Tuesday, October 31, 2017

An Opinion : What exactly are "Protocols" and "Standing Orders"?

[ File under : FOR EDUCATIONAL DISCUSSION ONLY ] 

Hi fellow CMIOs, CNIOs, Informatics leaders, and other #clinicaljedi,

Protocols and standing orders. Next to order sets, these are two of the most ubiquitous tools in modern healthcare, used to create predictable routines and outcomes in clinical care. So what exactly are they? And what exactly is the difference between a "protocol" and a "standing order"?


For the Informaticist, these are not easy questions to answer. The confusion starts with the search for regulations and definitions, where there is a curious paucity of information. As of this writing, most major regulatory bodies have somewhat vague or conflicting information. 

Historically, it seems many regulatory bodies simply frowned upon the use of "protocols" or "standing orders". Why? Probably because of their function - If a doctor writes an order like "Vent liberation per protocol", he/she is actually asking someone else to take on the responsibility of managing a ventilator on his/her behalf. So it's actually a tool of delegation.

So I'm guessing the concern was, if the 'protocol' was a tool of delegation, then it's someone else providing that care at the direction of, and on behalf of the doctor. This raises some valid operational questions : 
  1. By using "per protocol", does the order actually refer to a approved, documented set of well-definedclearreasonableevidence-based, and agreed-upon instructions?
  2. If a nurse, pharmacist, or someone else can follow those instructions - What if something doesn't go according to plan? Would the nurse, pharmacist, or other care team member have the same skills and training as the doctor to manage any unexpected outcomes or scenarios?
  3. As the nurse, pharmacist, or other ancillary team member follows the written instructions - Are there any key points in the patient's care that the ordering doctor should at least be aware of? (e.g. if the protocol keeps asking the nurse to give  higher levels of oxygen, is that OK?)
  4. If the doctor is effectively unaware of the minute-by-minute details of what the nurse or pharmacist is doing, or the patient status, will the doctor still be responsible for the outcome of their pre-defined instructions? Or will the nurse or pharmacist be responsible?
  5. How do we know this delegation agreement was clear, effective, and appropriate?
So for many years, many of those regulatory agencies were concerned and understandably frowned upon the use of protocols and standing orders. Not enough was known about them, and the risks seemed to outweigh the benefits. And let's face it - If it's a tool of delegation, what's to stop a doctor from writing the "Dr. ______-is-away-this-weekend-protocol", making the nurses shoulder all of the responsibility for care? 

But then, around 2008, after more rigorous discussion and a few safety incidents where nurses were unable to initiate common life-saving treatments because their patients needed them and no doctor was immediately available - it seems like some agencies may have re-looked at protocols and standing orders, had a change of heart. In 2011, CMS issued this communication : 
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R77SOMA.pdf 
... which says : 
"Standing orders 
Hospitals may adopt policies and procedures that permit the use of standing orders to address well- defined clinical scenarios involving medication administration. The policies and procedures must address the process by which a standing order is developed; approved; monitored; initiated by authorized staff; and subsequently authenticated by physicians or practitioners responsible for the care of the patient. The specific criteria for a nurse or other authorized personnel to initiate the execution of a particular standing order must be clearly identified in the protocol for the order, i.e., the specific clinical situations, patient conditions or diagnoses in which initiating the order would be appropriate. Policies and procedures must address the education of the medical, nursing, and other applicable professional staff on the conditions and criteria for using standing orders and the individual staff responsibilities associated with their initiation and execution. An order that has been initiated for a specific patient must be added to the patient’s medical record at the time of initiation, or as soon as possible thereafter. Likewise, standing order policies and procedures must specify the process whereby the physician or other practitioner responsible for the care of the patient acknowledges and authenticates the initiation of all standing orders after the fact, with the exception of influenza and pneumococcal polysaccharide vaccines, which do not require such authentication in accordance with §482.23(c)(2). 
The policies and procedures must also establish a process for monitoring and evaluating the use of standing orders, including proper adherence to the order’s protocol. There must also be a process for the identification and timely completion of any requisite updates, corrections, modifications, or revisions." 
This was a big step forward in creating some clarity around the subject of "standing orders", but does this also apply to "protocols"? It seems there is still a great deal of confusion over this issue. Articles like these : https://www.medscape.com/viewarticle/775617  suggest that people are still trying to understand if these are legal, and if so, how to design them safely.

So from a terminology standpoint, most Informaticists routinely have to struggle with questions like : 
  1. "What exactly is a protocol?" and 
  2. "Is it the same as a standing order?" or 
  3. "Is it the same as a clinical protocol?" and 
  4. "Is it the same as an oncology protocol?"
These are not easy questions to answer when the regulations and definitions don't guide you very well. 

So what is an Informaticist to do to help resolve the issue? Focus on the function, and work backwards to redefine the archetype and definition!

Let's look at a few things we *do* know : 
  1. The terms "Protocol" and "Standing Order" are almost used interchangeably - But not quite - So they still must have some kind of relationship.
  2. They seem to allow someone else than the provider to enter, modify, or stop an order, on behalf of the provider - so they appear to be some kind of tool of delegation.
  3. They seem to follow some kind of documented instructions, explaining exactly WHICH order(s) to start, modify, or stop, and when.
  4. For safety, the reasons that someone else is starting, modifying, or stopping an order should be very concrete and clear, without need for interpretation.
So if we can accept the above as true, then we can start drafting a definition :
DRAFT ] DEFINITION - PROTOCOL (n.) - A tool of delegation that allows a __________ to INITIATE, MODIFY, or DISCONTINUE an order on behalf of a Licensed Independent Practitioner (LIP), Advanced Practice Registered Nurse (APRN) or Nurse Practitioner (NP), Resident Physician, or Physician Assistant (PA).
Now, who exactly can start/modify/stop an order on behalf of a provider? From the patient care standpoint, you want the person following the protocol to have the training and clinical understanding to follow the protocol properly, and know how to navigate when things don't go as planned. Commonly, there are four roles that could likely fill this role : 
  1. Registered Nurses
  2. Registered Pharmacists
  3. Registered Dietitians
  4. Registered Respiratory Therapists
But if you want to include other care team members (like Medical Assistants), it is probably in an organization's best interest to make sure all team members expected to follow the protocol have a solid system of certification, training, and supervision. Either way, you'll need to work this into your organization's definition of a protocol : 
DRAFT ] DEFINITION - PROTOCOL (n.) - A tool of delegation that allows a Registered Nurse, Registered Dietitian, Registered Pharmacist, Registered Respiratory Therapist, (or certified and trained Medical Assistant) to INITIATE, MODIFY, or DISCONTINUE an order on behalf of a Licensed Independent Practitioner (LIP), Advanced Practice Registered Nurse (APRN) or Nurse Practitioner (NP), Resident Physician, or Physician Assistant (PA).
This is a pretty good start, but let's see if we can help craft some additional functionality and safety into this definition. 

If protocols should address common, well-understood clinical scenarios, then we need to consider what types of common, well-understood scenarios we might need protocols for : 
  1. Scenarios that only apply to a specific patient (e.g. Heparin titration protocols, Vent Liberation Protocols), and
  2. Scenarios that apply to a population of patients (e.g. Nurse vaccination protocols, pharmacy substitution protocols, etc.)
And so it seems like there is a need for two different kinds of protocols : 
  1. Protocols that only apply to a specific patient (e.g. Heparin titration protocols, Vent Liberation Protocols), and
  2. Protocols that apply to a population of patients (e.g. Nurse vaccination protocols, pharmacy substitution protocols)
And so, this suggests that the term "Protocol" might actually comes in two types : 
DRAFT ] DEFINITION - PROTOCOL (n.) - A documented tool of delegation that allows a Registered Nurse, Registered Pharmacist, Registered Dietitian, Registered Respiratory Therapist, (or certified and trained Medical Assistant) to INITIATE, MODIFY, or DISCONTINUE an order on behalf of a Licensed Independent Practitioner (LIP), Advanced Practice Registered Nurse (APRN) or Nurse Practitioner (NP), Resident Physician, or Physician Assistant (PA). All protocols are categorized as either : A. Protocols that apply only to a specific patient, or B. Protocols that apply to a defined population of patients. 
So if a protocol only applies to a specific patient, there must be some way that a provider can specify which patient(s) to use the protocol on - A way of turning the protocol "on-and-off", to tell a nurse when to follow the protocol, and when NOT to follow the protocol.

Likewise, for those protocols that apply to a defined population of patients, there must be some way to define which population of patients the protocol should be applied to.

