Retired Lt. Gen. (Dr.) Paul K. Carlton Jr., right, directs responders after the Pentagon attack Sept. 11, 2011.

WASHINGTON — Mass-casualty management planning that occurred at the Pentagon in the months and days before 9/11 helped medical personnel respond appropriately and saved American lives, according to  retired Lt. Gen. Paul K. Carlton Jr., MD, who was involved in that planning as the Air Force surgeon general.

“I have no question that it helped tremendously,” Carlton told U.S. Medicine. In what he said was “providential” and not coincidental, that training actually involved the scenario of having a plane hit the Pentagon.

Last month, the nation reflected on the 10th anniversary of 9/11. For Carlton, that day has deep personal significance. He was at the Pentagon assisting in rescue and treatment of the victims injured when American Airlines Flight 77 hit defense headquarters, killing all 59 passengers aboard and 125 workers within the Pentagon. He was the most senior military medical officer at the Pentagon when the plane struck.

The Airman’s medal citation that he was awarded for his contribution on Sept. 11 gives a snapshot of what he encountered.

“Gen. Carlton entered a room filled with chest-high debris. Although half the room was engulfed in flames and smoke-filled, Gen. Carlton and several other rescuers located a trapped victim who was stuck under some fallen debris. The men could see the trapped victim but could not quite reach the man. One of the rescuers cleared the debris, while Gen. Carlton tried to pull the victim free. He then placed a water-soaked T-shirt on the victim’s face to aid his breathing. The victim was roused and, realizing the imminent danger they were all facing, rolled to his left, far enough for Gen. Carlton to grab him. They were then able to move the victim to safety. All the while, the room continued to rain fire and debris on Gen. Carlton and the others. As the fire intensified and moved closer in the room, Gen. Carlton continued to sweep the room for other victims. There was a loud noise, the flaming ceiling began to fall, and one of the rescuers shouted for all to leave the area. As the metal caging in the ceiling gave way, Gen. Carlton helped the others to escape the burning room.”

Terrorism Strikes

Sept. 11 began like any routine Tuesday, Carlton recalls. Every  Tuesday and Thursday, he made a trip over to the Pentagon from his office at Bolling Air Force Base for  a meeting with the Air Force secretary.

During that meeting in the basement of the Pentagon, Carlton and his colleagues were interrupted with news of what was happening at the World Trade Center in New York. They then watched in real-time on TV as the second of two airplanes hit the towers.

It wasn’t long after that American Airlines Flight 77 crashed into the west side of the Pentagon, causing it to shake and fill with smoke. Carlton said that, if he had followed a standardized evacuation plan for the Pentagon, he would have been evacuated by helicopter to a secure location to do planning. Instead, he realized he was likely the senior military physician at the Pentagon that day and wanted to stay to help victims. 

pentagon_911_1.jpg‘Providential’ Preparation

When the plane struck the Pentagon, there were pieces in place that Carlton calls “providential,” Including that he had already done work on mass-casualty management.

Carlton was the “readiness guy,” as he puts it. As the Air Force surgeon general, one of his main areas of focus had been mass casualty management for Washington and New York. He had forged relationships with the Washington Hospital District and, recently, with the New York Area Council of Hospitals in New York to work on those issues.

“I am a student of history,” he said. “I was concerned about the ’93 attacks [at the World Trade Center]. If you go back, historically, when a terrorist group decides to do something, generally they will accomplish it.”

In addition, he had been involved in planning and approving mass-casualty exercises at the Pentagon earlier in 2001 that involved a plane scenario.

That came about in February 2001 when he and the Air Force’s Flight Medicine Clinic commander in the Pentagon at the time, now-retired Air Force Col. John Baxter, MD, were having a conversation in a stairwell in the Pentagon.  Baxter suggested doing a mass-casualty exercise. For a moment, they had to stop the conversation because of noise from a plane taking off at nearby Ronald Reagan Washington National Airport.

Fortuitous Mass-Casualty Training at Pentagon Saved Lives 10 Years Ago Cont.

“So we had to stop talking for a moment as the airplane went by, and then he looked at me and said, ‘We have airplanes flying over here, hundreds a day’,” said Carlton. “Why don’t we do an airplane hits the Pentagon?”

Carlton liked the idea and suggested having the plane hit some birds, lose an engine and then do a VMC rollover and crash into the Pentagon.

“Reagan airport has a real bird problem. It was a very realistic scenario,” said Carlton.

A tabletop exercise of the scenario was done in May that included the Arlington County Emergency Medical Services, as well as  the Army’s DiLorenzo Tricare Health Clinic and the Air Force Flight Medicine Clinic, both located at the Pentagon. The scenario involved 187 dead from the crash.

During that exercise, officials identified the command and control difficulties and that they needed to do team training. Additionally, they realized they needed equipment for the teams and a way to identify who was a doctor, nurse and EMT during a mass-casualty event. This planning resulted in the distribution of blue, flame-retardant vests that were labeled “Nurse,” “Doctor” and “EMT” for the medical personnel at the Air Force Flight Medicine Clinic and the Army’s DiLorenzo Tricare Health Clinic.

Because they did not feel they had done well enough, Carlton said they set up another mass-casualty exercise for August 2001 that involved medical personnel practicing treating the wounded and working on evacuation. A “get-well” date to correct deficiencies in their plans then took place in an exercise on Sept 1, 2011. 

Managing a Chaotic Situation

Officials credit the airplane scenario exercise with helping them manage the situation at the Pentagon on 9/11.

“I think partly because we had worked over the scenario so closely in May, things were actually fairly well organized for such a chaotic situation. The triage area was being set up. They had the vests available to identify your level of training — physician, nurse, EMT, and so on,” Baxter said in an interview for Soldier to the Rescue: The Medical Response to the Pentagon Attack.

An Arlington County After Action Report also said that the exercise done with Arlington County EMS in May 2001 “helped response preparation for the Pentagon attack.”

Carlton said, for him, the exercises at the Pentagon and the resulting protective equipment that was issued were lifesaving. He recalls catching on fire at one point and one of the members of his team putting the fire out.

“In particular, it saved my life and the [life] of the kid behind me, because we had these protective vests on,” he said.

Another element of medical planning that Carlton said ended up playing an unexpected role on Sept. 11 was the use of the Air Force EMEDS. Carlton said he was not able to reach his hospital contact in New York to find out if they needed assistance. The Air Force went ahead and sent EMEDS as a system to provide back-up medical help to New York at McGuire Air Force Base, NJ. The assistance ended up not being needed, but it was good practice because it was the first time the entire EMEDS fleet was prepared to deploy with all of its assets, he said.

“It was a brand-new system for us,” Carlton said of EMEDS. “We had just gotten our teams equipped, literally just 11 days before. As it turned out, that was a great exercise to prove that we really could launch in a short window and we could respond both nationally and internationally.”

Carlton does not credit any of the planning or the Pentagon mass-casualty exercises that took place that year just to coincidence.

“I think it was purely providential,” he said.

Carlton currently is director of Innovation and Preparedness for The Health Science Center at Texas A&M University in College Station.

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