With only 46 hospital burn-unit beds in the city, New York's ability to cope with the medical catastrophe created by the World Trade Center attack will depend upon heroic levels of work by nurses and physicians, not only in the 170 hospitals within the city, but at medical facilities regionally.
The numbers of patients - perhaps more than 1,000 yesterday, with at least 150 considered critical, according to Mayor Rudolph Giuliani - far exceeds the toll taken by the subway fire of 1990 - or the World Trade Center bombing of 1993.
Most of the injuries will be basic traumas, such as broken bones, glass cuts and smoke inhalation. The most serious will involve major second- and third-degree burns.
"This will be the worst event they [hospital staff] ever have experienced," said Jim Owen, a nurse who worked on the Cornell Medical Center burn ward during both the subway fire and World Trade Center bombing. "Nothing in their past could compare."
New York has only two dedicated burn treatment centers. The larger, at New York Weill Cornell Medical Center in Manhattan, has 40 hospital beds. After the 1990 subway fire, Cornell had to shift some less critical patients onto general medical wards so it could admit 12 severely burned people.
The smaller unit, at Staten Island University Hospital, can house only six patients at a time. Several other facilities in the city have isolated burn treatment beds, but only Cornell and Staten Island have personnel specifically trained and experienced in the care that is essential to burn survival.
During the first hours after a severe burn, the key task of health providers is to bring the victims successfully out of shock. Twenty-four to 48 hours later, however, burn damage will begin to affect all systems in the patient's body, taxing the immune system and causing extreme pain. It is then that people are most vulnerable to random infections, and may lose a desire to put up a fight, overwrought as they are with pain and depression.
The trauma injuries can, by and large, be handled by surgeons and emergency personnel in any of the city's 170 hospitals, experts say.
"Actually, I think our country is better prepared to deal with the sorts of injuries that would come out of this sort of attack than chemical or biological terrorism," said Amy Smithson, a terrorism expert with the Washington, D.C.-based Stimson Center, a think tank that focuses on security issues. "Burns, broken bones - at least it's an injury we know how to treat. Things like smallpox - I don't think our physicians are prepared to deal with at all. All hospitals - especially in New York - are required to do annual trauma drills. And New York is about as prepared as any city can be."
To assist exhausted medical crews, the U.S. Public Health Service announced it will send eight disaster medical assistance teams to New York. The teams will focus on the most emotionally arduous aspects of emergency medical response: forensics, morgue support, victim identification and disposition of the remains of the dead.
In addition, the U.S. Department of Health and Human Services will send emergency support personnel to assist directly in hospital operations citywide.
A key problem in planning medical responses, and in deciding how many patients to send to any given hospital, is knowing whether New York has seen all that its terrorist attackers had in mind.
"The really difficult thing right now is not knowing if there is another shoe to drop," said Dr. Michael Osterholm of the University of Minnesota, one of the world's leading experts on medical responses to terrorism. Just hours before yesterday's attacks, Osterholm was in a classified Washington, D.C., meeting on counterterrorism.
"Has there been a biological agent released today?" Osterholm said. "Are they going to do something next? We're so used to going to consequence management - not deterrence. This has rewritten all of the books."