And this brings us to the question of how to initiate/activate, or 'trigger' a protocol - If you need to activate/deactivate the protocol, then a handy trigger would be an ORDER, e.g. :
  • "Initiate/Follow heparin titration protocol" and 
  • "Discontinue/stop heparin titration protocol".
But if it's a protocol that is 'always on' for a defined group of patients (say, adult inpatients), then a handy 'trigger' could be a POLICY, e.g. "All adult inpatients will be on the pharmacy PPI substitution protocol" that allows a pharmacist to STOP one PPI and START another PPI (to replace one for the other).

So if we can accept that there are probably two ways to activate/'trigger' a protocol : 
  1. ORDERS - For those 'on-off'-type protocols, that need to be initiated/discontinued for a particular patient
  2. POLICY - For those 'always-on'-type protocols, that are always in effect for a defined patient population
... then we can work this into our drafted definition of a PROTOCOL (click below to enlarge): 
... and for additional clarity, we can bring in a few common, real-world examples below : 
So this is a reasonable starting point. But does this help us, yet, with a definition for "Standing Order"? I think it does - The term "Standing Order" is commonly used to describe scenarios where the provider has granted pre-approved, written, delegated authority to perform an action without their input or awareness. This is especially helpful in common scenarios where the risks/benefits of administration outweighs the risks/benefits of getting a provider order - E.g. For Public Health reasons, many states allow Registered Nurses to order and administer (low-risk) vaccinations without a provider's input.

So is it possible that the term "Standing Order" is actually a synonym for all or part of this protocol definition? I think it works pretty well for part 1.b below : 
And so, a "Standing Order" could then be defined, simply, as a PROTOCOL that is initiated/triggered by a POLICY (See section 1.b above.)

This leads me to ask about other common terms/synonyms - E.g. "Nurse-driven protocol", "Pharmacy-Driven Protocol", "Respiratory Therapy Protocol", etc. What exactly are these?

The problem with these other synonyms is that the terminology overlaps a bit, and when referring to a protocol, it's important to note both the method of initiation (e.g. Policy or Provider), and the team member(s) expected to follow the protocol, to initiate orders on behalf of the attending or ordering provider (e.g. Registered Nurse, Registered Dietitian, Registered Pharmacist, etc.)

So when referring to a protocol, it's always important to consider both : 
  • "____________-INITIATED protocol" - Describes the mechanism for initiating/triggering the policy (e.g. Provider-initiated, Policy-initiated)
  • "____________-DRIVEN protocol" - Describes the team member(s) who is/are expected to follow the protocol (to start/modify/stop orders, on behalf of a licensed prescriber) (e.g. Nurse-driven, Pharmacy-driven, Dietary-driven, etc.)
We can use these terminology concepts to help fill out our definition of a protocol / standing order even more - see 'synonym : Provider-initiated Protocol' in 1.a below :

And if we want to give some examples of each type of trigger, to help make the definition even more clear, we could include them too  - See 1.a.i and 1.b.i below : 
This is a pretty good start, but we'll want to work in some features of attribution, for the orders that are initiated, modified, or discontinued by these protocols. Since we now have a definition with two types of protocols : 
  1. Order-Initiated (aka Provider-initiated protocols)
  2. Policy-Initiated (aka Standing Orders)
It makes sense that for the resulting 'child' orders : 
  1. Order-Initiated (aka Provider-initiated protocols) - Attributed to the ORDERING provider
  2. Policy-Initiated (aka Standing Orders) - Attributed to the ATTENDING provider
And we can work this into our definition, too - See 1.a.ii and 1.b.ii below : 
Finally, for safety, we should consider the circumstances in which someone else other than a doctor might assume responsibility for INITIATING, MODIFYING, or DISCONTINUING an order - We want it to be very clear about WHENexactly, to start/modify/stop that order - In other words : 
  1. ACCEPTABLE = Clear, discrete data elements
  2. UNACCEPTABLE = Vague, ambiguous, or complex data elements
So we can work this safety feature into our definition too - See #2 below : 
This definition is much more robust than many regulatory agencies currently offer or publish. Some might see the adoption of such a definition as risky ("You don't want to paint yourself in a corner!") - However, it does provide a great deal of clarity and predictability, and if it exceeds the expectations of the regulatory agencies, then you are still meeting their expectations while simultaneously creating clarity and predictability - Which creates more predictable outcomes, which can lead to faster development time, higher development standards, and more standardized care. Before deciding whether or not to adopt such a definition and approach in your organization, your legal counsel, senior leadership, and informatics leadership will need to discuss the risks and benefits in detail.

However, if after rigorous examination and debate, you do adopt a similar definition, then it could help you answer questions like : 
  • Q : "What exactly is a protocol?"
  • A : See the [ DRAFT ] definition below (click to enlarge) : 
  • Q : What exactly is a standing order?
  • A : It is a PROTOCOL which is activated/triggered by a POLICY. The provider is not required to initiate action, and child orders are attributed to the ATTENDING provider. See the definition of PROTOCOLsection 1.b above.  
  • Q : Do I always need to activate a PROTOCOL with an order?
  • A : No - See the definition of PROTOCOL, section 1.b (aka 'Standing Order'). 
  • Q : Is a PROTOCOL the same as a 'research protocol'?
  • A : Without a solid definition of 'research protocol' it is not easy to answer this, but research protocols are typically used to guide the screening of research subjects, plan their data collection and management, with the goal of studying a subject. A PROTOCOL is only used to define a common clinical scenario where a licensed prescriber is delegating the authority to start, modify, or stop an order on his/her behalf.
  • Q : Is a PROTOCOL the same as an 'EMS protocol' or 'Emergency Protocol'?
  • A : Without a solid definition of 'EMS protocol' or 'Emergency Protocol', this is difficult to answer concretely - But in fact, many state EMS protocols have the same sort of functionality as a clinical PROTOCOL - Allowing a trained medical professional (paramedic or EMT) to initiate care in the field, on behalf of a supervising Emergency provider or Medical Director.
In my next blog post, I'll show how such a [ DRAFT ] definition could help you develop a protocol template that supports your protocol definition by creating an easy way for your protocol-builders to plan and build a professional-looking protocol document that supports your desired workflow and EMR configuration.

Remember this blog is for educational discussions only - You should consult your own legal counsel, senior leadership, and informatics professionals before considering adoption of any of the above approaches or definitions. Have any good definitions or regulations to share, or other ideas or comments? Leave them in the comments box below!

Saturday, October 14, 2017

What exactly is a "Nursing Policy"?

Hi fellow #HealthIT, #Informatics leaders, and other #clinicaljedi, 

Today's post actually started many years ago, when I was a Hospitalist taking care of a med/surg acuity patient on my service with a low magnesium level, and who needed intravenous (IV) magnesium replacement. After I entered the order for IV magnesium, the nurse taking care of the patient told me : "There is a new nursing policy on electrolyte repletion - If you want to give IV magnesium, you'll have to move the patient to a higher-acuity telemetry bed for monitoring, while we replace the magnesium." 


If you're not clinically trained, some brief explanationElectrolytes are chemicals in your blood that you need to be healthy, and so too much or too little can be potentially life-threatening scenarios -  but the dose of magnesium I was looking to replace was a fairly common practice, often used in alcoholic patients undergoing detoxification, who have not kept up with their nutritional needs. So this nursing policy would mean that alcoholics undergoing detoxification would require me to transfer the patient to higher-acuity bed and nursing care, if they needed to get their magnesium replaced intravenously.


Wanting to understand and comply with the clinical standards of the organization, I sought more information and looked up this nursing policy. It basically stated, 'All patients requiring IV electrolyte replacement must be in a monitored telemetry bed.' Even if it might increase the demand for telemetry monitoring, the standard seemed to exist for a good reason - out of an abundance of caution for these patients - and so this nursing policy was signed off by nursing leadership.


And yet, I couldn't help but wonder - Was this really just a nursing standard? Or a nursing-and-doctor standard? If the nursing policy essentially changed how and where physicians ordered magnesium on alcoholic detox patients, should it not have been reviewed by one of our physician leaders, who might have educated me about this standard at our department meetings? And yet, there was no review or signoff by anyone in physician leadership, probably because it was identified as a "Nursing Policy".




It wasn't a big deal for me to transfer the patient to a higher-acuity, monitored telemetry bed, and the patient got the IV magnesium uneventfully, but they still had to find an available bed, and it still took me a little while to get my patient transferred. 

Since then, I've often wondered about this nursing policy, and how it impacts the configuration and use of Electronic Medical Records (EMRs) - Who exactly makes clinical standards, who reviews them, and who approves them? If nursing policies are standards only for nurses, should there also be doctor policies that describe the standards for doctors

Now entering my 10th year as a HealthIT professional (CMIO), I'm busy with EMR implementation, informatics design, and engagement of clinical staff, planning for workflows that deliver great medical care. And after engaging many physicians, nurses, pharmacists, and other clinical and administrative team members, I've still continued to wonder : What exactly is a "Nursing Policy"? What is a "Pharmacy Policy"? "Radiology Policy"? Are each of these tribes of modern healthcare living on their own islands, setting their own rules? What if we need to make workflow standards across these islands?


