The Continuing Response 181

Chapter Seven

The Continuing Response

Introduction

The experiences of medical personnel in the response to the 9/11 attack on 

the Pentagon provided valuable lessons to regional hospitals, the Army Medical 

Command (MEDCOM), the Army Center for Health Promotion and Preventive 

Medicine (CHPPM), and military and civilian mental health professionals. During the months and years following the terrorist attacks, these organizations and 

individuals revised disaster plans, improved communications, strengthened alliances, expanded readiness training, and wrote new procedures and doctrine. As 

a result, responders are much more prepared for a terrorist attack today than they 

had been in September 2001. 

Hospitals

Area hospitals were quick to analyze their problems and to plan solutions. In the 

months following 9/11, hospital staffs revamped emergency preparedness plans, 

rethought training issues, updated equipment, restocked supplies, tackled communication problems, and made other changes to respond to terrorist attacks in 

general and to bioterrorism in particular. To coordinate responses and determine 

mutual needs, hospitals and clinics in the national capital region increased their 

networking within healthcare coalitions and became strong partners in emergency 

preparedness.

Military Hospitals

The Walter Reed Army Medical Center (WRAMC) led Army medical facilities 

in the Washington, DC, area in emergency preparedness. The command changed 

the process of dealing with emergencies by blending the Federal Response Plan’s 

incident command system into the Army command system: the highest ranking 
182 Attack on the Pentagon: The Medical Response to 9/11

person at the scene would take command until someone with higher rank arrived. 

In a fire, however, the fire chief continued to outrank everyone else. The WRAMC 

hospital restructured its emergency plans based on the probability of being involved in a response to a terrorist attack. It also adopted the DC fire department’s 

codes, as did all hospitals in the Washington area. Emergency codes became universal.1

WRAMC produced the “Red Book,” an emergency management procedures 

handbook, that contained emergency telephone numbers and defined and explained emergency codes. Code red, for instance, meant that everyone had to 

evacuate the building. Ward masters were responsible for making sure that every 

floor and every ward had one of those books. To maintain readiness, all hospital 

staff were required to take an emergency readiness training course once a year.1

WRAMC also provided readiness training to hundreds of military and civilian 

healthcare providers in the North Atlantic Regional Medical Command (NARMC) 

and in the national capital region in the medical management of chemical and 

biological casualties. WRAMC also established a chemical decontamination program for the base and provided guidance throughout NARMC on decontamination requirements and training. In addition, under the direction of Colonel Michael Dunn, commander of the Walter Reed Health Care System, the hospital 

established a coordinated nuclear, biological, and chemical casualty care network 

that improved the capabilities of the military training facilities in the national 

capital region.2

WRAMC also increased its ability to work with other hospitals in an emergency. Through the District of Columbia Hospital Association, WRAMC’s emergency management committee worked with other area hospitals and agencies to 

improve information sharing about numbers of casualties, kinds of injuries, and 

bed space available, in a timely and secure manner. In November 2005, association hospitals participated in a city-wide mass casualty exercise using the Internet 

to exchange information. Participants later added other information-sharing systems, including a group alert paging system for key emergency personnel, e-mail 

alerts, and a hospital metro-area radio system. For a time, Colonel Edward Lucci, 

WRAMC’s chief of emergency medicine, served as cochair of the DC Hospital Association’s emergency management committee along with a representative 

from the Washington Hospital Center. In addition, WRAMC became the back-up 

clearing house hospital to Children’s Hospital (also in Washington) for emergencies and patient over-flow.2

The Military District of Washington has improved communications by updating 

its radio systems to include hospital-based systems and hand-held radios. These 

actions have improved communications among hospitals, between hospitals and 

individuals, and among individuals at the emergency site. Military personnel tested the system, with success, at the Veteran’s Day ceremony at Arlington on 10 

November 2005.2

Within NARMC, the DeWitt Army Community Hospital, at Fort Belvoir, Virginia, began improving its planning and preparations for future crises. Hospital 

commander Colonel Eileen Malone believed that DeWitt’s emergency prepared-
The Continuing Response 183

ness plan worked well on 9/11 because the tragedy happened on a Tuesday, when 

the hospital had a full staff. Had the attack occurred at 0300 on a weekend, the 

setup would not have worked as well. Hence, DeWitt rewrote its emergency preparedness plan to work at any time, day or night, on any day of the week. It was 

produced as an easy-to-follow manual with removable, color-coded pages to correspond with threat levels (during a code yellow event, the yellow pages could 

easily be pulled out).3

DeWitt also took new measures to deal with mass casualties. The hospital set 

up a quick reaction team that could staff the gate and provide alternative access if 

needed; established a safe security system to prevent contaminated people from 

entering the hospital; prepared suitable command and control standards so that 

patients did not overwhelm the health care system; and listed personnel according to skill so that the hospital would know where it was lacking expertise on a 

given day. DeWittt secured space in nearby Bardon School as a place to evacuate 

patients in case of a bomb threat. Colonel Malone wanted the plan to be “as automatic as fire drills.” The staff would be able to respond instantly and appropriately 

without thinking about what actions to take.3

In preparation for a chemical or biological warfare response, DeWitt acquired 

more protective equipment and respirators, outfitted its surgical pavilions appropriately, and installed more water lines to help with decontamination. The hospital 

trained its staff in decontamination techniques and stocked supplies of atropine 

for a chemical attack and ciprofloxacin and doxycycline antibiotics for a biological attack.3

The intention of the commanders of DeWitt and other Army hospitals was to 

be able to respond to weapons of mass destruction scenarios using a complicated 

healthcare system composed of military and civilian providers. Healthcare facilities at the federal, state, and local levels, Colonel Malone believed, had to 

work together and be “perfectly integrated.” One alone could never handle the 

response, so joint planning was necessary for a successful response.3 (The Walter 

Reed Healthcare System consisted of WRAMC, the DiLorenzo Clinic, DeWitt, 

and Kimbrough Ambulatory Care Center at Fort Meade, MD.)

DeWitt’s emergency department chief, Major Michael K Halliday, served as 

the military representative to a core regional disaster response group that was 

developing emergency policy. Each of DeWitt’s three family health centers in 

three different counties worked with their communities in developing plans to 

coordinate the different area hospital systems. These measures were ongoing and 

took months to develop. By 27 October 2001, Colonel Malone could say, “We’re 

certainly in a thousand percent better position today to deal with weapons of mass 

destruction than we were on the 11th.”3

Civilian Hospitals

Although the Virginia Hospital Center in Arlington was prepared to handle the 

casualties it received on 9/11, the facility made improvements to make sure it was 

ready for any future attack. The hospital fine-tuned its emergency preparedness 
184 Attack on the Pentagon: The Medical Response to 9/11

plan, obtained new equipment, established new processes, and provided hospitalwide educational services to its nursing and medical staff. The infectious disease 

department offered several programs, and lectures open to the public and staff included topics such as bioterrorism and some of its agents, anthrax, smallpox, and 

botulism. The hospital’s leaders attended county-wide monthly planning meetings 

with other medical facilities, and its nursing staff joined in formal consultations 

with nurses from other hospitals in Northern Virginia and Washington, DC.4,5

Potential problems surfaced at the Washington Hospital Center’s burn unit 

shortly after the attack. Caring for nine Pentagon burn victims while continuing to serve the community had exhausted the unit’s surgical teams by the third 

week after September 11. Dr Marion H Jordan, director of the burn unit, came to 

believe that burn centers needed to assess their ability to care for multiple burn 

patients from a major disaster in addition to their daily patient census. He suggested in a speech to members of the Association of Burn Surgeons at the National 

Disaster Medical System (NDMS) conference in Atlanta, Georgia, in May 2002, 

that in a future attack, ground zero burn centers should distribute burn patients 

to multiple burn facilities so they would be able to continue their normal patient 

flow and fulfill responsibilities to the community. Had the Pentagon wedge and 

the Twin Towers not collapsed, and more of the injured escaped, the Washington 

Hospital Center and Cornell University Hospital in New York City would have 

been swamped with thousands of burn victims. Burn centers across the country 

began to incorporate plans for such cooperation in their emergency preparedness 

documents.6,7

In its disaster plan, the American Burn Association recommended that US Army 

burn special medical augmentation response teams (SMART teams) assist in secondary triage and transport of burn patients to burn centers not in the disaster area. 

