In the first few hours following the attack, communication was poor and rumors were rampant. The hospital's internal and external phone lines were overloaded and a dial tone was unavailable; internal and external pagers and cell phones were working only intermittently. Given the sketchy and unreliable nature of the information, our hospital's response was to fully prepare all areas for a worst-case scenario involving high volumes of critically injured patients. The Anesthesiology Department alone reported a cost of over US$20,000 for the period 11–12 September 2001, which was attributed to setting up all operating rooms, drawing up drugs, opening consumables, and lending out equipment that was never returned. Much of this expense could have been prevented.
Better media equipment and handheld two-way radios could have overcome the communication problems. Hospital command centers should be equipped with radios, cable and antenna television, and Internet access. Broadband Internet access and certain satellite-linked devices, neither of which depend on telephone landline integrity, proved themselves reliable sources of media information. Our broadband Internet backbone performed flawlessly, enabling us to download media news sites, such as CNN. Some portable personal digital assistants have satellite-based Internet capabilities and, in fact, traders on Wall Street found these worked throughout the attack. Future preparations may be able to take advantage of these reliable components and applications of the Internet. To date, however, this technology is not widely available.
At Bellevue, with better communication, staff in secondary and tertiary care areas could have anticipated the lag time from triage to the patients' arrival in the departments. Instead of opening kits and trays, spiking extra intravenous drips, and moving patients, staff could have waited until there was some indication from the triage areas (either within the hospital or at the attack site) that such actions would be needed. Furthermore, the Outpatient Department was converted into a makeshift emergency room, and the cystoscopy and obstetrics operating rooms were prepared for general surgery and trauma. If resources were to become overwhelmed, however, it would be better to triage and coordinate resources across the whole of the city, rather than adapt current, local resources. In other words, the first step should involve maximizing familiar systems, locations, equipment, chains of command, and routes of communication before mobilizing auxiliary resources.