The Psychological Aftermath of Terrorism


I HEARD THE CALL FOR HELP OVER THE RADIO, “TWO-Six David calling central,” the radio chirped.

The dispatcher answered, “Proceed Two-Six David.”

“We have 14 children and two adults involved in a school bus accident …. I need three more BLS and a supervisor, central; staging is located at East Tremont and Morris Park Avenue.”

The short pause of radio silence was interrupted, “Conditions 55, respond to the 10-32, Ground Transport Incident.”

I acknowledged the assignment, “10-4, Conditions 55 responding.”

I responded as a supervisor to this motor vehicle accident to oversee Medical Branch Operations as dispatch began assigning units ….

“Two-Six Boy, Twenty Adam, I need you ….”

On arrival, I found a small school bus involved in an accident with a van. The bus had minor front-end damage. The emergency medical technicians (EMTs) requesting backup were triaging 14 children as additional units were arriving. The children had minor injuries requiring only evaluation at the hospital. The biggest obstacle seemed to be packaging and transporting the children.

While tracking the patients, I was recording each patient’s name, age, triage status, and hospital destination. EMT William Heilman began reading off the information on his patients: Their birthdays in particular stood out-August 15, 2001; September 7, 2001; September 11, 2001. I quickly realized that these children were all five years old and were born right around or on September 11, 2001. Events during this school bus collision reminded me of just how real an issue post-traumatic stress is.

I thought to myself, How will being born around September 11, 2001, affect these children? A happy occasion of childbirth for their mothers was overshadowed by terrorism. I wondered how this event will affect these kids. I thought I alone was thinking about the children born on September 11, 2001.

But, when I made a passing comment to Heilman, he looked up with glassy eyes and echoed my concern, “That’s messed up, Lou; all these kids were born around 9/11.” Each of the EMTs in earshot looked up with the same distressed look. I then became aware that the skin on my arms had tightened and gooseflesh had formed. In an instant, September 11 was back and a very vivid memory for all of us. I realized I was not alone; the event I thought I had put behind me was still in all our minds. What seemed like a minor motor vehicle accident and a routine response evoked deep-seated emotions in EMS providers on the scene-even five years after 9/11!


While working as a paramedic in the Bronx for many years, I had always thought that critical incident stress was a fallacy, something experienced by other people. I learned first-hand in the months following 9/11 how events can work their way into our minds and overwhelm us.

Fire Department of New York Chief Daniel Nigro spoke during the EMS Week 2002 Memorial Ceremony held to commemorate the loss of the EMTs and paramedics on 9/11. He spoke inside St. Paul’s Chapel, located next to the World Trade Center recovery site. He began his speech, “Here we stand today as the Trade Center casts a shadow over all of us.” As I thought to myself, “The Trade Center is gone; what is he saying?” he continued, “The World Trade Center will always cast a shadow over our minds for the rest of our lives; there is no getting over this one.” His words were the truest I have heard relating to the World Trade Center attack and post-traumatic stress.

Prior to the 9/11 attacks, the idea of emergency responders’ needing help was commonly perceived as a sign of weakness. The concept of “seeking help” by going to counseling has been made acceptable because the effects of 9/11 were so widespread within the fire service, EMS, law enforcement, and the general public.

Critical incident stress debriefing (CISD) counseling is now a more accepted practice. I have learned how to recognize the signs of post-traumatic stress disorder (PTSD) in myself and in my coworkers and to deal with critical incident stress in a healthful manner. I think we can help each other by sharing our experiences and supporting others through tough times caused by stress resulting from terrorism and other factors in our line of work.

During our careers, we see life at the absolute worst times. We like to think we are “used to it” and take it all in stride. How do firefighters, EMTs, and paramedics deal with the psychological aftermath of critical incidents? Some traumatic incidences are not easy to put aside. PTSD is a reality in emergency services work. Even after you have forgotten an incident, one sight, smell, sound, or thought can bring you back to the moment and stimulate a vivid memory of a traumatic incident. We each react differently to these stimuli.


What can we do to deal with these reactions and prevent our job from affecting our personal lives? “Post-traumatic stress disorder is the development of characteristic symptoms following a psychologically stressful event outside of the normal range of human experience …. The characteristic symptoms involve re-experiencing the traumatic event, avoidance of stimuli associated with the event or numbing of responsiveness, and increased arousal.”1

Stress reactions are frequently caused by “triggers” that remind us of incidents we found traumatic. Triggers are emotional trip wires that evoke memories of traumatic incidents. They can be sights, sounds, smells, and feelings and are timeless, capable of making memories years later feel as if they occurred yesterday. Traumatic events like 9/11 create large multicasualty incidents; mark the loss of our illusion of safety from attack; and take the lives of firefighters, EMTs, and paramedics. Incidents that create PTSD can be large critical incidents or small individual incidents. Examples of large-scale incidents that may cause PTSD include mass fatalities, multiple burn patients, incidents where a possibility of a rescuer’s death occurs or is possible, and terrorist incidents.