(Under the NDMS, the regulation and movement of patients is the responsibility 

of the Department of Defense [DoD].) Of the 37 Army SMART teams, two are 

burn teams operated by the Army Institute of Surgical Research, at Brooke Army 

Medical Center, Fort Sam Houston, Texas. The Army’s burn teams were not needed and not used in the response to the Pentagon attack.8(pp104,105)

Hospital Alliances

An important improvement after 9/11 was the strengthening of regional hospital alliances, which included both civilian and military hospitals. There was a 

precedent for such coalitions: before 9/11, a committee of civilian and military 

emergency medical service (EMS) workers from different counties in Northern 

Virginia met monthly to discuss various needs and problems. EMS personnel from 

the DC Hospital Association held similar monthly meetings. After 9/11 hospital 

personnel and public health staff also became interested in meeting to discuss 

disaster preparedness. Dr Daniel Hanfling, chairman of the Disaster Preparedness 

Committee at Inova Fairfax Hospital; Dr Yorke Allen, chairman of emergency 

medicine at Virginia Hospital Center–Arlington; and Craig DeAtley, an expert on 
The Continuing Response 185

disaster medicine, formed an emergency response working group that came to be 

known as the Northern Virginia Emergency Response Coalition. Beginning on 

23 September 2001, key clinical and administrative hospital leaders throughout 

Fairfax (including DeWitt Army Community Hospital), Alexandria, Prince William, and Loudon counties met once a month to discuss ways to improve regional 

healthcare and how to respond collectively to future terrorist attacks. Topics of 

discussion included emergency preparedness, chemical and biological warfare, 

effective communications, and the need for similar equipment. Planning, resources, and mutual aid needs were examined “in earnest” at those meetings, said Dr 

Hanfling. “If there’s a silver lining [to the September 11 attack], that’s one of them 

for us.”9 Gradually, regional fire, law enforcement, intelligence, EMS, and public 

health personnel were brought into the coalition to make decisions about healthcare for the entire community.9,10

As these people came together to discuss preparedness issues, Dr Hanfling became convinced that the Northern Virginia hospitals needed their own more inclusive and better structured forum for coordinating planning efforts, including 

the development of “a comprehensive [mass casualty] hospital communication 

and information management system between the 13 NVHA [Northern Virginia 

Hospital Alliance] hospitals in six counties in northern Virginia.”9 As a result, he 

helped form the NVHA in September 2002. The alliance supplemented the ongoing work of the Emergency Response Coalition. Inova Fairfax Hospital became 

the lead agent of the group and the hub of the network that coordinated activities 

with outlying community hospitals, including military facilities, and with hospital 

organizations in Washington, DC, and Maryland. The state of Virginia adopted the 

model and created regional hospital coordinating centers for its six regions.9–13

The Northern Virginia Hospital Alliance realized that in order for its members 

to respond in concert with multiple agencies in multiple jurisdictions to mass 

casualty incidents involving weapons of mass destruction and other hazards, effective communication and healthcare information management systems needed 

to be in place. Based on predictions of potential terrorist actions by the Federal 

Bureau of Investigation (FBI), Central Intelligence Agency, and other agencies, 

regional hospitals needed the capacity to admit 500 to 1,000 casualties. Hospitals 

also had to be able to work in concert with first responders such as fire and police 

departments, EMS units, and with other agencies including public health offices, 

the American Red Cross, mental health organizations, state and national guard 

bureaus, and the DoD.13,14

Dr Hanfling and Major General (Retired) Michael Wyrick, who served as executive director of the Northern Virginia Hospital Alliance from October 2002 

through September 2005, wrote a proposal to develop such systems in October 

2002. By using key reference sources and experienced leaders, Hanfling and 

Wyrick created a model for identifying essential elements of an emergency preparedness program. Subject matter experts earmarked 13 major functions: public 

health, communication, information management, patient movement, chemical 

decontamination capability, radiological decontamination capability, surge capac-
186 Attack on the Pentagon: The Medical Response to 9/11

ity, hospital clinical management, mental health, family support, volunteer support, media management, and provider licensure and credentialing. The model 

also fostered the use of common definitions of terms. The Northern Virginia Hospital Alliance implemented the proposal in early 2003.13–15 Since that time, “a 

reliable communication system complemented by an information management 

system connecting all these agencies,” has been in place.13 “What began as a communications solution,” stated Dr Hanfling, evolved “into a more comprehensive 

healthcare information management system.”14

One aspect of the improved coordination among hospitals was the practice of a 

“command hospital communication concept”11(p29) during regional disaster drills. 

During the drills, the incident commander, or the commander’s designee, relied 

on the command hospital, Inova Fairfax, which had the appropriate communications system, to serve as a link to other area hospitals and take responsibility for 

seeing that patients with specific needs were delivered to the appropriate medical 

facilities. Burn victims were sent to burn units, trauma patients to trauma centers, 

and the less seriously injured to other hospitals. The command hospital told the 

incident commander how many beds were available at particular hospitals and 

what kinds of patients could be sent there; in turn, the incident commander told 

the command hospital the number of patients involved. The absence of direct access to the incident commander early on 9/11 had put the hospitals in a situation 

that could have been disastrous had there been more casualties.11(pp29,30)

Another improvement was the institution of a radio communications system 

“to combat the chaos of disaster,” said General Wyrick.10 “What we realized from 

September 11, 2001,” said Dr Hanfling, “is that hospitals were the last to know 

about what was going on at the Pentagon.”10 During a mass casualty exercise 

involving the Pentagon in May 2001, telephone communication had proven ineffective and slow; finding out the number of beds available in Northern Virginia 

hospitals for the mock disaster victims had taken more than an hour. By using 

radio linkage such as citizens’ band (CB) radios, however, the same information 

could be spread in a matter of minutes, and hospitals would be linked with one 

another and provide continuous communication during a disaster. Radios could 

also rapidly transmit information on the best treatment for victims of biological 

or chemical attacks.10

The alliance used a $225,000 federal bioterrorism grant to build a radio network among the 13 Northern Virginia hospitals in 2002. These included DeWitt 

Army Community Hospital; Fauquier Hospital; Inova hospitals in Alexandria, 

Fair Oaks, Fairfax, and Mount Vernon; Loudoun Hospital Center; Mary Washington Hospital; Northern Virginia Community Hospital; Potomac Hospital; Prince 

William Hospital; Reston Hospital; and Virginia Hospital Center–Arlington.10

Although Army hospitals in the Washington, DC, area have their own reliable 

communication system and information management system through the Army’s 

healthcare program and NARMC, 9/11 showed that in an age of terrorism and 

nuclear threat military and civilian hospitals need to work closely together to provide expert care to multiple casualties. Since 9/11, military hospitals have partici-
The Continuing Response 187

pated more actively in their local hospital associations. One example is the service 

as co-chair of the DC Hospital Association’s emergency management committee 

of Colonel Lucci, WRAMC’s emergency medicine chief. Dewitt Army Community Hospital’s active participation in the Northern Virginia Hospital Alliance is 

another. Both military and civilian hospitals benefit from these associations.

US Army Medical Command

After 9/11, homeland security and bioterrorism incidents emerged as the two 

major issues requiring attention by MEDCOM. To that end, MEDCOM created a 

division of homeland security under the leadership of Lieutenant Colonel Bernard 

Hebron to develop plans for providing medical support to federal, state, and local 

governments in the event of a national disaster. Staff studied major bioterrorism 

as well as chemical scenarios. Although MEDCOM was unsure what the requirements for this support or the Army Medical Department’s ultimate role would be, 

doctrine began to emerge on how the Army would respond with medical assets 

to support civilian authorities, including the development of a list for patient decontamination kits for Army medical facilities containing detection devices and 

equipment to neutralize chemicals on a person.16

MEDCOM had been preparing for a possible weapons-of-mass-destruction 

attack on US soil even before 9/11. By 1999, for example, WRAMC was well 

equipped with decontamination equipment and had trained a large number of personnel in decontamination activities. In August of that year, DeWitt Army Community Hospital and Weed Army Community Hospital at Fort Irwin, California, 

each obtained a portable decontamination unit and the training to use it. After both 

hospitals expressed satisfaction with the package, MEDCOM standardized the 

equipment and training among the 21 remaining Army medical facilities. By April 

2001, those facilities had received delivery of the equipment and training.17(encl1)

In addition, before 9/11 MEDCOM’s Plans Division had designed a pamphlet 

providing guidance to medical facilities on the preparation of emergency management plans, including how to respond to weapons of mass destruction and how to 

use the Army’s SMART teams. The leaflet had been staffed and was waiting for 

the surgeon general’s signature when the 9/11 attack occurred. After the tragedy, 

the brochure was returned to the MEDCOM Plans Division for expansion, for the 

inclusion of more defined protocols, and for another review. It was published in 

October 2003 as MEDCOM Pamphlet 525-1, Medical Emergency Management 

Planning.

