The 9-11 Attack and Emergency Management

September 11th is a day that no one on the face of this earth will ever forget. This was the day when New York was crippled by terrorist attacks. On the morning of September 11th, at 08:46 local time, an American Airlines Boeing 767 hijacked by terrorists crashed into the North Tower of the World Trade Center in New York. On board there were 92 people, including five terrorists who has taken the passengers hostage. 17 minutes later, a United Airlines Boeing 767 with 65 passengers on board, including another five terrorists, crashed into the South Tower of the World Trade Center. The days after the attack many were exposed to a combination of air pollution, dangerous work conditions, and psychological trauma.

New Approach to Managing 9/11 Emergency

In a disaster such as 9/11 a robust Emergency Operation Plan is crucial to the survival of many. One feels using the NIMS Incident Management System and its component, ICS Incident Command System, would be the best method to use. The Figure 1 is a good example of a violence and public threat emergency response flow chart provided by WHO and EHA (1998). NIMS helps with directing local agencies on how to work together while ICS assists with interacting with local agencies. Under ICS it consists of principles that are to be thoroughly followed to ensure the safety of all.

The principles of ICS are mitigation, preparedness, response and recovery. In the mitigation phase a risk assessment that identifies hazards is considered to be most critical element, thus it needs efforts to focus on in the upcoming year. Preparedness principle encompasses the process of ensuring that all workers are trained in full scale exercises maintaining and building the response team. Response is comprised of the men and women who work at local facilities and organizations that are part of Environmental Health and Safety and Public Safety Departments. Final principal explains the recovery phase during which New York City needed to be restored to the way things were before the emergency.

Fig. 1. WHO and EHA (1998). Violence and Public Health Emergency Response Flow Chart

Mechanism of Injury (MOI)

During 9/11 many lives were taken, and many put forth the effort to help save other people. The individuals who provided assistance to emergency departments that day have suffered various diseases later due to ingestion of harmful particles in the air at the site of catastrophe. Seil et al. (2021) state that “many survivors of the 9/11/2001 terrorist attacks in New York City sustained injuries” (p. 873). They were not wearing the proper PPE and did not have the equipment to measure possible contaminants in the air. For example, medical evaluations of 415 non–English speaking nonunionized temporary workers were conducted in a mobile van located near the former World Trade Center (Klitzman and Freudenberg 2003). The major symptoms were found to be upper airway irritation and other nonspecific symptoms including insomnia, headaches, and dizziness. According to NYU Langone Health / NYU Grossman School of Medicine (2021), “first responders who developed metabolic syndrome shortly after 9/11 were more likely to have higher rates of asthma” (para. 7). Kwon et al. (2021) also claim that “metabolic syndrome increases the risk of World Trade Center lung injury” (p. 1035). The direct victims of the buildings and plane crash had suffered from multiple burns, fractures, head injuries, and asphyxia.

Casualty Figures

The terrorist attack of September 11, 2001 became the largest in world history in terms of the number of victims. As a result of the plane collisions, a massive fire began in both skyscrapers, which weakened the internal structures of the buildings and ultimately led to their collapse. At 09:59 am, the South Tower collapsed, and about half an hour later, the North Tower. Debris from skyscrapers damaged nearby buildings, including the 47-storey high-rise WTC-7, which also crashed down. Simultaneously with the attack in New York, terrorists carried out a similar advance on the headquarters of the U.S. Department of Defense. The attackers were planning to commit a fourth act of terrorism as well. To do this, they hijacked another plane – a United Airlines Boeing 757, en route from Newark, New Jersey, to San Francisco, but it fell in a field 200 km from Washington. There were 44 people on board, including four terrorists as well. In total, 2,977 people became victims of the September 11 attacks, including 343 firefighters and dozens of police officers, and over 6,000 were injured (Jacobson et al. 2019). Among the victims of the tragedy were not only Americans, but also citizens of more than 90 other countries.

Triage Challenges

Triage is carried out in the lesion focus and at each stage of medical evacuation in the provision of all types of medical care. To conduct triage at the stages of medical evacuation, it is necessary to involve the most experienced, specially trained doctors and nurses. These doctors and nurses must be capable, without removing bandages and without resorting to complex research, of establishing a diagnosis and determine the prognosis of each patient as quickly as possible. The main methods of medical triage should also be explained to the personnel of rescue teams designed to search for victims and provide them with first aid in the lesion focus.

In the event of a disaster or accident involving multiple casualties like 9/11, most of whom need urgent medical attention and evacuation from the affected area, an imbalance inevitably arises. This imbalance lies between the number of people in need of medical care and the health resources and capacities currently available. Naturally, in such conditions, the provision of medical care in full to all victims is almost impossible. This situation forces to concentrate efforts in providing priority medical care to those victims who need it most urgently and at the same time have a real chance of survival. To achieve this goal, it is necessary to single out this category of victims from among those who need medical care in a minimal amount or those whose life support is extremely uncertain. This should be done even despite the fact that efforts may take a long time and require a large amount of medical resources. Thus, sorting in an emergency is not always aimed at providing help to those most critically affected, but rather those who are more likely to survive.

