Triage and treatment teams entered the collapse zone to begin what would be a Herculean effort. The EMS operations resumed literally before the dust settled. This was a monumental task given the psychological impact of the event, the damage to local telephone services, and what can only be described as the 'fog of war' view at the site. However, we rapidly re-established a temporary medical command post at one of the adjacent undamaged hotels and the operation was once again broken down into task-specific branches. It was difficult to adapt operations to the new demands a difficulty that increased exponentially when Tower 1 collapsed. The collapse of Tower 2 caused havoc for the command and control structure, overloaded the operations' radio frequencies, and resulted in immense loss of life among the emergency teams.

Before much could be achieved, however, the second aircraft hit Tower 2 and, as we all know, Tower 2 soon collapsed. My Chief and myself were asked to organize a safe and, if possible, covered way out for self-evacuating civilians and to create a triage area on a floor in 1 World Trade Center below the fire. Inside 1 World Trade Center, the tower that had just been hit, a command station had already been set up and was staffed by the FDNY, the New York Police Department, and the Port Authority Police Department of New York and New Jersey. On arrival we received orders from the Emergency Medical Services (EMS) Major Response Duty Chief to take over medical operations inside 1 World Trade Center. The New York Police Department had done a magnificent job of clearing major roads and thoroughfares. It took less than 30 min to travel from the Bronx to lower Manhattan, despite it being the morning rush hour. That was until we turned on the local 24 hour television news station. When the FDNY heard an aircraft had struck the World Trade Center, my Chief and I assumed it was a small observation plane or a light aircraft that had left its authorized air corridor. After triage, those with green tags are encouraged to assist the more severely injured (called 'buddy aid'), which helps to maximize the amount of care one paramedic can provide. New York City uses the METTAG © triage card, which uses color to identify patient status: black for deceased, red for when immediate attention is needed, yellow for when attention can be delayed, and green for minor injuries. The patients' priority is indicated by a color-coded triage card that is tagged to them and holds the most basic information. The goal is to identify the most life threatening problem, to correct it, to assign the patient a priority, and to move on. This method is designed to allow advanced Life Support Paramedics and Basic Life Support Emergency Medical Technicians to triage patients in 60 s or less using three observations: respiration, circulation and mental status. In New York City, mass casualty triage is accomplished through the START system - Simple Triage and Rapid Treatment. The idea is that each branch operates dynamically and can expand or contract as the situation escalates or de-escalates. The tasks include communications, logistics, setting up a morgue, safety, transportation, triage, and treatment.

As part of the ICS plan, the Incident Commander breaks down the operation into task-specific branches. The World Trade Center attack was primarily an aircraft crash, so the Incident Commander came from the Fire Department of New York (FDNY). All incidents have an Incident Commander.

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