18 At this writing, it is undergoing revision and expansion again to incorporate new guidance from federal authorities, various program and organizational 

changes, new terminology, and new missions for SMART teams, including the 

addition of SMART-logistics teams. When changes are completed, the pamphlet 

will be a supporting document to Medical Command Regulation 525-4, which 

governs emergency preparedness.17(encl2) A new version of another document, Regulation 525-4, was published on 15 January 2010 to reflect the “many changes in 

Federal Response, Defense Support of Civil Authorities (DSCA) and Homeland 
188 Attack on the Pentagon: The Medical Response to 9/11

Security policies and guidelines affecting preparedness for and response to allhazards incidents.”19 

On 17 December 2001, the Army surgeon general, Lieutenant General James 

B Peake, issued a memorandum17(encl3) to the commanders of his major subordinate commands on plans for enhancing medical nuclear, biological, and chemical readiness. Appended to the memorandum was a table of 20 scheduled tasks 

and aggressive timelines to be executed “as quickly as possible” if an attack 

occurred. According to the memo, the Medical Department would provide exportable courses to enhance the performance of medical activities under nuclear, 

biological, and chemical conditions. Medical care tasks for the victims of such 

attacks were “to be trained, tested and measured.” Regional medical commanders 

were to put these plans into effect, giving priority to emergency room personnel 

and first responders for training support packages when they were developed and 

fielded.17(encl3)

The Medical Department’s council of colonels determined that medical treatment facilities and SMART teams should receive personal protective equipment 

and civilian respirator face masks. Each facility was to receive ten sets of the 

equipment and at least two face masks per emergency room treatment bed. At 

little added cost, the Plans Division matched personal protective equipment to 

masks and purchased 1,355 sets of the equipment, which were delivered from 

December 2002 through March 2003. Medical treatment facilities also received 

funds through regional medical commands for additional purchases, if they became necessary, such as equipment for the new SMART-logistics teams and for 

the treatment facilities themselves.17(encl4)

SMART teams of nuclear, biological, and chemical experts and patient decontamination teams at medical centers needed a device to detect chemical warfare 

agents and toxic industrial materials in order to ensure separation of the decontaminated patient from other patients as quickly as possible, and to confirm that 

victims were contamination free. The Plans Division purchased 11 ChemPro 100 

handheld chemical agent detectors from Environics (Mikkeli, Finland) “with 

training and support packages” for the nuclear, biological, and chemical and patient decontamination teams, greatly enhancing their capabilities.17(encl5)

MEDCOM also strengthened its biosurveillance activities through several 

clinical databases, with MEDCOM preventive medicine specialists analyzing the 

data daily.20 Since 9/11 MEDCOM also has been upgrading hospital training and 

equipment to be able to identify and treat any early cases of a bioterrorist-induced 

illness. The Army’s Institute of Chemical Defense Research and Walter Reed’s 

Army Institute of Research are involved. The Army has increased its stocks of 

nerve agent antidote, chemical agent kits, and protective suits. The Army Medical 

Department (AMEDD) is integrating emergency management plans and contingencies with the civilian sector, especially the Centers for Disease Control and 

Prevention.20,21

In improving hospital training, equipment, and biosurveillance systems, the 

Medical Department relied on the expertise of its own professionals, especially 
The Continuing Response 189

the commander of Walter Reed Health Care System, Colonel Michael A Dunn, 

who had commanded the Army’s Research Institute of Chemical Defense and had 

been the main Persian Gulf War chemical defense trainer. The Medical Department also worked diligently with the civilian sector in training for the detection of 

early cases of biological or chemical contamination. Its personnel likewise joined 

committees to develop more comprehensive and better researched biological incident response plans for the metropolitan Washington area. The steps taken by the 

Medical Department were similar to efforts undertaken throughout the country after 9/11, when states received large sums of federal money for improving hospital 

training and equipment and for biosurveillance systems.20

As discussed in Chapter 2, Colonel Bruce Burney, chief of the Operations Division in MEDCOM’s Directorate of Health Care Operations, believed that the 

subordinate commands would consider the two most important shortfalls in the 

Medical Department’s response to 9/11 to be the lack of intelligence information in the Army’s major commands, and the inability of those organizations to 

provide guidance to their subordinate commands based on this intelligence. After 

9/11, the mission of Ronald Hatton, MEDOM’s senior intelligence officer, expanded to include security as well as intelligence. In addition to force protection 

guidance, Hatton began providing intelligence updates to all the commands and 

major subordinate commands.22,23

As part of its post-9/11 strategy, MEDCOM moved toward implementing new 

DoD instructions involving significant coordination between installations and 

medical treatment facilities. In emergencies before 9/11, the Medical Department 

relied on a few specially trained and equipped regional response teams. After 

9/11, every Army post was required to have a medical team capable of responding to a 9/11-type of event involving hazardous substances. Medical facilities had 

to be able to support the response teams being created at every military post for 

the installations to have the capability to counter a terrorist attack. Army hospital 

staffs had always been able to triage and handle mass casualties, but dealing with 

a terrorist attack on a 9/11 scale was a much larger task than those in scenarios 

practiced by installation hospitals for years. 

Implementation of the DoD’s new plan required increased personnel, training, 

and exercises, which 2002 levels of staffing and funding made difficult to achieve. 

Medical response teams were being formed on an ad hoc basis, with dubious 

training and abilities, according to Colonel Tim Mallon, CHPPM’s director of 

clinical preventive medicine. Although MEDCOM had a plan for how to implement the DoD instructions on nuclear, biological, and chemical situations—casualty support had been a part of preventive medicine and occupational medicine 

for some time—staffing would take time. Colonel Mallon believed that even if the 

Army doubled the number of its occupational medicine doctors, one-third of US 

Army installations would be without one. “So essentially you haven’t changed the 

situation,” said Colonel Mallon.24(p18) “We may be heading there,” added Colonel 

Paul Smith, an occupational medicine staff officer at the Office of the Surgeon 

General, “but we’re not there yet.”24(p18) By April 2002, the well-intentioned plans 
190 Attack on the Pentagon: The Medical Response to 9/11

of the DoD and MEDCOM for a post-9/11 military response to a terrorist attack 

might not have had the necessary staffing and resources, but efforts were moving in that direction. However, the October 2001 anthrax contamination incident 

in Washington, DC, involving the city’s mail handling systems seemed to have 

overly influenced the command’s planners, who then focused more on developing 

strategies to deal with hazardous materials such as anthrax and less on devising 

ways to handle explosive damage in another mass casualty event like the attack 

on the Pentagon.24

Nevertheless, MEDCOM improved its ability to respond to terrorism both medically and operationally by developing plans and issuing instructions on ways to 

improve training; nuclear, biological, and chemical casualty treatment capability; 

intelligence proficiency; and the documentation of medical competencies. MEDCOM stockpiled chemical agent kits, nerve agent antidotes, and protective suits 

and masks, and worked on better command, control, and coordination among its 

own personnel, within the DoD, and with the civilian sector. During all of those 

activities, MEDCOM continued to manage healthcare and beneficiary care and to 

plan for deployments around the world.16,25

Colonel Stephen Wallace and the Army Medical Department Response

MEDCOM digested and incorporated into its plans and training exercises some 

of the ideas it received from Army medical participants in the 9/11 response. Colonel Stephen Wallace, Army Medical Department liaison at ground zero in New 

York City (see Chapter 6, New York City), wrote a prescient after-action report 

including 22 recommendations that the Medical Department might use to implement measures in preparation for another attack. Wallace based his proposals on 

his liaison experience in New York City; his many military assignments, including 

service as a medical operations planner for missions in the Balkans, Croatia, and 

Liberia; his years of military professional education; and his personal experiences 

as an emergency medical technician with fire and rescue departments. A 49-yearold military field grade officer and combat veteran, he “had seen and done a lot,” 

according to Wallace. He sent his report in a 5 October 2001 memo to Major 

General Harold Timboe, commanding general of NARMC and WRAMC. Wallace forwarded copies of the report to other Army Medical Department officers, 

commands, departments, and divisions.26,27 In making the following suggestions, 

he became the intellectual force for determining “where do we go from here.”26

Below are his 22 recommendations, followed by MEDCOM responses.