In a study completed before 9/11, the rate of PTSD in American and Canadian firefighters was found to be 22 percent and 17 percent, respectively.2 Schlenger, et al, found the PTSD level in New York civilians following the 9/11 attack to be 11.2 percent.3 The prevalence of PTSD for civilians after terrorist attacks varies from 12 percent4 to 36.8 percent.5 From these statistics, we can see that firefighters have had an abnormally high incidence of PTSD even prior to the terrorist attacks. In PTSD, an event in the present, perhaps unnoticed at the time, triggers a memory from the past, leading to feelings similar to those experienced in the first event. For example, an individual blown under a bus by the “black cloud” of debris on 9/11 could some time later pass a smokestack and, without being consciously aware of the reason, begin to experience anxiety and emotional feelings resulting from the “black cloud” event. Responding through a particular neighborhood or hearing a familiar song may trigger the memory of a coworker lost in the line of duty. Triggers differ for each person. The common experience of the EMS workers’ recognizing that the children in the motor vehicle accident above were born around 9/11 is one example of how everyday stimuli can provoke a reaction in responders with PTSD.


We who need to perform in crises have developed coping strategies so we can perform to the best of our ability and survive emotionally. We have learned to maximize the use of our intellect in crisis and to distance ourselves emotionally. We do this to protect ourselves and our patients; we can’t help them if we aren’t okay ourselves. We may convince ourselves that “I can handle this; I have seen this stuff before.” The difference with incidents such as the attacks on the World Trade Center and the Pentagon and Hurricane Katrina is that the consequences and the death toll are increased dramatically.

Traumatic experiences heighten our feelings; each moment operating at a traumatic incident is recorded by our mind. While we work and suppress our feelings, our mind records the sights, sounds, and visual images. On a deeper level, we also do not realize how working in a truly unsafe environment with buildings collapsing, terrorist attacks, or severe hazards makes us feel unsafe. Combining the sights, smells, sounds, and feelings with the hazardous environment makes an event stand out. Somehow, we tuck in our feelings, button up our turnout coats, step forward, and get the job done. After the event is over, the psychological effects may surface.


What are the symptoms of stress we can watch for to indicate that stress is building? Repeated exposure to stressful incidents or a catastrophic event like 9/11 can overwhelm and surpass our protection. It is not pathology or weakness but our humanity and compassion that make it possible. Traumatic events are timeless. When they are triggered, we can feel years later as if they had just occurred-with accompanying vivid memories and strong feelings.

A person’s reaction to stress is individual. It is affected by previous exposure to the stressor, one’s perception of the event, general life experiences, and personal coping skills. Triggers vary as well. Some responders feel affected following a pediatric cardiac arrest. A bad burn patient and the smell of smoke may remind you of a firefighter who died in the line of duty. In the years since 9/11, many have had their memories triggered by watching a newsreel or documentary shows. Some remember the collapse of the World Trade Center when an elevated train passes overhead. The thundering noise of the train reminds them of shuddering steel as the World Trade Center collapsed. Even a fun activity, a familiar song, or bagpipes may make you remember a coworker who died in the line of duty.

I noticed that details I never even expected to affect me did-the smell of gypsum board and loud noises, for example. I couldn’t sleep at night. The common trigger for responders to the World Trade Center is perhaps the clear blue sky that was the ironic background for the horror that was 9/11. To this day, firefighters mourn the loss of 343 brother firefighters and refer to 9/11 simply as “that day.”

We can deal with these triggers by recognizing what situations, sights, smells, or sounds may evoke a reaction within us. By learning the signs and symptoms of PTSD and the strategies for dealing with it, we can become aware of a reaction within ourselves or our coworkers and deal with the feelings effectively.