After a great deal of analysis and evaluation, I believe I have some insight about these questions, which ultimately help answer this common EMR governance question - Who exactly designs, reviews, approves, and maintains the workflows of a healthcare organization?


So I share what I think are the three key challenges that require discussion before we can have a better understanding of a typical policy manual.

A. THE FIRST CHALLENGE - Terminology - Clinical vs. Administrative : 
We need to start by first looking at two common terms used every day in healthcare : 
  • 'Clinical Staff' - Term sometimes used to refer to those people involved in direct patient care, e.g. Doctors, nurses, respiratory therapists, pharmacists, dietitians, etc.
  • 'Administrative Staff' - Term sometimes used to refer to those people NOT involved in direct patient care, e.g. Administrators, finance, safety, engineering, human resources, etc. 
The first problem is that these are loose terms, and not solid definitions -They fray around the edges. For example : 
  • What about the Education department? Even if they don't provide front-line patient care, they are training the clinical staff on medical practice - So is that really an administrative function, or a clinical function?
  • Or what about the Clinical Directors who run the clinical departments, but don't provide direct patient care? If they are designing order sets to update the care their staff provides in treating pneumonia, is that really an administrative function, or a clinical function?
  • Often, roles that one might consider to be non-clinical, like supplies management, housekeeping, bed management, etc. actually do have a real impact in clinical operations. (E.g. Housekeeping technique can be very helpful in reducing infection rates.)
So the first step in understanding the policy chapters is accepting that these general terms may not be strict definitions, but somewhat ambiguous terms to loosely describe two different concepts - Clinical work (providing care?), and Administrative work (somehow supporting that care?). 

B. THE SECOND CHALLENGE - WHAT EXACTLY IS A POLICY/PROCEDURE? 
Surprisingly, the definitions for policies and procedures can vary. Legal dictionaries, technical dictionaries, and even HealthIT dictionaries all offer slightly different definitions. As of this writing, Google currently offers these :

While these are perfectly reasonable, it's worthy to note that the definition of "Procedure" does not identify "workflow" as a synonym. So even if you accept the Google definitions, I'd still like to offer these slightly refined, functional definitions : 
  1. POLICY = A documented organizational standard
  2. PROCEDURES (aka workflows) = How you will achieve those standards, or "an ordered set of tasks that uses people, time, and resources to achieve a desired outcome."
Generally, both policies and procedures are often found on the same document, for good reason : 
  • If you are documenting an organizational standard with a policy statement,
  • It's important to make sure you have planned and agreed about how to achieve that standard (procedure) 
So by outlining your standards, and how you achieve them, these policies and procedures can be very helpful documents. But given the ambiguity behind the terms "clinical" and "administrative", this can make their categorization (secondary definitions) a little difficult : 
  • CLINICAL POLICIES - Are these policies for "clinical people" to follow? (Does that include education?) 
  • ADMINISTRATIVE POLICIES - Are these policies for "Administrative people" to follow? (Does that include education?)
C. THE THIRD CHALLENGE - WHO EXACTLY ARE THEY WRITTEN FOR?: 
This third challenge starts to show up when you look at the typical chapters one finds in the "Clinical" and "Administrative" policy manuals : 
A. Clinical Policies :
  1. Nursing Policies
  2. Pharmacy Policies
  3. Radiology Policies
  4. Laboratory Policies
  5. Infection Control Policies
  6. Respiratory Therapy Policies
  7. ...and so on...
B. Administrative Policies : 
  1. Finance Policies
  2. Human Resources Policies
  3. Safety / Engineering Policies
  4. Information Technology Policies
  5. ... and so on...
Looking at this index, it's only logical to ask - Who are these documents for? Are the nursing policies just for nurses? If so, where are the physician policies, outlining the physician standards? Don't we all work together to take care of patients? Where are the documents that span nursing AND pharmacy AND laboratory?

SOME THOUGHTS :

There is a fundamental truth that's important to consider before we move on. Healthcare is a team sportWe all work together. Having standards on separate islands does not seem to help us all function together, so the idea of these standards all applying to (serving) different islands does not seem conducive to good teamwork and collaboration.

So how does the Informaticist approach this challenge, and create clarity and definition? By reviewing the definitions, archetypes, and indexing for these documents!


THE INDEXING CHALLENGE : 

IF a "Nursing Policy" were really just standards for nurses, then it would be OK to have only nurses writing, reviewing, and approving them. But in my IV magnesium example above, this "Nursing Policy" impacted my (physician) ability to care for the patient in that location, and so I had to transfer the patient to another bed to get the IV magnesium. So I'd like to offer the argument that, perhaps, "Nursing Policies" are not simply 'standards for nurses only' - This nursing policy created a standard for my physician activities, too.

The same argument would also apply to "Finance Policies" and "Human Resource Policies" - If the policy manual chapters only describe the people expected to follow them, then doctors and nurses would not have to honor Finance or HR policies. (We know this is not true.)


And so I believe this is a compelling argument to say that the policy chapters are not describing who's expected to follow the policy. If that's so, then what exactly are the chapters describing?

Before we can offer up an answer, there are two final definitions to ponder and consider :
  1. Policy Author/Owner - The person responsible for writing, monitoring, and upkeep of a policy
  2. Policy Stakeholder(s) - The person(s) impacted by the policy standard, who for review and education, are responsible for reviewing (vetting) the policy before approval
If we assume that the policy author/owner is a stakeholder too, then we could potentially refine these definitions slightly : 
POLICY STAKEHOLDER(S) - The person or people impacted by the policy standard. These are categorized as : 
  • PRIMARY STAKEHOLDER (aka "Policy Author" or "Policy Owner") - The stakeholder with the time, training, expertise, and responsibility for creating, maintaining, and updating the policy.
  • SECONDARY STAKEHOLDER(S) - Additional stakeholder(s) impacted by the policy standard, who for development and education purposes, are responsible for reviewing ('vetting') the policy before final approval.
And if we can accept these expanded definitions for policy stakeholders, which separate the primary stakeholder from the secondary stakeholders, then we have a much better chance at decoding the policy manual! Maybe that "Nursing Policy" is in the chapter of "Nursing Policies" NOT because it's a 'policy that only nurses have to follow', but because nursing is the primary stakeholder - They had the time, training, expertise, and responsibility to create, update, and maintain the policy. And so as the physician who had to move my patient because of this policy, am I a secondary stakeholder, still required to follow the policy...?

SO WHAT EXACTLY IS A "NURSING POLICY"?
If these arguments are compelling to you, and your organization formally accepts the definitions I've proposed (ask your legal counsel), then we can first summarize some of our findings here :
  1. Healthcare is a team sport - We all work together to take care of patients.
  2. The terms "Clinical" and "Administrative" are not as well-defined as we wish they were - There are plenty of examples of roles and functions that overlap both.
  3. The chapters of the policy manual are probably not just describing the 'people expected to follow the standard'.
  4. More likely, the chapters of the policy manual are describing the primary stakeholders, with the time, training, and expertise to create, maintain, and update the policy. But each policy may have additional secondary stakeholders.
If the above (#4) is true, and a policy can have multiple secondary stakeholders, then the policy chapters are more likely describing only the primary stakeholders - Those expected to create and maintain the policies. And so the chapters could maybe be better described as: 

A. Clinical Policies - policies maintained by clinical departments
B. Administrative Policies - policies maintained by administrative departments

And so we might further describe the policy manual as : 

A. Clinical Policies - Organizational policies maintained by clinical departments

  1. Nursing Policies - Clinical Policies maintained by the Nursing Department
  2. Laboratory Policies - Clinical Policies maintained by the Laboratory Department
  3. Pharmacy Policies - Clinical Policies maintained by the Pharmacy Department
  4. Radiology Policies - Clinical Policies maintained by the Radiology Department
  5. Infection Control Policies - Clinical Policies maintained by the Infection Control
  6. ... and so on...
B. Administrative Policies - Organizational policies maintained by administrative departments

  1. Finance Policies - Administrative policies maintained by the Finance department
  2. Human Resource Policies - Administrative policies maintained by the Human Resources department
  3. Safety Policies - Administrative policies maintained by Safety department
  4. Education Policies - Administrative Policies maintained by the Education Department
And each of these policies, both clinical and administrative, could apply to physicians if the physicians are one of the secondary stakeholders in the policy. This now helps us [DRAFT] some answers to some common policy questions : 