1. Begin medical surveillance on all military personnel who were at Ground Zero due 

to the various HAZMAT [hazardous materials] and environmental substances detected there. 

The PGI Surveillance Program format could be used to accomplish this effort for active duty 

military. Recommend NYARNG [New York Army National Guard] also participate through 

their NY State health resources.26(p3)

In response, the Army surgeon general directed CHPPM to conduct postdeployment medical surveys for all 9/11 military responders. 17(encl6),26(p3)
The Continuing Response 191

2. Be ready for other possible attacks by forming a group of MEDCOM LNOs [liaison 

officers] who can be immediately deployed if this happens again in other cities. These LNOs 

could serve as the RMC [regional medical command] commanders’ and TSG’s [the surgeon 

general’s] eyes and ears on the ground; provide a direct link between MEDCOM and all responding local, state and federal agencies to include the DCE [defense coordinating element] 

and FEMA [Federal Emergency Management Agency]; and provide an important show of 

support for the local officials who would appreciate this representation (note: not all cities are 

as well prepared as NYC [New York City]).26(p3)

MEDCOM believed that its SMART teams could function as liaisons, particularly when the Medical Command control, communications, and telemedicine team, known as SMART MC3T, deployed with other specialty teams.17(Encl6)

MEDCOM Pamphlet 525-1, issued in October 2003, stated that SMART teams 

are composed of military officers, warrant officers, enlisted soldiers, Department of the Army 

civilians, and appropriate Department of Defense contractors assigned to Medical Command 

by name. The SMARTs are capable of deploying to provide liaison to local, state and federal 

response assets in domestic support, military installation support, civil-military cooperative assistance, and disaster relief and humanitarian assistance operations in CONUS [the Continental 

United States].18(p30)

3. Implement a MEDCOM Homeland Defense Medical Operations Cell (modeled on the 

efficiency and effectiveness of the NARMC Operations Center) manned 24/7 to keep TSG and 

all subordinate commanders operationally aware of issues pertaining to Homeland Defense 

medical issues and intelligence especially during and after an attack in CONUS. In the past, 

MEDCOM’s war mission meant deployment of our soldiers overseas to combat zones. Unfortunately, our nation has become a combat zone for terrorists. As Homeland Defense takes 

shape, MEDCOM should be represented.26(p4)

Since 9/11, MEDCOM has made homeland defense a major priority. It has established a dedicated homeland security cell, and the emergency operations center 

at the Office of the Surgeon General, known as Ops Center XXI, has become a 

permanent, 24-hour facility.17(encl6) This center, along with the regional medical 

commands’ emergency operations centers and MEDCOM’s quarterly contingency planning workshops, helps provide information and intelligence on homeland 

defense medical issues.17,18(pp32,33)

4. Send more MEDCOM officers, senior NCOs [noncommissioned officers] and DACs 

[Department of the Army civilians] to FEMA and other disaster/WMD [weapons of mass 

destruction] training seminars and conferences. Valuable education gained at these conferences will better prepare more MEDCOM personnel for attacks, disasters and MASCALs 

within their areas of operation.26(p4)

Each year individual officers and teams attend conferences and exercises that 

focus on responses to disasters and chemical, biological, radiological, nuclear, and explosives incidents. The annual Association of the US Army Medical 

Symposium and the annual Force Health Protection Conference (sponsored by 

CHPPM) are two of many that are well attended. MEDCOM’s Plans Division 

conducted SMART team/homeland security conferences in February 2001 and 

February 2003. The division also has quarterly contingency planning workshops. 
192 Attack on the Pentagon: The Medical Response to 9/11

Army personnel assigned to the FEMA NDMS Federal Coordinating Center program attend the NDMS national conference annually. Regional medical command 

personnel and FEMA regional staff work together at consequence management 

exercises that deal with response to disasters. In addition, many Army installations conduct their own large-scale disaster exercises in conjunction with local, 

state, or regional agencies.28 

5. Incorporate lessons learned from the Pentagon and WTC [World Trade Center] attacks for immediate MASCAL training exercises throughout the MEDCOM. Just as we 

are sending medical staff to civilian Trauma Centers to better prepare for battlefield surgery, 

also send some MEDCOM officers to civilian hospitals in Virginia, Washington, DC, and NYC 

to gain further information on their responses to the Pentagon and World Trade Center MASCALs. Include command and staff officers in these information gathering visits.”26(p4)

MEDCOM has published lessons learned and conducted training exercises 

throughout the organization. MEDCOM has not sent officers to civilian hospitals to learn from their experiences, but Medical Department personnel attend 

regular meetings of Washington-area hospitals, where discussions focus on how 

to improve regional healthcare and how to respond collectively to future terrorist 

attacks (see discussion of hospital alliances, above).28 

6. Immediately expand MASCAL, combat, weapons, and CTT (common task training) training requirements throughout the command. America is on the frontline and 

our CONUS MEDCOM MTF [medical treatment facility] personnel need to be as ready 

as TOE [table of organizaton and equipment] medical unit soldiers deploying overseas. At 

many MEDDACs where this officer has served, CTT is considered an inconvenience to 

many MEDDAC staff and something to suffer through once per year for several hours in 

a day. While PROFIS [Professional Officer Filler Information System] personnel usually 

get a little more advanced training, in this officer’s opinion, this is still not enough time 

to thoroughly train soldiers to maintain combat level proficiency in combat and medical 

skills for rescue and evacuation, casualty treatment, weapons and NBC [nuclear, biological, 

chemical] area. MTF DACs [military treatment facility Department of the Army civilians] 

need training too.26(p4)

Three months after 9/11, Surgeon General Peake issued a plan for enhancing 

emergency response capabilities in general and for nuclear, biological, and chemical response capabilities specifically. The Army Medical Department Center and 

School was to “prepare exportable, tailored and scalable courses”29 that explained 

how to perform medical tasks in a nuclear, biological, and chemical environment. 

Starting in December 2001 and continuing through 2002, the regional medical 

commands executed this plan by having their personnel take the courses, giving priority to emergency room and first responder training. In addition, military treatment facilities participate in at least one mass casualty exercise each 

year.18(pp102–104),29

7. Ensure every MEDCOM soldier is “110%” trained in NBC. Ensure every MEDDAC 

has NBC equipment for ALL staff. Provide NBC orientation training to DAC staff. In 

NYC, for two weeks after 11 Sep 01, there were daily discussions of the potential for a further biological/chemical (biochem) attack following the WTC attack. Hospital personnel there 
The Continuing Response 193

have had extensive training in case of a biochem attack. Their hospitals have equipment ready 

for use if biochem casualties arrive at their Emergency rooms. NYC EMS is ready to rescue 

and transport these type of patients to the hospital.26(p4)

From January through April 2001, MEDCOM equipped and trained for patient 

decontamination in all military treatment facilities with emergency rooms. On 17 

December 2001, the surgeon general issued his plan for enhancing medical nuclear, biological, and chemical readiness. In 2002 MEDCOM purchased 1,355 sets 

of personal protective equipment and powered, air purifying respirators, which 

38 medical treatment facility emergency rooms and SMART teams received in 

December 2002 through March 2003. This protective equipment capability enabled medical treatment facilities to meet the needs of their installations or the 

nearby community according to local plans. MEDCOM planned and programmed 

more capability for more facilities for the future. Although all staff would not be 

provided nuclear, biological, chemical equipment, all medical personnel, including military, Army civilians, and contractors, were required to complete nuclear, biological, chemical, and high-yield explosives training by the end of fiscal 

year 2006. MEDCOM developed a Web-based package of training consisting 

of four courses for clinicians, operator/responders, executives, and nonmedical 

personnel.17(encls1–5),28,30

8. Ensure every MTF DAC gets more training in building evacuation, personal protection 

in case of an attack, and emergency first aid (for non-medical DACs). As we learned in the 

Pentagon attack, our DACs are in this too. MTFs need to include them in training, which would 

benefit them in case of attack.26(p4)

On 9 January 2004, the assistant secretary of defense tasked the Army to provide chemical, biological, nuclear, and high-yield explosives training for military 

medical personnel, civil service, and contract personnel as recommended in no. 8. 