Medical Response

When organizing the provision of medical care to the population affected by terrorist acts, it is necessary to take into account the conditions that occur in each such emergency situation:

  1. A high degree of damage to the population. Terrorist acts are carried out mainly in crowded places, as their purpose is to intimidate the population up to physical destruction. As a result of terrorist attacks, a large number of people is affected. The 9/11 attack has more than 9 thousand of injured and killed.
  2. The nature of the object at which the terrorist act was carried out. This affects heavily the ability to provide medical care to the victims and requires the development of multivariate schemes of medical and evacuation support. Moreover, it is also necessary to take into account the peculiarities of the damaging factors. In the 9/11 tragedy, the collapsed buildings and resulting fires made it significantly more difficult to rescue people.

In the affected area, there is often no opportunity for the timely provision of the necessary amount of emergency medical care and treatment to the victims. Due to the emerging shortage of human and material resources, an acute contradiction arises between the massive sanitary losses and the lack of health care opportunities to provide all victims with full-fledged medical care. As the most dramatic scenario in the disaster area, a situation could emerge where there is nowhere, no one and no means to provide assistance to the victims. The only way out of this critical situation is to send into the emergency zone prepared in advance mobile rescue teams to provide emergency medical assistance on the spot and evacuate victims to medical institutions. Thus, the organization of medical response is based on the division of a single process of providing medical care to the affected population into its individual types using outside means.

Urban Search and Rescue

Some of the 9/11 survivors state that firefighters and police officers were not prepared for the event – they were confused and did not know what to do. The rescuers themselves explained how they decided to evacuate everyone in the immediate area of the crash, and only then go into the buildings. As FEMA reports on its official website, the National Urban Search and Rescue Response System was deployed shortly after receiving the news about the attack. The FEMA website (2021) also states that “the initial missions assigned to the task forces were technical search operations using specialized cameras and listening devices, as well as canine search operations” (para. 5). Thus, it can be concluded that the organization of urban search and rescue is one of the major aspects of the first response to a catastrophe of such scale. Nowadays, in addition to dogs and task forces, drones can be used to help seek out the people.

Inter-agency Collaboration

Federal Emergency Management Agency is the main responder to any disaster occurring in the United States. According to the Oak Ridge Institute’s description (2021), “FEMA is the Federal agency that coordinates the response of Federal agencies to disasters and the communication of information between Federal agencies and the public” (para. 16). Department of Transportation and Transportation Security Administration are the organizations that help with transporting the people from the site of disaster and ensure their secure arrival to a safe zone. The U.S. National Response Team is another agency that works as the emergency’s first responders. The U.S. NRT’s website (2021) states that “the U.S. National Response Team provides technical assistance, resources and coordination on preparedness, planning, response and recovery activities for emergencies” (para. 1). Finally, National Domestic Preparedness Office was created to assist the local responders and the state with any arising emergencies. Collaborated work of these agencies are the key measure during any disaster, especially as big as 9/11.

Public Health Issues

There are several public health issues associated with the attack of 9/11. The victims who managed to survive during the plane crash and the collapse of buildings have suffered multiple injuries, from which many of them died. The first responders, as well as people who decided to help rescuing others were exposed to smoke, fires, and toxic pollution in the air. Waszak and Holmes report that “there is a large population of veterans from the post-9/11 era who have complex primary and behavioral health needs relating to polytrauma, co-morbid chronic conditions, and/or ill-defined problems” (p. 431). Lowell et al. (2017) also state that “a substantial burden of 9/11-related PTSD among those highly exposed to the attack” (p. 537). Moreover, the dust from the collapsing buildings has spread over the neighboring area, also becoming a health hazard even for the people who were not around the towers.

As has been stated above, in such a situation, where a massive disaster with many casualties has occurred, the medical resources are often scarce, at least during the first response. The state needs to ensure that special mobile teams are prepared before any new disasters occur, and that they are always alert. Moreover, during such events, it is crucial to provide the people with free quality medical care, funded by the local emergency agencies and government.

Communication and Media Relations

The 9/11 terrorist attack became not only the largest in the history of the U.S., but also the first “live catastrophe” in the world history: millions of people around the world watched the events unfold live. History has changed, and September 11th became the starting point, from which serious lines of transformation of modern society and modern politics began. For example, the documentary 9/11: Inside the President’s War Room tells the story of the day that changed America from the perspective of President George W. Bush. The events that occurred in the twelve hours that followed the attack portray the hardships of making decisions during such a precedent. It is worth noting that the President and his Cabinet reacted almost disbelievingly to what had happened – their confusion is almost visible in the film. Perhaps one could call it a failure of public relations management of the government, as they did not have a reliable plan for such occasion, and this is, indeed, a lesson to be learned.

Another interesting lesson lies in the way the public relations with other concerned countries were managed – for example, how Condoleezza Rice took time to brief the Russian President Putin on the issue. From the view of public relations, there is a crucial point that gives valuable conclusions: when talking of such crises, it is important to be honest with people. When a state is implementing a long-term program of countering terrorism, special services, power structures, and institutions of civil society must cooperate to achieve real results. Therefore, the involvement of domestic mass media in the work on prevention and countering terrorism is of particular importance to the issue of counterterrorism.