  • Q : "What exactly is a clinical policy?" - A : It's an organizational standard that is maintained by a clinical department and listed in the clinical section of the policy manual.
  • Q : "What exactly is a nursing policy?" - A : It's a clinical policy maintained by the nursing department.
  • Q : "Do doctors have to honor nursing policies?" A : If physicians are a secondary stakeholder in the policy, and the procedure was reviewed and vetted by physician leadership, the answer is clear - absolutely, yes.
  • Q : "If there are nursing policies, why are there no physician policies?" A : Probably because of the definition of the primary stakeholder (aka policy author / owner) - E.g. "A person with the time, training, and expertise to create, maintain, and update the policy." While physicians may have expertise about evidence-based practice, they also cost a lot in salary, and generally don't have the time, training, or responsibility to create or update policies. As long as healthcare continues to see this function as a nursing-only responsibility, these policies will probably continue to be published in the chapter of nursing policies
  • Q : "What's about education policies? Are they clinical or administrative?" - A : They can be either, it doesn't matter so much about which section (clinical or administrative) they are found in. What really matters is that they create standards to ensure reliable education of all employees on important operational issues.
  • Q : "So do we really need to divide the policy manual into clinical and administrative policies? What good does this serve?" - A : I think many in healthcare have historically made this distinction because, in general, it's hard to be good at both, e.g. there are not many people who are good at both financial planning and treating pneumonia. The terms loosely describe a focus, with different skill sets that both require a long and different educational pathways. So using these terms may loosely help us plan for resources, such as the general hiring/training of staff. But it's still important to note that these terms are somewhat vague, and may also create unnecessary divisions and confusion when it comes to shared decision-making across the organization
  • Q : "So if I want to write a policy, how do I do it?" A: It probably makes sense to first identify the standard (policy), and the steps you will use to accomplish it (procedure). Once you have the procedure written, it should help you figure out all of the stakeholders involved - Nursing, physician, pharmacy, lab, education, HR, housekeeping, finance, etc. Once you have all of the stakeholders identified, then you'll need to figure out who will be the primary stakeholder, responsible for getting all of the secondary stakeholders together, talking about the policy, and securing their buy-in, working out the details, getting it approved, and then finally, publishing it in your chapter of the policy manual so that you will revisit it regularly and make sure it's still meeting your needs.
Please remember, this is all just an educational discussion, and since I'm not a lawyer, the [DRAFT] answers I've offered above depend largely on your organization's willingness to adopt some of the [DRAFT] definitions and processes I've offered in this post. Your mileage may vary considerably, and so before making any changes, changing any definitions, or answering these questions in your own organization - Please make sure to discuss with your senior leadership and review these definitions with your own legal and clinical informatics teams, to make sure they make sense to your organization, before you consider  formally adopting them.

A big special thank you to mentor and quality guru Dominick Lepore, MS CTRS for sharing every lesson learned.

Have any thoughts or comments you would like to contribute? Feel free to respond in the box below. 

Saturday, September 9, 2017

My recollections of 9/11/01

Hi all,

Just taking a brief break from my routine posts about clinical informatics, to help repost a story about my experience on 9/11/01. It was originally posted on an old web server at  http://www.westnet.com/~ds/wtc.html but since that server is no longer functioning, I wanted to move it somewhere else, until I can find a better home for it.

I started writing down the story below on 9/14/01 (the weekend after 9/11), and finished it about 9/21/01. I quickly wrote everything I could remember, because I knew that one day I would want to remember. Since the original recording, I've made a few edits, usually when I found a new picture or had to correct something (such as the photographer from our site), but otherwise, the story is largely intact from the original version. There are some edits of this story archived in the 9/11 historical record.

Sixteen years later, I'm amazed at the deep emotions New Yorkers still feel about this day. It's just as heartbreaking today, to learn of the people who lost their loved ones, as it was combing through the missing persons flyers posted on the walls of the Grand Central and Times Square stations back on 9/11/2001. I'm so thankful to have worked with FDNY, NYPD, and many other medical professionals who all showed their best on this day. I'm only sad that it takes this kind of senseless tragedy to be able to see the best of human cooperation and compassion.

Finally - Some of the links in the story no longer reference the original pieces, but I left them (for now) just to maintain the history of the piece. If I can find the time, will see if I can dig up the original materials and see what I can do to fix them. 

Thank you for allowing me to repost this story, and I promise my next post will return to my usual musings on Health IT and clinical informatics.

- Dirk 

------- ORIGINAL POST -------

My recollections of September 11th, 2001 : The World Trade Center Triage and Disaster Response 
(An attempt to document the 9/11 triage effort on Greenwich and North Moore)
Robert “Dirk” Stanley
Then : 3rd year Medical Student, St. George’s University
Now : Attending physician / Hospitalist, Northampton, MA
Email me : DlRKSTANLEY@GMAlL,COM

 
(ON LEFT : L-to-R : My cousin Peter, his son Simon, and myself, during a visit to Liberty Island – June 8th, 2001)
(ON RIGHT : A picture I snapped taking the Q-train over the Manhattan Bridge while going into Manhattan on September 9th, 2001)

-------------------------------------
UPDATED as of July. 1st, 2011
-------------------------------------
Notes :
(1) I typed this all and put it online for my own therapy, for historical purposes and in case anyone wanted information, not for any commercial or other purpose.
(2) I have updated this page with some pictures from 9/11 which were obtained from public 9/11 photo web pages. If anyone owns the rights to these photos, please let me know and I will gladly remove them.
(3) The photographer for our actual site has finally been found - Thank you Mark Casey for helping document our triage effort. J
-------------------------------------

Some other people’s descriptions, who were at our site :

-------------------------------------
Folks who I know were at our site :
 (If anyone knows any more please drop me an email!)


Robert Cartwright, PA-C
Scott Caruthers
Paris Datillo, RN
Mark Casey, RN, AP Photographer
Eve Dubowy, CSW
Lieutenant Tom Eppinger, FDNY
Beth Fertig, Reporter for NPR Radio
Scott Fleck, PA Student
Matthew Modine
Richard Gins, CSW
David Hostler, PhD EMT-P
Matthew Klam, Writer/Reporter
Marianne McCune, Reporter for NPR Radio
Rev. Paul Olssen, Minister at Christ & St. Steven’s Church
Joseph Ornato, MD FACC FACEP
Robert Dirk Stanley, MS III


On September 11th, 2001, I was a third-year medical student working at Brooklyn Hospital, only a block from the corner of Flatbush and DeKalb avenues. I had just started my six-week pediatric rotation the day before.

Our morning started around 9:00am with the pediatric morning meeting and case presentation. Right before the meeting started, I remember someone briefly mentioned, "Hey, did you hear there was an explosion at the World Trade Center?". Having been in NY for the 1993 bombing, I guess I realized the potential for a disastrous terrorist attack, but the more likely rationalization (before 9/11) was that an air conditioner exploded or something small. PERHAPS a small plane flew into the WTC. But it barely seemed worthy of attention, and we all returned to our meeting's agenda.

When the meeting finished at about 9:45, I started to walk out of the conference room when one of my classmates ran through the hall saying, "Oh my god, did you hear? One of the Twin Towers fell!"

I could hardly believe it -- It seemed SO impossible. Falling? You've got to be kidding me. This isn't some movie.

However, I have a very close friend Dave who actually worked in the WTC. (He started working on the 56th floor of Tower 1 about three weeks before.) At that point, starting to believe one of the towers might have actually fallen, I suddenly started to really worry. I could feel my heart racing.

I ran upstairs to the Nursery (where I was that week) to check out the TV (good for late night nursing), and to find out what was going on. The TV was on and all of the nurses were standing around it, looking on in disbelief. A PA student I was rotating with, Scott Fleck, followed me as I ran into the room.

On the TV, all I saw was one tower still standing, burning, and the other collapsed. Suddenly, all I could think about is my best friend Dave. He just started his job there about three weeks ago. Which tower was he in? What floor was he on, again? I started to completely panic. I was really worried that he was in the building.

I started to react in a strange way, kind of a cross between crying and hyperventilating. I picked up the phone and called his apartment - Nobody was there. I called his dad. I left him a message, asking him to call my cell phone if he knew Dave was OK. I called my own parents, asking them to find out if Dave was OK, and to call me as soon as they heard anything. Nobody was home.

I must have looked awful at that point, because Scott the PA and the nurses in the unit started to try to calm me down. They were saying things like, "Calm down, which building was he in? Maybe he was in the other building?" I didn't know.

I started to think, "Yeah, maybe he *is* still in the standing building", when suddenly, I watched on TV as the second tower went down, the newscaster screaming "OH MY GOD, THE SECOND TOWER IS FALLING!!"