See also the response to recommendation 7, regarding Army civilians.17(encl6)

9. Ensure every chain of command has leadership ready to take charge if the current 

leaders become casualties. NYFD lost dozens of senior officers when the WTC towers collapsed. The subordinate leaders were immediately promoted to fill the upper ranks. If a MTF 

HQ [headquarters] were destroyed, there should be an established second chain of command 

ready to take charge and continue MTF operations.”26(p5)

MEDCOM Plans Division conducts quarterly contingency planning workshops 

that focus on leadership skills and responsibility for military treatment facilities’ 

planners and other interested personnel.17(encl6)

10. Ensure every MEDCOM organization has a contingency plan if their headquarters 

and all of their telecommunication and IM/IT [information management/information 

technology] are destroyed in an attack. NYC OEM [Office of Emergency Management] was 

completely destroyed in the attack. A small temporary command immediately started operating 

and within three days, a brand new operational command post was fully operational at Pier 

92 with several hundred key staff. Also ensure all MEDCOM organizations have alternate 

methods of communicating with their higher headquarters in case of attack (cell phone rosters, 

internet email, etc.26(p5)
194 Attack on the Pentagon: The Medical Response to 9/11

MEDCOM plans quarterly contingency planning workshops. Emergency planners at every Medical Department level prepare and maintain emergency management plans and submit them to higher headquarters for validation.18(p5),19(p3)

11. Ensure redundancy in all key areas and operations. The Pentagon and WTC attacks 

taught us a lesson that ANYTHING is possible.26(p5)

According to MEDCOM Pamphlet 525-1 on emergency management planning, 

the logistics division of each military treatment facility oversees a four-tiered concept of medical logistics support: (1) The division provides installation support 

packages of 15 days of medical nuclear, biological, and chemical defense materiel 

for 25% of the regional population. These packages are maintained by the installation medical supply activity. (2) The logistics division also provides regional 

medical support packages of 15 days of medical nuclear, biological, and chemical 

defense materiel for 25% of the regional population. (3) Additionally, the division 

administers Army and DoD medical assets by utilizing existing depot supplies, 

vendor-managed inventories, and stock rotation contracts to store a 30-day supply 

for contingencies. (4) If directed, the installation medical supply activity may be 

required to store and maintain specific quantities of national stockpiled materials 

from the national pharmaceutical stockpile program managed and maintained by 

the Centers for Disease Control and Prevention.18(pp80,81)

12. Ensure every MEDCOM organization has the capability of an IMMEDIATE emergency reaction force response from garrison armed soldiers, ‘locked and loaded,’ or that 

weapons and ammunicaion are readily available to key staff if a MEDCOM or MTF organization is attacked by terrorists armed with small arms, explosives or knives. Patients, 

staff and the facility must be defended against cowardly terrorists who will hit unprotected soft 

targets. NYC hospital have armed NYPD and security personnel within their hospitals.26(p5)

Most military medical treatment facility security forces are either civilian contract personnel or a mix of civilian and military police. Quick-reaction forces 

under installation emergency management plans may be available to a military 

treatment facility during such an event.17(encl6)

13. Have teams sent out by OTSG [Office of the Surgeon General] or MEDCOM RMCs 

to perform operations readiness inspections (ORIs) on all MEDDACs for MASCAL and 

security responses. The MEDCOM has a wealth of talent in its senior ranks, many of whom 

have combat experiences and service in areas of the world where terrorism occurs. Use this 

talent to devise a uniformed security/force and facility protection system applicable to all MTF 

and MEDCOM organizations. Then send out inspection teams to ensure compliance.26(p5)

Under MEDCOM Regulation 1-2, which covers MEDCOM’s organizational 

inspection program, the Office of the Surgeon General’s inspector general, at the 

request of regional medical commanders and major subordinate medical commanders, inspects medical commands for systemic issues, such as readiness problems, and identifies opportunities to improve them. Military police provide security at MEDCOM and medical treatment facilities.31(pp1–3),32(p1)
The Continuing Response 195

14. Ensure MEDDACs take every opportunity to meet and train with FEMA organizations within their local areas. FEMA personnel (including those called up for disasters) 

would welcome this cooperation and joint training. MEDDACs should be strongly encouraged 

to perform mascal training with local area hospitals.26(p5)

MEDCOM’s joint exercises with FEMA occur at the regional level using 

SMART teams or similar groups. The Southeast Regional Medical Command has 

worked with FEMA in a region-wide exercise called Consequence Management 

since 2002. The Northern Virginia Hospital Alliance and the DC Hospital Association encourage mass casualty training at local area hospitals, including military 

hospitals.17(encl6)

15. Ensure MEDDACs “stock up” on emergency mascal supplies and items which would 

be needed if the garrison is attacked. After an attack, Prime Vendor may take days to restock 

emergency items and garrison security may hamper medical resupply operations.26(p5)

According to MEDCOM Pamphlet 525-1 on emergency management planning, 

due to the increased threat level to Continental United States installations, medical nuclear, 

biological, and chemical defense materiel must be on hand in greater quantities, have decentralized storage, have rapid distribution to systems, and be readily available to installation and 

military treatment facility commanders.18(p259) 

A 15-day supply of this defense materiel must be on hand for 25% of a regional 

population. This materiel, which is a component of medical equipment sets, also 

supports nonmilitary personnel in overseas areas, Army National Guard incident 

teams, emergency response teams, SMART teams, and ready reaction forces that 

are not part of the installation force protection program.18(pp259–265)

16. Ensure sufficient supplies are stocked to handle biohazards especially bodies and 

body parts if a major attack occurs. Have a MEDDAC and a garrison plan on where to place 

bodies and body parts in case of a major attack (in Panama, the Howard AFB Bowling alley 

was turned into a temporary morgue). NYC used a financial building lobby as a temporary 

morgue.26(p6)

At this writing, MEDCOM had not dealt with this issue, believing that body 

bags and other recovery equipment would not be part of its responsibility, but 

would belong to Army mortuary affairs units or Department of Homeland Security NDMS disaster mortuary operational response teams.17(encl6)

17. Ensure all MEDCOM organizations have 100% personnel rosters and standing instructions on what to do if attack/disaster occurs. All staff should know where to call in for 

accountability and reporting instructions (and have a secondary number to call in case normal 

communications is disrupted).26(p6)

MEDCOM’s quarterly contingency planning workshops provide guidance on 

what to do should an attack or disaster occur. Also, chapter 5 of MEDCOM Pam-
196 Attack on the Pentagon: The Medical Response to 9/11

phlet 525-1 provides information and specific guidance on the development and 

execution of the activity’s emergency management plan.17(encl3),18(pp40–53)

18. Ensure all MEDCOM organizations have either a secondary temporary badge ID 

[identification] system or stickers to place on current badges in case of an attack. (NYC 

OEM Ground Zero Red Badges were compromised on Day 6 by someone making copies of 

them at Kinko’s in Manhattan.)26(p6)

Most military treatment facilities have ID badges, but not a secondary method 

of identification.17(encl6)

19. Ensure all MEDCOM organizations have plans for Mental Health support if an attack occurs. (For MEDDACs that would mean having or being [sic] to obtain sufficient mental 

health resources for the wounded, MTF staff, garrison personnel and family members.)26(p6)

MEDCOM planners are in the process of writing the physical and behavioral 

health follow-up plan to the medical emergency management plan, which will be 

published as annex S of chapter 6 of Pamphlet 525-1. The most current version is 

dated 1 October 2003.18

20. Inventory civilian hospital capabilities near every US Army post. (Know which hospitals can take burn cases, head and chest trauma, biochem victims, etc. Have MTF personnel 

tour those civilian facilities and meet their staff.)26(p6)

MEDCOM plans quarterly contingency planning workshops in which participants discuss the capabilities of local civilian hospitals. MEDCOM Regulation 

525-4, Emergency Management Planning, states:

Procedures and agreements for mutual emergency medical support between military and surrounding civilian medical facilities [are] included [in emergency management contingency 

plans]. The procedures and agreements [are] exercised during semi-annual mass casualty exercises and continually updated to ensure the availability of a full range of emergency medical 

services to the supported installations.19(pp5,6)

In addition, coalitions of Washington-area hospitals encourage mass casualty 

training with local area military medical facilities.19(pp2,5)

21. Inventory personnel records in the MEDCOM for officers and enlisted with considerable experience (military and civilian) in the Middle East; linguistic skills, etc. 

