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When you imagine a large-scale disaster, you probably envision treating scores of injured patients. For ED nurses in New York City and Washington, DC, the opposite was true after the Sept. 11 terrorist attacks: There was a chilling silence as nurses waited for patients who never came.
Immediately after the terrorist attacks occurred, the well-practiced disaster plans of New York City EDs went into effect. Nurses who were stuck in roadblocks managed to find a way to work somehow and were ready to do whatever was needed to save lives. But after an initial rush of patients, EDs suddenly became eerily quiet. "Everyone looked at each other, but no one was saying anything. Finally I said what everyone was thinking: I think there are not many survivors,’" says Anna Chin, RN, an ED nurse at New York Presbyterian Hospital-Weill Cornell Medical Center.
As of press time, the total number of people missing was 4,979, with 393 confirmed dead. In New York, 75 hospitals treated more than 5,000 patients injured in the attacks. "We thought we would have at least 48 hours or 72 hours of patients coming in, and the truth gradually sunk in," she recalls. "It was very disheartening at that point."
Although most nurses interviewed by ED Nursing agreed that private or group counseling was beneficial, many admitted they had chosen not to attend. "That’s the nature of working in the ED. You want to appear as if you’re doing fine, but inside you’re all torn up. You don’t want to share it with your colleagues," says Chin. Chin says that "deep down" she knows she needs to go to a debriefing session. "I see the personalities of nurses changing, myself included. We are all very cranky and irritable," she says.
Here is how ED nurses coped after the attacks, along with strategies to consider when your facility treats victims of a disaster. (See "Checklist to revamp plan," in this issue.)
• Waiting was the worst part.
For several days, EDs in New York City and Washington, DC, were on high-alert status and expected to receive hundreds of patients at any moment. "It didn’t matter that we heard nothing encouraging. We were ever hopeful that in 10 minutes there would be 300 people to treat," says Marion Machedo, RN, nurse manager of the ED at Bellevue Hospital in New York City.
The ED at Saint Vincents Hospital treated more than 300 patients in the first four hours after the attack, reports Suzanne Pugh, RN, nurse manager. "The first wave of patients was followed by an extreme slowdown. After that, new arrivals were primarily rescue workers," she says. (See "Quotes from ED nurses on the front lines," in this issue.)
Waiting anxiously for survivors turned into the single biggest stress factor affecting staff, according to Pugh. "By early evening of the first day, we were beginning to realize what this meant: that there were not going to be many survivors," she says. "Over the following hours and days, this was proven true, as the last person pulled from the wreckage was early Wednesday morning."
The next hurdle for nurses was dealing with the multitudes of family and friends who descended upon the ED searching for their loved ones, says Pugh. The day of the attacks, an information table was set up in front of the ED with patient lists from several local hospitals. The table was manned by staff from the development office and volunteers who acted as "runners" between the fax machines and the table. "We faxed updated lists to each other that enabled us to check the whereabouts of known patients for their families," Pugh explains.
• Additional help was available to assist nurses in caring for emotional needs of patients.
When Chin treated a 34-year-old woman with chest pain who said she couldn’t sleep at night, she instinctively guessed it was a stress reaction from the terrorist attacks. "Then she told me that her neighbor didn’t come home from the World Trade Center," she says. "When she was here, she fell asleep. I think she felt safe because we were around her." The scenario illustrates the challenges of meeting the needs of patients after the tragedy. "We were all emotionally burnt out, and we also had patients depending on us for their mental health," says Chin, who arranged for a social worker to meet with the woman.
At Saint Vincents, social workers assisted ED nurses in dealing with the emotional needs of patients. "There were many rescue workers coming to the ED for treatment who also needed stress and crisis interventions," Machedo says.
• Staff took advantage of help offered by the community.
There were many individuals in the community who volunteered their services, including massage therapists who treated patients and family members 24 hours a day. A separate "stress relief" area was set up for staff to receive massage therapy, acupuncture, acupressure, and guided meditation. "Almost all members of the staff utilized at least one of these modalities," says Pugh. "The massages were particularly popular." Food and the ability to enjoy meals as a group was very important, says Pugh. "Volunteers coordinated food donations from various restaurants for staff and rescue workers, and leadership provided areas for staff to sit and eat together," she explains.