At that point, I lost all composure.

It really sank in that the WTC had actually fallen. It wasn’t in the skyline anymore. The magnitude of such an event was enormous, and I guess I realized the nursery was the last place I wanted to be. Having five years of experience doing EMS up in Westchester, I guess it kind of came naturally to me to tell the nurses, "I think they might need us downstairs", and I left (with Scott in tow) to go down to the ER.

Scott and I rode the elevator down to the basement, where the Brooklyn Hospital ER is located. I walked through the ER once. All I saw was chaos. Attendings were ripping up big pieces of cardboard to be used as signs to organize the patient flow. Nurses were rolling stretchers down the hall. There were a few patients covered with dust from head to toe, with non-rebreathing masks on, sitting on stretchers. I stopped for a moment, and talked to one of the ER residents. She gave me a quick run-down of what she had seen on the news at that point. Loosely, it went something like this : "They hijacked several jets, they also hit the Pentagon. The news was showing footage of people jumping from the buildings, but now they're not showing it anymore, I guess it's too distasteful. And I heard that Bush shot down a jet in Pennsylvania. The press said he didn't, but you know the government wouldn't admit to that." (Note : This was her opinion, not mine, but it does show how hard it is to get the facts in a moment of chaos.)

I walked out to the ambulance staging area (again with Scott in tow), and all I saw were thousands of people walking up Flatbush Avenue. Some were completely covered in dust. Lots were crying. I realized this was not a joke, this was not a test, this was really happening. And again, all I could think about was my best friend Dave. Not being able to imagine anyone surviving that, and knowing that he’s usually early to show up for work, I actually had the full suspension of belief that he had died.

At this point, the best way to describe my emotion was a mix of helplessness, anger, and sadness. I was crying uncontrollably. One of the residents (Mike Lynette) came up to me and suggested I sit down and relax. I didn't feel comfortable with that idea. One of my classmates, Nazli, came up to me and let me cry on her shoulder for a moment.

Between my sobs I tried to explain why I was freaking out. "My best friend works in the Trade Center!" Somehow it seemed really silly that I should be freaking out that much about a ‘best friend’, but since I have so little family in America, my best friend IS my family. Dave is like an adopted brother to me. So when the security guard came up to me and tried to get me to calm down, I told him, "My brother works in the World Trade Center!"  He seemed to understand my anguish better.

So, standing in the small ambulance staging area at Brooklyn Hospital, completely surrounded by chaos and people crying and sirens and horns honking and cars unable to move... I decided to take control of my situation. I remember thinking to myself, "If something happened to Dave, I'm at least going to fight whatever it was that did all this.”

With that, I started to walk in the opposite direction of the mass of people. Scott the PA asked me where I was going. I told him, "I'm going down there, they're going to need help." Scott looked like he wanted to follow me, but he looked nervous. "Scott, seriously, stay here," I told him, but he seemed to cautiously follow me instead. "Do you think we'll get in trouble for leaving the hospital?" he asked. "Well, the World Trade Center just collapsed, sometimes there are bigger things to worry about than getting in trouble."

We started to walk down Flatbush Avenue, towards Junior's, when we ran into another man walking in our direction (opposite the crowd). He introduced himself as Robert Cartwright, a PA who works at Brooklyn Hospital in the ENT department. Robert seemed to be answering the same call as we were. His attitude was much more in line with my thinking at that point, saying stuff like, "I don't know, but I'm going down there to help." We decided to join him and walked down to Juniors, then turned right to walk towards the Manhattan Bridge.

With police holding all non-emergency vehicles at a standstill, Flatbush Avenue was in complete gridlock. The road going over the Manhattan bridge was basically empty to vehicles, but was moderately congested with people running away from Manhattan. I remember seeing a few odd things -- One man dragging his suitcase. Another man rolling some kind of a clothes rack.

(People coming into Brooklyn from Manhattan, over the Manhattan Bridge. Photographer unknown.)

The three of us walked up to the foot of the Manhattan Bridge, where there were police cars blocking the roadway so that only emergency vehicles and personnel could get through.

We waited there for a minute, looking at the large plume of smoke coming from the southern tip of Manhattan, and all took a moment to think twice before crossing the bridge going over. While we waited there, we were joined by another doctor who identified himself as a radiologist. I think he said he worked at Mt. Sinai or somewhere. He joined us as we stood there, listening to the sirens, and watching the occasional emergency vehicle race over the bridge at breakneck speeds.

We identified ourselves to the police standing at the entrance to the bridge, when they told us, "You guys are doctors? We have a pregnant lady in the building over here!"

I'm not sure what the building was, in retrospect. It looked like some kind of a grey, concrete-and-marble, federal/school-type of building, just a few feet south of the Manhattan Bridge. All I know is that she was up on the second floor, and the building had some kind of a nurse/infirmary that we were able to get some makeshift supplies from. We first evaluated our pregnant mother in front of us. The radiologist put on gloves and reassured the mother that she was going to be OK. He then quickly examined her, while the rest of us prepared for an impending delivery by opening up boxes of maxi-pads and paper towels.

Fortunately, after inspecting the patient, the radiologist reported that she still had time before she was going to deliver. Great. Sensing a need for supplies (all I had was my stethoscope), we packed a plastic bag full of maxi-pads, tape, and as many gloves as we could fit, and brought it along.

We carried our mother down to the front of the building, and reassured her. Someone with an SUV/van-type mobile drove up and volunteered to take her. We put her in the SUV with the nurse from the building and directed them to take her to TBH as soon as possible. I remember there being a moment where I worried if she would get to Brooklyn in time, but then I looked to my left and saw the enormous plume of smoke on the other side of the East River, and thought, "She’s only a few blocks away, has police escort, and this is not a normal situation… I think we might be needed down there."

(Note : I was never able to figure out who the mother was. I didn't remember her name, and when I did my rotation in OB/GYN a month or so later, none of the residents were sure who she was. I have since forgotten her name.)

So the four of us walked up to the foot of the bridge again. We waited there with the officers standing guard, and asked if any vehicles were crossing over. "Well, yeah, they're going over, but I don't know when the next one is coming." We waited there watching the flow of people over the bridge ebb, and when no vehicles came for four or five minutes, we figured we would hoof it. With the policeman's permission, we started walking over the Manhattan Bridge towards Canal Street in Manhattan.

As we walked over the bridge, I was in full EMS-mode. Ray Thompson, my EMT instructor from way back when, always talked about the need to be resourceful when times are tough. The example Ray always talked about was using a car visor as a splint, in a pinch. So as we walked over the bridge, I found some long steel bolts, about 18 inches long, that were lying on the side of the roadway, apparently left there by workers who were repairing the bridge. I thought to myself, "What great splints these could make!" as I grabbed two of them and kept walking.

The mood was a little strange. There was the "Do you have a wife and kids?"-type of talk going on among us, since now the picture was emerging more vividly than ever. But we kept walking.

(View of the Brooklyn Bridge and downtown Manhattan, while walking over the Manhattan Bridge. Photographer unknown.)

Around halfway over the bridge, an emergency vehicle pulled over, a red Buick-Regal-type car with a emergency flasher stuck onto the dashboard. The woman inside picked us up. I don't remember what she said her role was, but I remember it being sort of a peripheral role, like, "Police Safety Officer" or something. Nonetheless, she was in as much of a rush as we were in, and we were plenty happy to get the ride over the second half of the bridge.

The radiologist at this point told us, "Listen, I'm not sure what use I'm going to be to you guys, I think I would be of better use up at the Mt. Sinai".

So when we hit the gridlock awaiting us at the other end of the bridge (Canal Street was being closed and was full of emergency vehicles and other cars stuck in the confusion), we exited the car. The radiologist headed north to his hospital, and Scott, Robert, and I walked south on Church Street.

As we walked south, we were still fighting against a big crowd of people running north. At this point, not too many were completely covered with dust, as we saw in the earlier crowd. They were still crying and anxious, but there didn't seem to be anybody to treat.

We walked about three blocks south, and stopped in a Korean Grocery. The sun was actually pretty hot that day, and Scott was complaining of the heat. I think Robert also suggested that we get some water, not only for us, but for emergency purposes. We walked into the grocer and asked for water. I wasn't sure if we were supposed to pay for it, or not. I hoped that they didn't ask us for money, since none of us really had any. Robert came up with some cash, which we offered, but the grocer seemed to understand this was not a normal circumstance. Thankfully, when they saw us in our scrubs, and Robert in his white coat, they gave us several bottles of Evian for free. We took a few sips and packed the rest into our plastic bag / makeshift first-aid kit, and headed further south.