(Offer these soldiers useful opportunities in TOE units, MEDCOM Headquarters and Joint 

Staffs, to provide expertise which will be needed to defeat and defend against this terrorist 

enemy.)26(p6)

MEDCOM’s Plans Division has stated that this issue is outside its jurisdiction 

and is in the health language skills area of responsibility. MEDCOM continues to 

update its capabilities and doctrine and to reach out to other organizations with 

health language skills and emergency healthcare responsibilities.17(encl6) 
The Continuing Response 197

22. Think outside the box—Always! (After the Pentagon and World trade Center attacks, 

ANYTHING can happen—we must be ready!)26(p6)

MEDCOM has not addressed all the lessons from 9/11; for example, although 

MEDCOM has discussed the need for more assistance to the families of injured 

Army civilians in a disaster, the provision of assigning an assistance officer to the 

families of the injured civilian has not been instituted. 

US Army Center for Health Promotion and Preventive Medicine

While MEDCOM headquarters worked on improving its ability to respond to 

the terrorist threat, CHPPM developed antiterrorism policy and procedures. In 

particular, it strengthened its ability to respond to nuclear, biological, and chemical threats such as contaminated water supplies, radiation, anthrax, smallpox, 

and toxic chemical substances. In addition, the agency worked more closely with 

nonmilitary government agencies such as the Centers for Disease Control and 

Prevention, which included DoD in its communication planning sessions. Indeed, 

remarked Kevin Delaney, chief of CHPPM’s Health Information Operations, 

since 9/11 the military had developed more capability to deal with a crisis and 

had better command and control mechanisms in place than did the “Centers for 

Disease Control, or even FEMA, or the FBI.”21 (As far as the FBI is concerned, in 

the author’s opinion, he is probably wrong.) As a result, federal agencies began to 

take a closer look at what the military and CHPPM, in particular, had to offer. The 

linkage of DoD with other response agencies to discuss strategies for future crises 

was a major consequence of 9/11.21,33

After 9/11, CHPPM began developing a contingency plan that included 

practicing responses to nuclear, biological, and chemical threats. Before 9/11 

CHPPM was responsible only for providing SMART team consultation; however, its response to the Pentagon involved much more than that. As a result 

of 9/11, Colonel Mallon believed, “our response needs to be more thoroughly 

thought out, more thoroughly equipped, trained, exercised.” He and his colleagues focused their efforts on issues and concerns defining CHPPM’s future 

responses.24

CHPPM also took a number of actions to protect drinking water supplies against 

terrorist acts. The water supply management program of CHPPM’s Environmental Health Engineering Directorate developed a “Fact Sheet on Countering Terrorism of Water Supplies” to help Army and DoD personnel to better understand 

likely water supply targets, ways to improve preparations and responses, and how 

to access other important sources of information on the subject.33(p3-23)

Radiological threats in the workplace were also of high concern. CHPPM’s 

health physics program provided Army radiation safety staff officers and other 

professionals with a protocol to assess the radiation emitted by x-ray cabinets and 

scanner systems that agencies were purchasing to check packages and equipment 

for contamination.33(p3-63)
198 Attack on the Pentagon: The Medical Response to 9/11

As part of the Army’s response to the 9/11 attacks, CHPPM’s industrial hygiene 

field service program supported the investigation of the October 2001 anthrax 

contamination incident in Washington. Program members deployed with the preventive medicine team to help the US capitol incident management team, a multidisciplinary federal agency force, deal with the presence of anthrax contamination 

in the Hart Senate Office Building by instituting protocols and strategies for taking anthrax samples from the environment and the workplace. Program members 

also partnered with the US Marine Corps’ hazardous materials units, whose personnel were the first responders, and with the Centers for Disease Control and 

Prevention, the National Institute for Occupational Safety and Health, and the 

Environmental Protection Agency to collect samples of anthrax and confirm and 

document its presence in the buildings of the US Capitol. 

From 19 October to 31 December, this multidisciplinary team worked around 

the clock to collect and analyze over 10,000 samples for Bacillus anthracis in 

over 30 buildings. Its findings enabled its members to offer advice on respiratory protective equipment and the decontamination of affected offices. The preventive medicine teams’ contributions included surveying and experimenting 

US Army Center for Health Promotion and Preventive Medicine’s rapid-response team is assessing 

the Hart Senate Office Building’s HVAC (heat, ventilation, and air conditioning) system for future 

sample locations and gathering information for future fumigations. 

Photograph: Lyn C Kukral, Public Affairs Officer, US Army Center for Health Promotion and Preventive Medicine. 
The Continuing Response 199

in known “hot zones” of contamination; reviewing the “remediation” plan of 

the Hart Senate Office Building; voting as a part of the review working group 

on guidance to the incident commander on the reopening of buildings cleansed 

of anthrax; leading, directing, and advising members of Congress at congressional meetings on industrial health matters; working closely with members 

of Congress, the FBI, the US Coast Guard, the Agency for Toxic Substances 

and Disease Registry, and the US Capitol Police to plan the cleaning of afTony Intrepido, US Army Center for Health Promotion and Preventive Medicine, and Mark Durno, 

US Environmental Protection Agency, leave the Hart Senate Office Building after conducting research 

on anthrax spore behavior in Senator Tom Daschle’s office (where an anthrax-contaminated letter was

opened). 

Photograph: Lyn C. Kukral, Public Affairs Officer, US Army Center for Health Promotion and Preventive Medicine. 
200 Attack on the Pentagon: The Medical Response to 9/11

fected buildings and to identify and describe potential health threats to building 

occupants.33(pp3-66,4-2,4-4)

WRAMC contributed to CHPPM’s anthrax mission by sending infectious disease doctors and nurses to the Capitol building to help test people for anthrax 

infection after the anthrax spores were found in the Hart Senate Office Building’s 

mail, and to administer antibiotics. These experts spent about 10 days on the job. 

The US Army Medical Research Institute of Infectious Diseases conducted the 

anthrax microbiology analysis that determined the positive and negative results of 

the swabs. Laboratory results were compiled and recorded in the Army’s computerized Composite Health Care System, a health information management tool.20

From 25 October to 2 November 2001, CHPPM personnel provided support to 

the US Postal Service’s Brentwood office in Washington, DC, where two postal 

workers died as a result of handling mail contaminated with anthrax spores. A 

team of two industrial hygienists and two environmental engineers first observed 

and then guided safety and health practices at the facility, consulted with outside health contractors hired by the Postal Service, and maintained command 

and control of decontamination operations. CHPPM personnel coordinated their 

activities with the Occupational Safety and Health Administration, the Environmental Protection Agency, and the National Institute for Occupational Safety and 

Health.33(p3-66) The staff of the DiLorenzo Tricare Health Clinic, with additional 

staff from WRAMC and assistance from CHPPM, tested military mail handlers at 

risk for anthrax (the DC General Hospital offered anthrax testing for all mail handlers, including those of the city’s various federal agencies, but the DoD wanted 

to take care of its own personnel).20

After 9/11, the Deployment Environmental Surveillance Program supported the 

surgeon general’s Directorate of Health Care Operations by developing a model 

and preparing casualty estimates and information for a mass casualty incident 

involving toxic industrial chemicals or materials in a major metropolitan area. 

