's not in my hands; I have to live my life. I don't feel our enemies are as strong without Bin Laden, but I'm not foolish enough to think they're incompetent.

We had a very busy schedule that day. Once we heard about the disaster, we (Jacoby and representatives from other disciplines) all went to the trauma center, where I reported how many rooms were running and how many were empty. (The main OR has 18 rooms.) Knowing the extent of the destruction, we knew we had to cancel our cases in preparation for patients. Many of our surgeons went down to the financial center to see if they could help.

It was very emotional. We had all the resources and wanted to help, but there was nobody to help. Our nurses were here to put the pieces together and there was nothing to do.

Nurses didn't want to leave. Nurses with children ended up going home; young nurses without children volunteered to stay. We have showers and sleeping facilities they could use. We tried to strike a balance between letting them stay and knowing when they needed to go home. One nurse's husband had been onsite when the World Trade Center was bombed in 1993; he was fine. This time his wife was off duty at home. He came to the hospital covered in ash, looking for his wife. We were able to call her and let her know he was okay.

We also cancelled cases the second day. On the third day, we started doing cases, but didn't run a full schedule. We tried to do only quick cases such as gallbladder and not the very long cases that would take up room time. Staff could access counselors in employee health services at no charge.

I briefly thought about moving away from New York, but I quickly told myself, "You can't run away." We love the city.

We're more conscious of who's coming in and out of the OR. If staff see someone without an ID, they ask, "Can you please identify yourself?"

We know we always have to be ready. Even when the plane landed in the Hudson River (U.S. Airways flight 1549, disabled during takeoff by a bird strike on Jan. 15, 2009), we knew there could be a possible tragedy, so we immediately checked which ORs had surgeons who were closing and got prepared just in case.

Because of our location, we're not complacent about disaster preparedness. We're just a few blocks from the United Nations; we're in a very busy place. New York will always be the number one target for terrorism because we're the financial center, so we're always vigilant. It's a commitment for us.

September 11 started like any other day. We were following our normal schedule. About 9:30 a.m., I was in my room doing the first case of the day when one of the managers came in to tell me it would be the last case of the day because a plane had just crashed into the Pentagon. Each room finished their case so we could be ready to receive casualties.

We were ready every minute for anything that would come. Unfortunately, most of the victims didn't make it to the hospital. Everybody was sad. We were there for the victims, but were unable to help.

(Washington Hospital Center received 10 critically ill burn patients on 9-11; one died from her injuries. Some went to the OR on that day, others directly to ICUs. Many of the patients had surgery during their hospitalization.)

In the last 10 years we've learned a lot about disaster response. We have classes every 6 months and drills in the OR. Everybody knows what to do. When Bin Laden was killed, people were worried that something would happen again. Even now we're ready, something could happen at any time and on any day; we're in a big city—our nation's capital.

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1. September 11 Victim Compensation Fund. U.S. Department of Justice. http://www.justice.gov/civil/common/vcf.html.

2. de la Hoz RE. Occupational lower airway disease in relation to World Trade Center exposure. Curr Opin Allergy Clin Immunol. 2011;11(2):97–102.

3. Aldrich TK, Gustave J, Hall CB, et al. Lung function in rescue workers at the World Trade Center after 7 years. N Engl J Med. 2010;362(14):1263–1272.

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© 2011 Lippincott Williams & Wilkins, Inc.