As we walked another three or four blocks south, the police had set up barricades, preventing people from trying to walk south. They let us through without a question, I guess because they figured we were medical people going down to help.

(Folks walking north, at the foot of the Brooklyn Bridge. Photographer unknown.)

At one point, the sky started to get darker and there was this fine ash/dust falling all over. We actually stopped three Hispanic ladies who were walking out of the mess, and asked them for their masks, since we were walking into the mess. They happily gave us their masks and headed north while we walked south.

We walked only a few blocks further south, the sky getting darker, and the dust getting so bad that I had to squint to keep it out of my eyes. The space between my mask and my face became very apparent, since I suddenly tasted the dust. It felt and tasted like a cold, gritty material. I figured it was a mixture of concrete and maybe very finely ground glass and asbestos. Scott started to get nervous again, and Robert and I offered him the opportunity to go back, but he followed along.

(Views of the streets approaching Fulton. Photographer unknown.)

The street followed down until we hit Fulton Street. Robert seemed excited to find Fulton street, since he told us he had worked down in the neighborhood before and knew the area. I remember Fulton was down near the WTC, but having never worked in downtown Manhattan, I didn't realize it was actually the street that crossed over the north part of the WTC complex. For some reason, I kept thinking of the Fulton Fish market, and how my high school visited the fish market back in 1988.

(My crude sketch of turning down Fulton, as I presented it at the SAR City EMS/Rescue Conference in Sept. 2002)

As we turned onto Fulton, the scene changed dramatically. Now the dust was very bad. Breathing became very difficult, even with a mask. It no longer seemed like daytime - When I play this part back in my mind, it seems like it was midnight. Only later when I stopped to really think about it did I realize it was daytime.

To give you an idea of the mood at this point, I can only describe it as being similar to the final scenes in the movie "Titanic", when Leonardo DiCaprio and Kate Winslett are below deck as the ship is sinking, and they see the random person running off with their suitcase, and another person running with their child and a bag of clothes. This was very similar in feeling. I remember seeing a random businessman trying to make his way home, and a person carrying a plastic bag as they walked north. There was also the strange feeling that something worse could actually still happen. I didn’t know if we should be expecting more, like an atomic blast, but again I figured it was probably over, and if not, this is how I wanted to spend my last moments – Trying to help someone.

The roads were strangely quiet. Not a single sound. Stores were all closed. Those that had metal grating in front had closed them in a hurry. Some stores had messy makeshift signs saying "CLOSED TODAY" hung in front of them. There was a small group of 2-3 teenagers looking nervous as they stood in front of a broken storefront, looking inside the store. I thought they might be looting, which pissed me off. I walked up to them to try to figure out what they were trying to steal, since the store looked like some kind of a jewelry store, and briefly said, "You guys aren't seriously looting, are you?” but then they looked back at me, and I realized that if an altercation were to happen, the police wouldn't be there to investigate. So I left them alone, and the three of us continued walking up Fulton.

And in the midst of all of the doom and despair was suddenly this young woman, in her 20s, who was standing on a street corner all by herself. She had a shopping cart full of bottled water and paper cups. She was offering it to anyone who walked by, to help wash out their eyes. I thought it was peculiar that she had paper cups -- It seemed like such a nicety in the middle of all of this, an unexpected sign of civilization amidst the chaos, kind of like making sure your suit is pressed before you're going down in the Titanic. But she stood there, alone, offering it to the few people who were still there.

To this day, I have no idea who that woman was, but I would like to thank her. If anyone knows who she is, please contact me. I think about her a lot.

We explained that we were going down to the site to look for people, and she immediately gave us a gallon of water to carry along. After exchanging brief words, we continued on. I still feel kind of bad that we left her there. I'm not sure what she had seen an hour or two earlier, but clearly she was as determined as we were to try to have SOME control over this chaos.

The dust was pretty thick at this point. I remember looking down and noticing it was up to my ankles. Suddenly, there were women's shoes all over the street. I was trying to figure out where they came from. Morbidly, I thought they might have been from the passengers in one of the jets, but more likely they were women's shoes that were quickly discarded as people fled the scene quickly.

I also remember tripping several times over various things. Metal beams lying in the street. Papers from people's desks were blowing all over. I picked up one - I don't remember the details, but I remember it was a double-spaced legal document describing part of some lawsuit. I thought for a moment and wondered if the lawsuit was still going to happen after this.

Once, while tripping over debris, I dropped my glasses in the dust. They completely disappeared in the 4-5 inches of dust that laid on the street like snow. I frantically tried to blow the dust away, only to get a mouthful of the stuff back in my face, but fortunately I was able to feel for them and get them out.

We walked on, looking for anyone, any cries for help, when suddenly we came upon what I call "THE STUMP". The Stump was the remaining pile of burning debris that sat there at the site of the former Twin Towers. It burned intensely. Not just a crackling-type fire, but a real blow-furnace type fire, like when they are blowing glass and put it into that inferno to melt it. The WTC was right in front of us, the pile several stories high, burning intensely. And despite the bright, shooting flames, it still felt like nighttime. The dust was so thick that the light from the flames barely reached us.

(My crude computer graphic demonstrating what I remember seeing, when I replay it in my head – Smoke and some intense fires burning.
 Note that this appeared different than many of the news shots because we approached from the east,
 which was a really not a good idea since the wind was blowing all of the smoke and ash eastward that day.
In retrospect, it would have been better and safer to walk around and approach from the west.)

At that point, we realized we couldn't go straight, so we walked right past WTC building 7 and turned right to head north. The air seemed to get a little lighter, and firemen were rushing down to the rubble, carrying hoses.

Another interesting note : There were several cars parked along the side streets that were completely crushed by debris, but there were also several that were burned. I was trying to figure out how a car would be set on fire. Did a fireball race down one of the canyons? One of the cars that was crushed and burning had it's alarm going, amazingly. "God will someone shut off that alarm? I hate those car alarms!" was overheard. It shows the morbid sense of humor the firefighters were having at that point.

We walked further north, asking the firemen and police repeatedly if there was a triage station set up. Nobody seemed to know. We trudged on, covered in dust and still tasting concrete, and kept asking if anyone knew of a triage center. None of the police or firemen at that point had a clue. My guess is their radios were jammed with transmissions from other officers trying to coordinate bigger things.

So we kept walking around. At one point we were picked up by a Hatzollah Ambulance that was partly crushed, its front windshield cracked, but it was still driveable. We jumped in and joined several orthodox EMTs who were also looking for where to go. They were a very nice bunch. Apparently, they were right under the overpass that led to the WTC, when it collapsed around them, and their ambulance got stuck under part of the overpass. Rather than just sit there helplessly, though, they managed to wedge it out from the overpass, and kept driving around, looking for where to go.

Their ambulance got stuck behind a bunch of other emergency vehicles, so we stepped out (leaving our steel rod splints in their ambulance), and walked around again. Still, we kept asking the firemen and policemen if anything had been organized. Nobody seemed to know. Finally, one fireman said, "Well, they're supposed to set something up over on Greenwich and North Moore, but nobody is here yet."

(Left :Again, a crude sketch I used to try to show why the corners of Greenwich and North Moore were ideal for triage.)
(Right : An actual photo of the Traveller’s Insurance Umbrella at the site. Photographer unknown.)

The corner of Greenwich and North Moore, 388 Greenwich Street, is the site of the Citicorp building. It was an ideal place for a triage unit. It has a decent sized courtyard, perfect for setting up the triage area. It has a good stretch of street in front of it, perfect for setting up an ambulance staging area. And it has a big red metal umbrella -- A piece of modern art -- But the big umbrella made it feel safe, and was a good place to tell people to meet when nobody knew the area.

The only problem was that there were a bunch of EMS workers, paramedics, doctors, and other volunteers standing around, but still nobody to organize it.

We all stood there for about a minute, waiting for updates of what we should do. At some point someone asked if we were supposed to be setting up a triage site here, and someone else yelled out, "Yeah, but FDNY isn't here yet."

And then suddenly I felt the need to assume some responsibility. It seemed ridiculous to wait. We should start acting now. We didn't know who our patients would be, or how many we would have, but the World Trade Center has just fallen, and we can't just stand around and wait.

So suddenly the leader inside me came out, and I started barking out orders and assuming control. I don't like to toot my own horn, so let me just say that it was very Forrest Gump-ish. I was just the right person with the right training in the right place at the right time. I don't think there was anything to it, really, it just needed to be done. So I started barking out orders and began to organize the triage effort there on the corners of Greenwich and North Moore.