People with PTSD tend to be edgy, irritable, nervously watchful, and easily startled.6 PTSD may also manifest itself as grief, fatigue, and anger. You may also observe signs such as short-term memory loss resulting in repeating questions, losing vehicle keys, or trouble concentrating while reading. Short-tempered behavior may result in your or a coworker’s frequently “losing it” when stressed out. You might be hypervigilant about hazards in the workplace and your safety and find it difficult to concentrate. You may become detached and withdrawn or lose interest in activities you once found enjoyable. Some may abuse medications or alcohol and engage in risky behavior such as dangerous driving. Survivor’s guilt may affect you when you think of those close to you who were lost. You might feel guilty that you survived while others did not. You might find that you are angry, bitter, or perhaps numb, unaffected by emotion. Physical symptoms include headaches, anxiety, insomnia, and an increase in diseases caused by stress. “Prolonged stress can have a negative impact on your health. Prolonged grief, anger, or even boredom can undermine the body’s physiological systems, most notably the integrity of the immune system.” (6)


The problem with PTSD is that you are not able to sense that you are “in need” of help. PTSD creeps up on you slowly. How do you help a coworker suffering from stress without intruding? Pointing a fellow firefighter to help should be done in steps. First, reach out to coworkers with the simple line, “You look a little down; is everything okay?” Throwing a “lifeline” to coworkers or friends makes them realize that someone cares. Our coworker’s validation that we are important and someone cares may be enough to start the recovery process. When trying to help a coworker, listen to what the person has to say, understand his feelings, and express empathy. Sharing your personal experiences may also help the coworker realize he is not alone. In trying to help a coworker, you are trying to encourage him to seek help, not to force help on him.

People may deny there is a problem. Avoidance is common with PTSD. By sharing your experiences and the actions you have taken to help yourself, you may be able to motivate your coworkers to get help and get back on track. When a “bad job” is bothering everybody in the station, a roundtable discussion helps members realize they all feel the same. A senior member of the company, a peer counselor, or an officer leads the discussion. During a roundtable discussion, we can discuss the call and how it was handled. Important lessons for future responses may be realized. During discussions of bad calls, it is crucial not to place blame. Venting thoughts and reviewing the chronology may be helpful in evaluating all aspects of the response and how performance can be improved next time.


The alternatives for helping a stressed-out coworker who won’t seek help and whose actions are affecting his health include getting others to come forward with the same observation to that person and peer counseling. You can invite a CISD peer support member to the station or mention your observations to your officer. Officers have the ability to talk to employees and give the benefit of their experience and perspective. Above all, coworkers talking about a specific suicide plan or exhibiting suicidal tendencies should be immediately brought to an emergency department that provides psychiatric care.

The days of looking at PTSD counseling as a sign of weakness are over. If we have PTSD, it is important that we get over our barriers and realize we’re human. We need to take care of ourselves to be there for others. We cannot be on the inside of a problem and view the solution as can a person who is distanced from the problem. By recognizing these signs and symptoms within our coworkers, we can help one another through a tough time.


Strategies for protecting yourself from stress include diversifying your interests, pursuing a hobby, eating a balanced diet, and getting regular exercise. We often bring stress on ourselves by working overtime, volunteering, and inadvertently overstimulating ourselves. It is important to find personal and family time to help strike a balanced and healthful lifestyle. By nature, we give to others and deny ourselves. By recognizing the signs of stress, we can realize when we need to take “a personal time out.” Emergency service work compels us to work long hours and holidays and push our limits. However, we have an obligation to ourselves to take the necessary actions to recover when we are stressed out and ineffective.

Five days, five years, 10 years-as noted earlier-trauma is timeless. If you or someone you know is affected by trauma, it is important to find help. To seek treatment, you can reach out to peer counselors and department employee assistance programs. Insurance companies and the American Academy of Experts in Traumatic Stress are two additional resources that can help you find an experienced clinician.

Thanks to Randy Bleiwas, CSW, MA, C.A.S.A.C., CHT, post-traumatic stress counselor, for his assistance with this article.


1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington, D.C., 1987.

2. Beaton, R, S Murphy, C Johnson, K Pike. “Exposure to Traumatic Incidents and Prevalence of Posttraumatic Stress Symptomology in Urban Firefighters in Two Countries.” Journal of Occupational Health Psychology; 1999, 4:2, 131-141.

3. Galea, S, H Resnick, J Ahern, J Gold, M Bucuvalas, D Kilapatrick, et al., “Post-traumatic stress disorder in New York City after the September 11 Terrorist Attacks,” Am J. Epidemiol; 2003, 158: 514-524.

4. Shalev, A Y, and S Freedman, “PTSD Following Terrorist Attacks: A Prospective Evaluation,” Am. J. Psychiatry; 2005, 162: 1188-1191.

5. Schlenger, W E, J M Caddell, B K Ebert, K M Jordan, D Wilson, et al., “Psychological Reactions to Terrorist Attacks: Findings from the National Study of Americans’ Reactions to September 11,” JAMA; 2002, 288:1188-1191.

6. Seaward, Brian Luke, PhD. Managing Stress. (Sudbury, Mass.: Jones and Bartlett Publishers, 2000.)

STEVEN KANARIAN is a lieutenant with the Fire Department of New York EMS Command and a former FEMA USAR medical specialist with NYTF-1.

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