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September 11, 2001: Terrorism External and Internal

St. Vincent's Comprehensive Cancer Center

Receiving a diagnosis of cancer is an enormously focusing event. Years ago, a patient told me, "You know, Doc, you may forget your wedding anniversary or your kid's birthday, but you never forget the day you were diagnosed with cancer." Cancer care as delivered in American cancer centers in the early 21st century is highly organized and follows a well-defined flow that gives the process a quality of automaticity. There is diagnosis, consultation, patient and family communication, treatment planning, therapy, and outcome. Throughout this process patients and their families experience a spectrum of emotions including surprise/shock, anxiety/depression, hopefulness, and acceptance. This self-contained cancer-dominated world is an overriding reality for many patients and their families. The "rest of the world" is still there but less relevant than the cancer experience that has become the dominant priority.

What happens to this microcosm of focused reality, the cancer experience, when events in the real world of enormous power and reality changing potential occur? In our nation, and particularly in South West Manhattan close to the Twin Towers where I work, September 11th was such an event. How has the tragedy of the terrorist assaults of September 11th changed or, for that matter, not changed the world for us as caregivers, for our hospitals/cancer centers, and for our patients?

I believe it is useful to look at a few of the components of cancer care at Saint Vincent's to understand the impact of September 11th upon us. There are three major areas within the spectrum of the cancer experience that merit exploration: these include the Cancer Center and Medical Center, the caregivers, and our patients. Our institution, Saint Vincent's Hospital and its comprehensive cancer center are located in West Greenwich Village, approximately 11/2 miles north of what were the Twin Towers (now Ground Zero). The hospital is the nearest major medical center to the site of the tragedy. Although Saint Vincent's was a major force in effectively delivering acute care to victims and rescue workers in the days immediately after September 11th, a role in which we all take pride, there also has developed an unusual emotional ambivalence at our institution. Saint Vincent's did all the right things. It activated its disaster plans within minutes of the first airplane striking the North Tower. Many have seen the picture of surgeons and emergency medicine specialists standing in scrubs outside our ER on 7th Avenue looking south and watching the towers burn and then collapse. It is relevant that these highly trained and experienced physicians were not pictured treating patients. The emotional ambivalence at our institution has its origin in this lack of patients. On both a conscious and, I am sure, unconscious level there is a feeling of regret over the helplessness our staff experienced. This stems from having been trained to save lives of seriously injured patients, but not having the opportunity to do so because the attack was so violent that the vast majority of seriously injured patients were killed by the buildings' collapse. Since the tragedy, medical staff as they come to grips with the various expected emotions of shock, anger, and fear also manifest a continual mild sense of sadness at not having the opportunity to use their lifesaving skills to help people.

September 11 also produced significant financial effects not only upon our institution but also upon health care delivery in general in New York City. In the weeks after the terrorist attacks much of the normal elective medical/surgical care disappeared from medical centers throughout the city. The absence of this business is projected to have a severe impact on institutional budgets. The financial impact is being looked at as a citywide problem with solutions that will be multi-institutional and citywide. It will be absolutely essential that there be some degree of city, state, and federal government support to lessen the financial impact of September 11th on hospitals in New York City.

The people at our cancer center directly caring for cancer patients, including doctors, nurses, research nurses/data managers, and patient care administrators were all affected by the events of September 11th. Patient caregivers (doctors and nurses) were mobilized by the disaster plan and the cancer center facility was prepared to house in-patients moved from the hospital to open up hospital beds for the expected influx of trauma cases. In the 24 hours after the towers collapsed it became clear that there were very few survivors requiring sophisticated medical treatment. Doctors and nurses emotionally prepared to help found little to do after their mobilization, a situation resulting in emotions similar to those experienced by the trauma teams.

The fact that the tragedy of September 11th made the expression of and sharing of emotions of all sorts more common has had an effect on our oncology staff. The act of caring for cancer patients is intrinsically an emotionally stressful affair. Most patients with metastatic disease from solid tumors die of their diseases. Oncology caregivers, and this term refers to the teams of physicians, advanced practice and oncology nurses working together in the care of patients, all have experienced the sadness of seeing patients slowly dying and the frustration of knowing that there is nothing in many cases that can be done to alter this process. These feelings are not frequently discussed. However, after September 11th, there has been an increase in the openness of communication among the caregivers. We are interested in each other in a way that was not apparent before. "How are you doing?" and "How is your family?" are asked now not as perfunctory greetings but rather as an opening to questions such as "How can I help you?" and/or "How can we help each other?" This openness to sharing our emotions of fear, anxiety, uncertainty, brought upon us by the September 11th tragedy has certainly been a comfort to us all. I also believe I see the concern we feel for each other reflected in the qualities of sensitivity and compassion in the care we are giving to our patients in their own battles with the terror of cancer.

What about the effects of the September 11th tragedy upon the central figures in cancer care delivery, our patients? The reaction of most patients has been surprising to me. A brief anecdote symbolizes to me a prevailing attitude among many of our patients. As many are aware, The New York Times has developed a new style of obituary for the September 11th victims. Each day the paper publishes about 20 obituaries. Each shows a picture along with brief anecdotes about the victim, aimed at describing what made each person special to those who loved them. Most victims are young and the obituaries are very sad. One evening my wife, while reading The New York Times, said to me "I imagine some of your older patients seeing these obituaries must say, ‘Why did this young person have to die? Why couldn't it be me instead? I have lived my life and have cancer and will likely not live much longer in any event.’" Not a single patient has voiced these thoughts to me. I have asked my colleagues and they also have not experienced patients voicing this sort of altruistic thought. Patients express concern and sorrow over the September 11th events, but they quickly get back to what is most relevant to them, which is their disease and their treatment. I think this behavior pattern reflects the power of cancer to focus one's attention and emotions. To paraphrase Samuel Johnson, "Nothing so focuses the mind as knowing that you will hang in the morning." The power of cancer as a force capable of focusing one's attention was reinforced for us by several patients who called the Cancer Center on Tuesday morning the 11th wanting to make sure that their chemotherapy treatments for that day would not be cancelled (they were cancelled due to activation of our disaster plan. We resumed a full schedule at the cancer center on the 12th). Of note, particularly in light of the general decrease in elective medical and surgical care after the 11th, at the Cancer Center we have seen essentially no drop in clinical activity. The lesson here is that if you have cancer, terrorist attacks are not going to keep you from the oncologist. As one of my patients told me, "I feel sorry for all the things that happened on September 11th, but I consider my colon cancer as my own terrorist within."

So now, four months after the terrorist attacks, where are we? There is no question that all New Yorkers have grown closer together both in our sense of purpose and determination to carry on, and in our concern for each other. Our institutions in the city delivering health care have come together to understand and develop appropriate strategies for dealing with the financial problems resulting from the terrorist attacks. Finally, we who take care of cancer patients carry on doing the best we can for our patients whose focus on their "terrorists within" remains unfailing.

FOOTNOTES

EDITORS' NOTE:

The Editors encourage our readers to send in their reflections on September 11.

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