I can't remember exactly how I responded to the guy saying that we should wait for FDNY to show up, but these are a few of the phrases I do remember shouting:

"No way, hold on, we're not going to wait. Okay, everyone, LISTEN UP! We're here at a time of a national disaster, our World Trade Center has just fallen. We don't have much information right now about who or how many need to be treated, but we can't just stand around. We need to set this up and I need your cooperation! I want all EMTs and Paramedics to gather over here. Doctors and nurses gather under the umbrella. I want all ambulance drivers over here!" (Pointing to street corner for ambulances to park.)

(In front of the group of ambulance drivers) : "I want all of the ambulances lined up over here, leave your keys IN THE AMBULANCE, and make sure they're off, I don't want any ambulances with dead batteries, and PLEASE STAY NEAR YOUR AMBULANCE, we need you to be available immediately."

(In front of the group of doctors / nurses) : "Okay, I need people to gather by whatever your specialty is, if you're a surgeon, stick with the other surgeons, if you're a pediatrician, stick with other pediatricians. Please identify yourselves by your specialties. I also need someone to be responsible for organizing the doctors."

(In front of the group of paramedics / EMTs) : "Okay, I need you guys to be our front line of defense, when patients show up here, you have to be the first to look at them and decide what to do with them. If there is something bleeding, put a gloved finger on it. Do whatever your skills are, but you're going to be our front line.”

(In front of the group of volunteers) : "I need two people to be in charge of organizing the supplies that are coming in. Your job is going to be to organize it and keep it safe. I'll show you what some of the basic tools are, but you have to provide them to any worker who asks for them. I also need one of you to be in charge of organizing volunteers across the street in front of the Ryder sign. Take all of these people, organize them across the street, and try to keep track of who can do what. If there are any CPR-trained people, keep them in a special area."

(To the police) : "Can we get the crowd back here? We're going to set up a triage site here. Do you have any yellow tape?"

(In front of the doctors who identified themselves as emergency physicians) : "Okay, we need to set up the triage areas, I need one person to be responsible for each area, and one person responsible for directing patients to the areas."

So, basically, I just started to delegate. And I guess people listened to me. Suddenly I found people coming up to me asking me what to do, and soon I found myself setting up the site. I guess at that point Robert was put in charge of organizing our first line of triage. Meanwhile, Scott continued to complain. I'm not sure if he was bored or nervous, but he tagged along, helping where he was asked.

We had put about an hour of work into organizing our site, and the building manager from the building had just stepped over to tell me they were making the entire building available for the triage effort, when suddenly I saw a group of very official-looking fire officials walk up to our site, which had by this time become semi-organized. At least people were split into the proper triage areas, we had ambulances lining up, and people were assigned specific tasks. The police had roped off the area.

One of the FDNY officials was Lieutenant Top Eppinger, who strangely enough is a spitting image of my old EMT instructor's son. I actually thought it was him at first.

Lt. Eppinger stepped into our crowd and asked, "Who's in control here?” Having worked with firemen before when I did EMS up in Westchester, I know better than to try to step on their territory, so I told him, "I'm not in control, but I'm trying to organize things so far!"

think he appreciated that. At that point, FDNY was able to come in and bring the heavy equipment. They brought in a MERV - Kind of a mobile operating room / MASH unit on a bus. We decided to park it out in front of the street, and Tom decided to move our site more towards the middle of the block.

At that point, I think Tom appreciated the work that had already been done, so he appointed me in charge of the medical services at the site. He would take over the fire / organizational stuff, and I would be in charge of all things medical : assigning doctors to teams, getting and organizing equipment, tracking patients, and making sure patients were receiving the care they needed. I even got a little red fire marshal hat that I wore the rest of the day. (Tom said I had to wear it so he could find me when he needed to.)

So during the next three hours Tom and I managed to build our little triage site into a full-scale, professional emergency triage site worthy of a disaster the size and scale of the WTC attack. We had a surgical bus with several surgeons. Paris Datillo, a nurse at Methodist hospital ER, was assigned to the bus to organize materials and assist the surgeons. Paris responded to the events of the day in the most professional and efficient manner, and kept totally calm. Paris and I kept reassuring each other that things were going to be okay, despite the chaos.

And so our site was finally set up. We had doctors from practically every medical field - Pediatrics, OB/GYN, Radiology, Surgery, Neurology, Internal Medicine, Emergency Medicine, Cardiology, Psychiatry, and Family Practice. We also had nurses from every specialty I can think of.

We also had an entire team of counselors, psychiatrists, priests, ministers, and chaplains who were organizing to provide emotional support to our patients. I was really impressed with the dedication of the group, led by Richard Gins. They banded together, bonded quickly, and became a team much faster than the medical groups did. They waited towards the back of the site, setting up some of the chairs on the grassy courtyard as a makeshift counseling center.

The only problem was, as the New York Times reporter Matthew Klam said in his description, “we needed bodies.” That is, we weren’t getting a whole lot of patients coming our way. And this led to frustration.

(One of our medical teams assigned to triage. (c) 2001 Mark Casey, AP Photographer and former ICU Nurse, center.)

Although we had treated about 10 patients by that time, mostly for minor injuries and chest pain, it didn’t seem like enough, and people were getting antsy. Of course, everyone was so anxious that the only way they could feel any control of the situation that day was to help someone. But without people there to help, it left people feeling demoralized.

The first sign of frustration was seen when the surgeons seemed to run off, leaving Paris in the MERV by herself. One of the last surgeons I talked to said something like, “Nothing’s happening here, I’m getting out of here.” With that, he left us.

Suddenly, my cell phone managed to ring. This was a surprise, since service had been very poor. I had heard the antenna for most cell phones was on the World Trade Center when it fell, so it seemed surprising that it was suddenly working. My parents called. I told them I was okay, and they told me that my friend Dave had called in to say he was okay. Dave called me a minute or two later. I told him that I came down to Ground Zero because I thought he was in the building, and warned him never to scare me like that again. He asked me, if I thought he was in the building, what did I think I could do to help him at that point? I pondered that for a minute before hanging up on him. Looking back, I guess it was the only way I could feel any control over the thought of having lost him as a friend.

(Our triage unit and myself (in blue scrubs and red hat) working on a
patient on the corner of Greenwich and North Moore – 9/11/01, (c) 2001 Mark Casey.)

As the afternoon wore on, and people were getting tired, Marianne McCune, a reporter from NPR, came by our site. She wanted to give a report live, but her cell phone had run out of power. She borrowed mine and was able to give her report. After making the call and being on the air live, she interviewed me and recorded the interview on her tape recorder, as I described the layout of the triage site. Her report was later aired (I had friends in North Carolina and Massachusetts tell me they heard me), and I recently found it on the WNYC web site, in RealAudio.

Although people were getting frustrated without more patients, there was actually a moment of excitement mixed with panic when 7 World Trade Center seemed to buckle, and finally collapsed as we all stood by on Greenwich Avenue and watched. I didn’t realize how close we were, but when it collapsed, the smoke came up the canyon towards our site, setting off a stampede of scared people. The stampede almost ran over everyone in our site, while I yelled “SLOW DOWN!! DO NOT PANIC!!” at the top of my lungs, leaving my voice sore until the next day. You can hear me screaming on the NPR report, right after my interview gets cut off. It was odd to watch 7WTC fall down. It almost seemed unimpressive, compared to the destruction that was already there, but a new plume of smoke certainly scared people. I understand some people in our counseling group were physically injured as the crowd broke through the yellow tape and rushed our triage site.

And yet, people were getting more frustrated. Tom, the lieutenant from FDNY, told me he was concerned that people would start leaving, and we would suddenly be put into action with half of our group missing. So we decided we would make a real effort to keep up morale.

Fortunately, Matthew Modine, the actor and star of movies like Full Metal JacketGross Anatomy, and As The Band Played On, stopped by. He tied a piece of yellow police tape around his arm (the sign that we were using for “people who belonged on the site”) and joined us. Mr. Modine was very nice. I talked to him and thanked him for coming down, and he said something to the effect of “whatever I can do to help support you guys, I’m here.” I actually think it helped people from getting frustrated. At least if there is a celebrity at your site, people think it’s worth sticking around for.

(Matthew Modine, taken from a fan site. Photographer unknown,
but I’m guessing it’s from a movie.
Please let me know if it needs to be removed.)

(I was also able to tell Mr. Modine that the movie As The Band Played On was one of the reasons I became an epidemiologist and ultimately went to medical school. He told me he was flattered to know one of his movies had made a positive impression in someone. Odd to have that kind of a conversation amidst all of the chaos and confusion, but he was very nice to stop by and hang around for a while.)

The group of volunteers across the street in front of the Ryder sign had now swollen to hundreds. People were coming up to me constantly, asking how they could help. A few people stand out in my mind. One man could barely speak English but said “I am a metal cutter, how can I help?” Another man told me he was a rescue worker in Israel and wanted to help. Another man told me he was from Poland but was a construction worker and wanted to help dig through the rubble. I had to focus on keeping up the medical effort of our triage site, so I sent them all over to the corner under the Ryder sign.