CHPPM’s Geographic Information System personnel interpreted these findings 

geographically, which was necessary for planning purposes and analysis. MEDCOM used the results to develop policy to support civilian populations in major catastrophes. CHPPM also shared the information with the EPA’s Chemical 

Emergency Planning and Preparedness Office, the science advisor to the Department of Justice, the US Chemical Safety and Hazard Investigation Board, and 

FEMA. In much the same way, CHPPM’s Field Preventive Medicine Division 

loaned personnel to the surgeon general’s Directorate of Health Care Operations 

medical nuclear, biological, and chemical section to help assess the vulnerability 

of military chemical stockpiles. A CHPPM team responsible for industrial health 

initiatives associated with the Army’s response to 9/11 also wrote guidance on 

personal protective measures for CHPPM personnel and for New York and New 

Jersey National Guard units to reduce their exposure during a chemical emergency response.21,33(pp3-103,4-7,4-25)
The Continuing Response 201

The Pentagon Post-Disaster Health Assessment Survey

In early November, seeking both to reassure the Pentagon’s employees and to 

document and assess postdisaster health problems in order to determine how best 

to respond to future attacks, CHPPM’s Directorate of Epidemiology and Disease 

Surveillance used the Internet to deploy a health assessment survey. A paper survey was also made available in the DiLorenzo Clinic. Whether injured or not, 

respondents were asked to describe any health problems they had developed in 

the days following the 9/11 attack and the effects the tragedy had had upon them. 

The questionnaire reached more than 19,000 Pentagon employees, and 4,751 responded to it.33(ppii,3-28),34–36

Analysis of the responses revealed that 96% of employees sustained no injuries 

during the attack, and 250 persons sought medical treatment after the tragedy. 

Other results were:

• A majority (84%) indicated that they did not have old and or new health problems or concerns that have become worse since the attack. 

• A majority (85%) indicated that they had some type of inhalation exposure 

that was mostly attributed to odors rather than smoke. 

• Of those exposed to smoke, a majority (68%) were exposed to light smoke 

only, and 64% of this group for 10 minutes or less. 

• A majority (72%) of respondents were located inside the Pentagon building 

during the attack and greater than 100 feet from the collapsed sections at the 

time of the attack.

• A majority (62%) were able to evacuate the building in 10 minutes or less and 

were not injured during the evacuation. 

• Of those injured during the evacuation, 20.8% fell and 20.8% suffered cuts 

from glass or structural debris.

• Most (20.8%) suffered cuts from glass or structural debris. 

• A majority (96%) were not trapped and were able to reach the outside. 

• Of those who reported being trapped (4%), most were trapped for less than 10 

minutes, mainly by smoke, a door, or debris. 

• A majority (58%) indicated that they knew someone killed or injured.36

Evaluation of the mental health impact was an important part of the assessment. 

Forty percent of respondents (1,837) had mental health concerns in the 4 months 

following the attack. Illnesses included alcohol abuse (2.5%), posttraumatic stress 

disorder (7.9%), depression (17.7%), panic attacks (23.1%), and generalized anxiety (26.9%). Respondents reported reduced daily functioning and use of counseling services.37–39 “Risk factors known to be associated with mental health problems after traumatic events were strongly predictive of the high-risk categories 

identified.”38(p284)
202 Attack on the Pentagon: The Medical Response to 9/11

World Trade Center Support Health Assessment Survey

In support of the Army’s response to 9/11, the Army surgeon general also asked 

CHPPM to conduct the World Trade Center Support Health Assessment Survey. 

Between January 2002 and June 2003, a CHPPM team headed by Colonel Richard Kramp built upon the Pentagon survey to create a similar program for those 

affected by the World Trade Center attack. Many of the questions also came from 

a questionnaire developed by the US Army Corps of Engineers for its own personnel who had worked at ground zero. CHPPM’s Directorate of Health Promotion 

and Wellness, the Walter Reed Army Institute of Research’s psychiatry department, the Corps of Engineers, the Uniformed Services University of the Health 

Sciences, and a triservice team of mental health experts also participated in the 

survey’s development.40(pp2,3)

Surveys were given to active duty Army personnel, the New Jersey National Guard, and Corps of Engineers employees who provided support in the area 

of the World Trade Center. Surveys were not sent to members of the New York 

Guard, who were participating in their own medical evaluation. One hundred and 

sixty-two individuals, accounting for 63% of the 256 surveys sent out, responded 

to the questionnaire. Activated Reserve or National Guard soldiers represented 

53% of those providing answers; the remainder were active duty or civilian 

employees.40(p4)

Survey respondents answered questions about their exposure to smoke, dust, 

chemicals, fumes, and the approximate percentage of time they wore respirators. 

Most reported wearing respirators at least part of the time. Those working within 

the exclusion zone (“collapsed remains/debris at World Trade Center Complex 

within ground zero”40(p6)) or at Fresh Kills landfill (the Staten Island debris field 

investigation site, which employed the New Jersey National Guard) reported the 

most exposure to pollutants—96% and 98%, respectively—and alluded to wearing respirators a larger percentage of the time. Thirty percent (46 of the 152 respondents) admitted they had not used respirators at one or more of the locations 

despite being aware of their exposure to hazardous materials.40(pp6,7)

All reported exposures to dust, chemicals and fumes, and smoke; 149 (88%) revealed vulnerability to dust, 108 (67%) to chemicals and fumes, and 71 (44%) to 

smoke (Table 7-1). Most believed they were threatened by more than one pollutant. Respondents considered exposure to dust and smoke to be light intensity, and 

exposure to chemicals and fumes to be medium. Most who responded reported 

exposure to contaminants for more than 30 hours. The greatest exposure was to 

dust, chemicals, and fumes (Table 7-2).40(p10)

Only 18%, or 291 individuals, reported worsened health problems or concerns 

since working at the World Trade Center. Eighty-two percent, or 132 survey participants, declared no worsened health problems or concerns at all (Table 7-3). 

New complaints since working at the World Trade Center were factors for 61 respondents (37.7%), while 101 (62.3%) reported no new health problems. In general, 71 people (44%) reported the worsening of old health problems and the development of some kind of new health concerns since beginning their tour of duty 
The Continuing Response 203

TABLE 7-1

WORLD TRADE CENTER Support Health Assessment

Survey Respondents’ EXPOSURE TO DUST, CHEMICALS/

FUMES, AND SMOKE

Contaminant Respondents (N=162) Percentage

Dust 142 87.7

Chemicals/Fumes 108 66.7

Smoke 71 43.8

None of the above 8 4.9

Data source: US Army Center for Health Promotion and Preventive Medicine. World Trade 

Center Support Health Assessment Survey, January 2002–September 2003. Aberdeen Proving 

Ground, MD: USCHPPM; 2003. Occupational Health Report No. 64-MA-3656-2. 

TABLE 7-2

WORLD TRADE CENTER Support Health Assessment

Survey Respondents’ ESTIMATED INTENSITY OF EXPOSURE*

Respondents

Contaminant (N=154) Light Medium Heavy

No. No. % No. % No. %

Dust 140 70 50.0 46 32.9 24 17.1

Chemicals/Fumes 106 36 34.0 44 41.5 26 24.5

Smoke 70 42 60.0 24 34.3 4 5.7

*Missing responses for two respondents exposed to dust, one exposed to chemicals/fumes, 

and one exposed to smoke.