The attack of 9/11 was the first act of terrorism which has started the discussion about the preparedness for such events. Counterterrorism measures were significantly reinforced after this tragedy, and federal agencies such as FEMA have developed plans for managing such events. The pre-planned coordination of organizational issues and a timely provision of assistance to the population is the crucial point in successful management of any emergency situation. The federal structures have been working together to map out possible strategies for immediate resolve of danger the population might encounter during an emergency. Moreover, the affected population also requires water, food, proper healthcare, a shelter, and a sanitation of their environment – in that concrete order. Establishing the right sequence of action before the accident has happened may prove to be of utmost importance when time and resources are limited, and the people are in dire need of government’s help.

There is a real importance of covering this aspect as much as possible specifically for the catastrophe management. During massive disaster events, people often have to stay behind in a dangerous area due to their inability to leave. A proper field planning has to take into consideration a multitude of factors affecting the population’s survivability, and it can be hard to include every possibility of harm, as these might be quite unexpected. DePierro et al. (2020) also add that “the mental health response to the 9/11/01 terrorist attacks, culminating in a federally-funded health program, provides a template for how providers may serve affected individuals” (p. 1). The success of the emergency management relies heavily on the strategical planning, as well as on a proper deployment of every stage of the plan.

Logistical Issues

Many logistical problems have arisen in the event of 9/11, as was expected. The immediate area around the collapsed buildings was heavily damaged, thus, it was near impossible to provide transportation for the victims during the first hours of the catastrophe. In 2001, the use of drones, especially, medical ones, was not introduced yet, but nowadays, it can be the right solution of some logistical issues. Drones can deliver medical supplies, defibrillators, medicaments, as well as survey the area and seek out the survivors. In the situation where the emergency car cannot reach the designated area, drones can provide immediate assistance to the doctors working on the site of disaster. Additionally, the police departments and federal transportation agencies must ensure that the roads are cleared as quickly as possible to allow the emergency cars to come through.


The events of 9/11 showed that America was not ready for the terrorists’ attack at all. The work of FBI and CIA before and during the event was questioned heavily in the years after the catastrophe. Moreover, the disaster showed that emergency departments did not have plans for such a massive issue with so many casualties, which resulted in even more injuries and death. However, one must say that it is nearly impossible to predict everything that can happen during such event, and even comprehensive planning will have its flaws. Moreover, the problems of delivering medical specialists and rescuers to the disaster site has also proven to be quite difficult to resolve. The shortage of doctors and nurses can also be considered as a pitfall, as it impacted the process of delivering emergency care significantly.


DePierro, J., Lowe, S., & Katz, C. (2020). Lessons learned from 9/11: Mental health perspectives on the COVID-19 pandemic. Psychiatry Research, 288, 113024. doi:10.1016/j.psychres.2020.113024

FEMA. (2021). The role of the Urban Search and Rescue System in the 9/11 response: Fred Endrikat shares his story.

Jacobson, M. H., Brackbill, R. M., Frazier, P., & Gargano, L. M. (2019). Conducting a study to assess the long-term impacts of injury after 9/11: Participation, recall, and description. Injury Epidemiology, 6(1). doi:10.1186/s40621-019-0186-y

Klitzman, S., & Freudenberg, N. (2003). Implications of the world trade center attack for the Public Health and Health Care Infrastructures. American Journal of Public Health, 93(3), 400-406. doi:10.2105/ajph.93.3.400

Kwon, S., Lee, M., Crowley, G., Schwartz, T., Zeig-Owens, R., Prezant, D. J. Nolan, A. (2021). Dynamic metabolic risk profiling of World Trade Center Lung Disease: A longitudinal cohort study. American Journal of Respiratory and Critical Care Medicine, 204(9), 1035-1047. doi:10.1164/rccm.202006-2617oc

Lowell, A., Suarez-Jimenez, B., Helpman, L., Zhu, X., Durosky, A., Hilburn, A.,… Neria, Y. (2018). 9/11-related PTSD among highly exposed populations: A systematic review 15 years after the attack. Psychological Medicine, 48(4), 537-553. doi:10.1017/S0033291717002033

NYU Langone Health / NYU Grossman School of Medicine. (2021). Decades after toxic exposure, 9/11 first responders may still lower their risk of lung injury. ScienceDaily.

Oak Ridge Institute for Science and Education. (2021). Get To Know These Agencies and Organizations. Web.

Seil, K., Yu, S., Brackbill, R., Alper, H., & Maqsood, J. (2021). Effects of 9/11‐related injury on retirement patterns among world trade center health registry enrollees. American Journal of Industrial Medicine, 64(10), 873-880. doi:10.1002/ajim.23288

Waszak, D. L., & Holmes, A. M. (2017). The unique health needs of post-9/11 U.S. veterans. Workplace Health & Safety, 65(9), 430-444. doi:10.1177/2165079916682524

WHO and EHA. (1998). Emergency Health Training Programme for Africa Part 1: Overview [Pdf]. Addis Ababa: Panafrican Emergency Training Centre.

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