• Counseling was available, but not all nurses attended.
Many EDs posted schedules for debriefing sessions and offered individual and group counseling with no appointment needed. But because many nurses chose not to attend, it was important to monitor colleagues for signs of stress, says Laura Giles, RN, clinical nurse manager of the ED at Mount Sinai Medical Center in New York City. (See "Self-care tips to use," in this issue.) "If a colleague seemed stressed, someone would ask him or her, Do you need to take some time off? Do you want to switch shifts with me?’ Just reaching out to someone can be very helpful," she says.
When one ED nurse was acting out in frustration, Giles responded. "She was stomping around and carrying on, and I told her she really should go talk to someone," says Giles. "She said, I think you’re right, I think I will try and go.’ My message got through."
• Community support was shared with staff.
Because everyone in the nation was affected by the attacks, ED nurses did not feel they were suffering alone, notes Machedo. "People were constantly talking about this, and not just in the ED. It was not the normal situation when nobody else knows what you are talking about," she says.
Machedo’s ED has "been inundated" with food, letters of support, get-well cards for patients, and drawings from children. "There was an incredible outpouring of help from the community," she says. "People have even offered spare beds if someone needed a place to stay, which was very touching."
Giles received a very special gesture of support: Deaconess Hospital in Oklahoma City sent a three-foot banner signed by the entire ED staff, which read, "Brothers and Sisters in Emergency Care: We send you our thoughts, strength, and prayers." Giles says she makes a point of informing nurses about all the well-wishers and posting all of the material in the waiting room, vestibule, and ambulance entrance for all to see. "It is a way for all of us to understand that the community supports us," she explains.
• ED managers thanked nurses.
The day after the attacks, the entire ED staff held a group meeting. "I told everybody what a fabulous job they did, and we all talked about what had happened," she says. Along with the ED medical director, Giles sent out a joint letter to all staff praising them for efforts. (To see a copy of the letter, click here.) "The way our staff responded showed me that I made the right decision to go into emergency nursing," she says.
For more information on helping nurses cope with emotional trauma after a disaster, contact:
• Anna Chin, RN, Emergency Department, New York Presbyterian Hospital-Weill Cornell Medical Center, 525 E. 68th St., New York, NY 10021. Telephone: (212) 746-5026. Fax: (212) 746-3821.
• Laura Giles, RN, Emergency Department, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029. Telephone: (212) 241-6273. Fax: (212) 427-2180. E-mail: firstname.lastname@example.org.
• Marion Machedo, RN, Emergency Care Institute, Bellevue Hospital, 27th and First Ave., New York, NY 10016. Telephone: (212) 562-4311, ext. 6561. Fax: (212) 562-3001.
• Suzanne Pugh, RN, Emergency Department, Saint Vincents Manhattan, 153 W. 11th St., New York, NY 10011. Telephone: (212) 604-2513. Fax: (212) 604-2339. E-mail: email@example.com.
The American Hospital Association (AHA) has a variety of resources on its web site (www.aha.org) related to disaster preparedness. The Disaster Readiness Advisory contains guidelines for emergency preparedness and can be downloaded at no charge. (Click on "Disaster Readiness," "AHA Communications to the Field," and "Member Advisory: Disaster Readiness.")
Nurses affected by the Sept. 11 attacks can get help from a disaster relief fund established by Nurses House, a nonprofit organization designated by the American Nurses Association, American Nurses Foundation, and New York State Nurses Association to accept contributions for registered nurses. The fund will assist nurses involved in disaster relief activities and those directly affected by the tragedy, such as those working in surrounding hospitals and those whose spouses were injured or lost in the disaster. Contributions can be made by sending a check to: Nurses Relief Fund, American Nurses Foundation, P.O. Box 96441, Washington, DC 20090-6441.