As the evening started to set in, Paris and I kept joking with each other, making a genuine effort to keep up morale at our site and keep people interested. Unfortunately, darkness started to set in. We had set up emergency lighting so that we could keep our triage site running well into the next day, but at around 8:30pm the decision came from Lieutenant Eppinger that FDNY had ordered our site to close.

(A physician waiting at our site, just before closing and consolidating
 the triage effort at the Chelsea Piers. (c) 2001 Mark Casey.)

Our total patient count? 19 patients. We treated a few patients with chest pain and respiratory distress, but most were patients with minor bruises and cuts, and a few came to us just to have the ashes washed out of their eyes. Even our fearless counseling team was demoralized, having been unable to offer assistance to any of the firemen who came to our site with stories of having lost so many of their co-workers.

At that point, I informed the various medical team leaders that the site was officially closing up. I asked people to stay to help put the equipment into ambulances so that it could be brought to St. Vincent’s hospital for further use, but of course, people generally don’t like to clean up after their mess. So I ended up cleaning up the site with a few other key leaders, until about 10:00pm. And around that time, I started to head uptown with Robert Cartwright, Scott, and Scott Caruthers, one of the ministers in our fearless counseling group.

As we walked north on Greenwich, now dark and empty, we passed several fire trucks loaded with firemen. The firemen were covered with the soot and ash from the collapse, and were collecting their hoses and fixing some of their gear. Everyone was so tired from the day we had all just had. Although our medical team was completely exhausted, I knew their day was far from over. I gave them all a tired smile and said thanks to them, as we walked on, looking for a subway. It was strangely quiet for downtown Manhattan.

The Canal Street subway station was closed, but we walked further north until we found an open station. MTA was not even collecting fares – The subways were running for free, to allow people to get where they needed. The N and R trains were not running, since they run right through Cortland Street and the WTC site, but we managed to find a Q train back to Brooklyn.

I said goodbye to everyone, as we all split up, and finally found my way back to Bay Ridge, where I picked up my cell phone and called a few friends to tell them I was still alive and well. Most of my friends weren’t home, but I left messages telling them that I was okay. When I came home, the email awaiting me was full of ominous-sounding messages saying things like, “Uh, we’re watching what’s going on in New York, are you okay? Please send us a letter so we know you’re okay.”

There’s really not a way to explain how that day has affected me. I know it’s different for every New Yorker. Many families senselessly lost loved ones. Some raced in to help rescue people and to put out fires. Still others have lost their jobs, their apartments, and their livelihood. There are too many things to be said about that day, and I don’t think any one person can ever really get the full picture. I think a lot of us keep trying to understand it by asking everyone we know what happened, where they were and what they were doing that day. And every person’s experience helps put another piece of the puzzle in place, to try to make sense of what happened. But this puzzle is too big -- Nobody will ever really understand all of the pieces of the puzzle. The best you can do is to ask the people who lived through September 11th, or the people who have lived through any war or senseless tragedy, and let their accounts give us all a little more insight into humanity.


1/1/2003 UPDATE :

(The makeshift memorial by St. Paul’s Chapel, right next to Ground Zero. Taken by me around August 2002.)

A year has passed since 2001. This year, on 9/11/02, I oddly found myself becoming a mini-celebrity (don’t worry my 15 minutes are long up!) as I was featured on an ABC News segment (filmed by KABC in Los Angeles when they flew over to NY) that appeared on their 11PM news. So far two people have told me they also saw the segment on Good Morning America. I’m working on getting a copy of the segment to put on this page, but so far I don’t have an MPG of it. After the TV segment, I was invited to speak at an EMS conference in San Bernardino County, California -- More specifically, Barstow CA -- to discuss what it was like responding to a catastrophe of this magnitude. Fortunately, the media hoopla has since died down. J

I’m still proud of being a part of it, but it’s become a little strange. It’s so distant already. Ground Zero is cleaned up – The vendors are selling T-shirts next to St. Paul’s, tourists are flocking to the area, the Post has almost daily articles about “what they’re going to build there”… It’s been SO overdone in the press and the media. I feel like all of the exposure takes away from what really went on there that day. Although I guess it’s just human nature to be fascinated with such an event, and the networks are just responding to what their viewers want to see, the actual understanding of what happened that day has been so watered down and devalued.

I’m also upset when anything from 9/11 gets used as a tool to argue for going to war, or to treat people differently. I’m not that much of an idealist to say it’s not all warranted, and there probably are some security changes that we should have made a long time ago, but there are also a lot of changes that are excessive, and it bothers me to see people who weren’t there pointing to the twin towers to support their argument. I also think that since 9/11 there is excessive paranoia about foreigners and terrorism in general, but who knows? I could be overly confident that we won’t see something like this again.

If anyone really wants to know what it was like to be there that day, I can only offer this advice : I don’t think you can get it from just reading about 9/11, the WTC, and the Pentagon. I think you have to dig deeper into all of the conflicts of the world, including every battle and every world war. Anyone who has survived hatred or war can tell you what it felt like to see society turned upside-down.

Fortunately, when there was complete social breakdown in lower Manhattan that day, almost everyone standing responded with the best of humanity. I’m still so proud of the way everyone reacted to the event. It’s like there was an innate sense of humanity that rose to the surface of our city. It’s comforting to know that just beneath the surface of our everyday worries and arguments and fights and moral wrongdoings, lies something very beautiful that can spring up when the need arises. I hope I can offer these thoughts to anyone who feels like they’ve lost their faith in humanity.

As for the new buildings, I think it would be great to rebuild the old buildings, move them over so they’re not on the footprints, and maybe even make them ONE floor taller – Just to show our ability to heal from such an attack. But, I’m not on any committee to vote, so my opinion won’t count much, but I have faith that whatever gets built there will be distinctive and will honor those who lost their lives that day.

July 1st, 2004
Soon it will be three years that have gone by since THE 9/11. Saw Fahrenheit 911 a week ago, hard to believe how the world changed in such a short amount of time. Looking back, we all sort of knew it was coming - There was some discussion that day, on the streets around the fallen debris, about 'Do you think the world is going to be different tomorrow?', and of course, it is. Again, I'm not sure this is surprising, but what continues to amaze me is how a few angry people did so much damage. My heart still goes out to everyone who lost a loved one that day, or who had to see a broken New York City, or who missed seeing a broken city heal back stronger than ever before. Eagerly awaiting the memorial and new 'Freedom Tower', so I can have something to tell my grandchildren one day.

June 1st, 2005
Now just a distant memory, it's hard to believe that these event triggered the current war effort. It almost feels like the two are separate events, but of course, I keep reminding myself that the two are linked. Anyway, some exciting news appeared recently, I thought I would link to it. Two architects have come up with a plan to redesign the World Trade Center towers, with 2005 technology. Donald Trump recently supported it, and I really liked the idea, so I thought I would let people see the models and plan here.

Sept. 9th, 2006
Was just reading an article in the New York Times about 'who owns 9-11'. I think everyone owns it in some way - Who on the globe didn't experience it and wasn't traumatized by what we watched? At the same time, it still really upsets me when people use it to further their cause. And it bothers me when people compare it with other atrocities and other killings, as if one was worse than the other. Yes, perhaps it was one of the most dramatic things we've seen on American soil, but wars and senseless killing have sadly gone on throughout world history. Perhaps the lesson we can learn is about how to stop this from happening in the future - Preventing terrorism, solving political strife, building even safer buildings, and most of all, the hardest part, learning to stop hating each other. Unbelieveable that it's been five years now. Seems like a good year to reflect.

July, 2011
So we're approaching the 10 year anniversary of the attacks. At this point, it all seems so distant - I'm glad I wrote this page, or else I would have trouble remembering all of the details. I've managed to link the ABC news piece here on YouTube. (God my voice sounds reedy and thin in this interview - Trust me, that day I channeled someone else by putting on my "authority voice".) :) I've also related the story to a few people, gotten some emails from other people, and fortunately I recently identified the photographer for a few of the pictures - who it turns out was at our site. In the public discussions, there has been some controversy about the new construction at the site, the memorial, and of course the famous mosque controversy... Again, my sincerest hope is that the anniversary isn't used to divide people and grow hatred. I'm hoping to reunite with some of the other people at our site that day, just to pinch myself and make sure it wasn't all a crazy dream. Also I now have kids, so I'm hoping all of this will help me tell them the story of what happened to us all that one day back in 2001.

Thanks for taking the time to read my page.

- Dirk ;)