Data source: US Army Center for Health Promotion and Preventive Medicine. World Trade 

Center Support Health Assessment Survey, January 2002–September 2003. Aberdeen Proving 

Ground, MD: USCHPPM; 2003. Occupational Health Report No. 64-MA-3656-2. 

at ground zero (see Table 7-3). Pulmonary symptoms headed the list of worsening 

health conditions, with cough and breathing problems being the most common 

(Table 7-4). Old and new ailments also included eye, nose, or throat irritations; 

stress-related headaches; and such injuries as burns and noise-related hearing impairments (Table 7-5). One hundred and twenty-four persons, or 76.5%, reported 

no mental health problems. The remaining 23.5% listed posttraumatic stress syndrome, depression, alcohol abuse, panic attacks, and generalized anxiety as concerns (Table 7-6).40(pp11,12,17)

Overall, the survey succeeded in reaching out to Army members working at 

ground zero after the 9/11 attacks by providing them with assurance that their 
204 Attack on the Pentagon: The Medical Response to 9/11

TABLE 7-4

WORLD TRADE CENTER Support Health Assessment

Survey Respondents’ Pulmonary Symptoms

Pulmonary Symptom Respondents (N=71) Percentage

No symptoms 15 23.4

Pulmonary symptoms not listed 17 26.6

Shortness of breath while walking 12 18.8

Early morning cough that wakes you up 16 25.0

Chest pain with deep breathing 14 21.9

A cough that occurs mostly lying down 15 23.4

Shortness of breath that interferes with job 11 17.2

A cough that produces phlegm 21 32.8

Coughing up blood 1 1.5

Wheezing that interferes with job 5 7.7

Missing 7 9.9

Data source: US Army Center for Health Promotion and Preventive Medicine. World Trade 

Center Support Health Assessment Survey, January 2002–September 2003. Aberdeen Proving 

Ground, MD: USCHPPM; 2003. Occupational Health Report No. 64-MA-3656-2. 

individual health problems were of concern to MEDCOM and giving them a 

venue where their concerns could be addressed and where they could be directed 

to sources of information for further assistance. Survey team members walked 

TABLE 7-3

WORLD TRADE CENTER Support Health Assessment

Survey Respondents’ HEALTH PROBLEMS OR CONCERNS

Respondents (N=162) Percentage

Worsened Health Problems or Concerns

No 132 82.0

Yes 291 18.0

Missing (or conflicting) 1 .06

New Health Problems or Concerns

No 101 62.3

Yes 61 37.7

Data source: US Army Center for Health Promotion and Preventive Medicine. World Trade 

Center Support Health Assessment Survey, January 2002–September 2003. Aberdeen Proving 

Ground, MD: USCHPPM; 2003. Occupational Health Report No. 64-MA-3656-2. 
The Continuing Response 205

TABLE 7-6

WORLD TRADE CENTER Number of Individuals at High

Risk for Mental Health Outcomes

Mental Health Outcomes Respondents (N=162) Percentage 

Posttraumatic Stress Disorder 17 10.5

Depression 27 16.7

Alcohol abuse 4 2.5

Panic attacks 24 14.8

Generalized anxiety 25 15.4

Any of the above 38 23.5

None 124 76.5

Data source: US Army Center for Health Promotion and Preventive Medicine. World Trade 

Center Support Health Assessment Survey, January 2002–September 2003. Aberdeen Proving 

Ground, MD: USCHPPM; 2003. Occupational Health Report No. 64-MA-3656-2. 

TABLE 7-5

WORLD TRADE CENTER Support Health Assessment

Survey Respondents’ Identification of New or

Worsened Health Problems or Concerns

Old/New Health Problems or Concerns Respondents (N=71) Percentage

Cough 39 55.7

Breathing problems 29 41.4

Irritated eyes, nose or throat 24 34.3

Headaches 19 27.1

Stress-related 16 22.9

Injuries 4 5.7

Burns 0 0

Hearing 3 4.3

Other not listed 22 28.6

Missing 1 1.4

Data source: US Army Center for Health Promotion and Preventive Medicine. World Trade 

Center Support Health Assessment Survey, January 2002–September 2003. Aberdeen Proving 

Ground, MD: USCHPPM; 2003. Occupational Health Report No. 64-MA-3656-2. 

door-to-door in the Pentagon to reach out to personnel while collecting data, and 

they also made high priority follow-up contacts with personnel having postattack 

mental health issues.40(p25)
206 Attack on the Pentagon: The Medical Response to 9/11

Mental Health

The Army learned from the Vietnam War, the Oklahoma City bombing, and 

other experiences the importance of providing mental health support to survivors 

in the wake of tragedy. After the attack on the Pentagon, MEDCOM deployed 

mental health teams to primary care clinics and other locations to assist survivors, 

hoping to reduce dysfunctional reactions, depression, anxiety, and other psychological concerns. During the first 4 months after the attack, psychological problems were evident, as the results to the Pentagon Post-Disaster Health Assessment 

Survey can testify; however, the kinds of problems and their numbers were not 

considered abnormal in light of the magnitude of the event, and during the following year MEDCOM did not see “a huge jump in . . . psychosomatic type issues, 

sick call rates, [or] things of that nature.”24(p47)

Nevertheless, a workshop on mental health and mass violence planned for the 

Washington, DC, area before 9/11 took on increased importance after the attack. 

Mental health experts from the Department of Health and Human Services, DoD, 

Department of Veterans Affairs, Department of Justice, and American Red Cross 

met at the Arlie Conference Center in Warrenton, Virginia, from 29 October 

through 1 November 2001, to evaluate various forms of early psychological intervention commonly used by mental health workers in initial responses to disasters 

and mass violence. The meeting’s goal was to reach a consensus on the best early 

practices to use with victims of such traumatic events. The participants found that 

evidence of the effectiveness of early psychiatric interventions following such incidents was limited. Although previous randomized controlled trials among small 

groups of disaster survivors indicated that early interventions could reduce distress in family members, and that certain cognitive behavioral approaches could 

reduce depression as well as incidence, severity, and duration of posttraumatic 

stress disorder, the clinical trials also suggested that some forms of psychological after-action reviews that encouraged expression of emotions after a traumatic 

event might have heightened the risk in some survivors for later development of 

adjustment difficulties or stress disorders. Because these trials were small in number and did not collect sufficient data, however, workshop attendees concluded 

that “early interventions should be delivered as needed, in an acceptable manner 

and in keeping with best available expertise” in response to mass violence or disastrous situations. But data “should be collected through systematic research and 

evaluation”41(p8) so that timing of early interventions would be better informed in 

the future. Military attendees of the workshop also admitted that military stress 

control systems had been long practiced but not long studied. Some studies had 

resulted from collecting and collating data from theaters of operations, but much 

research remained to be done.41(pp5,8),42

At the workshop, mental health professionals also developed a list of key components of early interventions. Among them were meeting basic needs; providing 

psychological first aid; discussing how well needs were being met; observing and 

listening to those most affected; monitoring the rescue and recovery environment, 

such as media coverage and rumors; offering information and therapy by “walk-
The Continuing Response 207

ing around”; providing technical assistance, consultation, and training; fostering 

resilience and recovery; conducting clinical assessments and referrals when needed; and providing treatment to reduce symptoms or improve functioning.41(pp13,14)

After the workshop, the three military services reached an agreement to stop 

using critical incident stress procedures, because they sometimes caused more 

harm than good for survivors who reacted adversely to hearing one-on-one recital 

of events. The Air Force personnel initially resisted the decision—critical incident 

stress management had been their most used procedure and they were skeptical 

of less formal procedures they thought could be too intrusive—but eventually 

agreed.43

In the post-9/11 period, the Army’s mental health planners focused on developing procedures for counseling and managing military disasters in garrison environments. This entailed improving the combat stress control model, which was 

based primarily on the general disaster stress management techniques as outlined 

at the Warrenton workshop. For the Army, mental health was part of disaster planning, and disasters were part of the continuum of combat.43 Also during this time, 

the military continued to work with civilian mental health workers in planning 

joint responses to future disasters. At monthly meetings, the military identified 

participating organizations and their resources; discussed processes; shared information; and formed relationships, including the organization of a mental health 

coalition in the national capital region to respond to future crises.44 

Summary

MEDCOM continued to respond to the events of 9/11 long after the attacks. 

With the emergence of homeland security and bioterrorism as important issues, 

Army hospitals in the national capital region coordinated antiterrorism activities, 

fine-tuned planning within the Walter Reed Health Care System, and worked with 

civilian healthcare coalitions. Civilian medical facilities reassessed emergency 

preparedness provisions and interhospital communications in light of the new 

threats. To counter terrorism, MEDCOM focused on crisis-action planning, training, equipment acquisitions, new kinds of SMART teams, and the implementation 

of DoD instructions for antiterrorism measures. CHPPM strengthened its ability 

to respond to terrorist acts by practicing responses to nuclear, biological, chemical, and radiological threats; protecting water supplies; and working more closely 

with government agencies. Part of CHPPM’s expanding role in bioterrorism was 

its support for the investigation of the anthrax contamination incident in Washington. Because of the experiences of 9/11, the Army Medical Department made crucial doctrinal changes to improve its ability to counter future attacks. As a result 

of the lessons learned in the Pentagon attack, the Army is much better prepared to 

respond to another such event.
208 Attack on the Pentagon: The Medical Response to 9/11

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