911: First Responders
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Emergency 4: Global Fighters for Life (known as 911: First Responders in North America) is a simulation video game developed by German studio Sixteen Tons Entertainment allowing users to manage emergency services on a variety of accident and/or accident scenes.
Adverse health effects have developed since 9/11 in workers and volunteers involved in the rescue, relief, and cleanup at the WTC site and at the Staten Island landfill (the major wreckage depository) (Edelman et al. 2003; Herbert et al. 2006; Landrigan et al. 2004; Lioy et al. 2002; Prezant et al. 2002). The health effects most commonly observed involved the upper and lower respiratory tract. Signs, symptoms, and findings include persistent cough, breathlessness, wheezing, asthma, sinusitis, laryngitis, and irritant-induced asthma, also named reactive airways dysfunction syndrome (RADS) (Herbert et al. 2006; Levin et al. 2002; Prezant et al. 2002). Cases of interstitial lung disease have also been reported, including acute eosinophilic pneumonia, granulomatous pneumonitis, sarcoidosis, and bronchiolitis obliterans (Izbicki et al. 2007; Mann et al. 2005; Rom et al. 2002; Safirstein et al. 2003).
The Mount Sinai WTC Medical Monitoring and Treatment Program (MMTP) was established to provide standardized screening and facilitate treatment of eligible responders who worked or volunteered at the WTC site. There is no systemic or comprehensive roster of all responders similar to the existing records of responders from the New York City uniformed services, such as the Fire Department of New York (FDNY) or New York Police Department, which frequently include their previous health condition. Estimates of the number of responders given by different sources range from 50,000 to 90,000 in total; we believe that the total, including FDNY workers, is likely to have been between 60,000 and 70,000 (Moline et al. 2009). In this article, we report on a case series of seven WTC responders enrolled in the Mount Sinai WTC MMTP who underwent video-assisted thoracoscopic (VATS) procedures at the Mount Sinai Medical Center and whose WTC exposures began on either 11 September or 12 September 2001. As of 11 September 2007, a total of 12,891 responders claiming first- and/or second-day exposure to the WTC pile had monitoring examinations at the Mount Sinai MMTP on or before 11 September 2007. Of these responders, one underwent VATS with biopsy in 2005, and six underwent VATS procedures between 1 January and 31 October 2007, because of severe pulmonary symptoms, impairment, or unexplained radiologic findings. We describe here the histopathologic patterns associated with these severe forms of respiratory impairment.
The seven biopsies revealed multiple, partly repeating and mixed histologic patterns. a) Small airways disease was present in almost all cases at different levels of severity, and we highlight patients D and F, in whom it was the main finding. Radiologically, these two patients presented with a mosaic pattern indicative of air trapping similar to that previously described in 25 WTC responders (Mendelson et al. 2007). Small airways disease is a condition that pathologically can be controversial and includes bronchiolitis (Fenton et al. 2007; Niewoehner et al. 1974; Wright et al. 1992). It may well be the most frequent injury pattern in exposed patients with severe respiratory impairment. b) Interstitial disease was present in four cases (Patients A, B, C, and E), characterized by a generally bronchiolocentric pattern of interstitial inflammation and fibrosis of variable severity. The lungs of these patients contained large amounts of silicates, and three of them showed nanotubes. The peripheral alveolar remodeling and fibrosis could variably be characterized as honeycombing, UIP- or NSIP-like, had some fibroblastic foci, or even resembled hypersensitivity pneumonitis (which was ruled out by pertinent serologies in all cases). Patient E even showed small numbers of poorly organized granulomas in one of the lobes and a mediastinal lymph node. The number of interstitial lymphocytes was variable, and some evidence of bronchiolitis was generally present. The bronchiolocentric characteristics seem consistent with an inhalation-related etiology. c) We had only one patient with the principal diagnosis of granulomatous disease (Patient G), although Patient E also revealed some small scattered granulomas. In the intervening years, this patient has developed evidence of interstitial disease, in the form of a miliary pattern of minute nodules, but no signs of sarcoidosis, including a negative Kveim test. Mineralogic studies may reflect sampling heterogeneity. Granulomatous disease has been previously described after WTC exposure (Izbicki et al. 2007; Safirstein et al. 2003).
We have not sought to describe the incidence of interstitial disease in the WTC MMTP patients. The sudden onset of six biopsies of our cases in January 2007 and the unexpected end of such cases, in October of the same year, is likely a reflection of the availability of federal funding for comprehensive treatment for WTC responders, which only first became available in the MMTP in November 2006. Patients may have sought care outside of the MMTP in earlier years, and some patients might have been too ill to visit the MMTP. Given these limitations, these cases are not an accurate representation of the time of onset. Whether they are an accurate representation of the total burden in this cohort remains to be seen, but it is unlikely, given the fact that physicians, including pulmonologists, have different criteria with regard to ordering diagnostic tests such as CT scans, diffusion measurements, and VATS biopsies.
Electron microscopic mineralogic analysis revealed CNT in WTC responders with extensive interstitial/parenchymal abnormalities (three of four patients) and in one of two patients with small airway disease, but not in the patient with nonnecrotizing granulomas. Nanomaterials such as CNT have many potential applications in electronics, computer, and aerospace industries because of their desirable electrical, mechanical, and thermal properties (Lam et al. 2004). CNT are hydrophobic carbon cylinders with a diameter of a few to 200 nm and variable length depending on their degree of aggregation (Florito et al. 2006; Li et al. 2007; Mercer et al. 2008; Murr et al. 2005; Shvedova et al. 2008a; Tian et al. 2006). There are single-walled carbon nanotubes (SWCNT), consisting of one such cylinder, and multiwalled carbon nanotubes (MWCNT), composed of cylinders concentrically stacked and in the form of ropes with a common long axis. They can either be commercially synthesized or can develop spontaneously over flames and high temperatures in the presence of carbon and a metal catalyst.
The etiology of the conditions described in WTC responders cannot be fully elucidated, because our analysis does not include toxic soluble gases. In this case report we identified the presence of unexpected CNT, silicates, and other elements, but it remains unclear whether any of these compounds may have caused the lung pathology. The combination of compounds may have increased the likelihood that individuals would develop pulmonary impairment. Further surveillance of individuals with these exposures should provide us with additional answers.
Twenty years after 9/11, the first responders who rushed in to save lives at the World Trade Center suffer higher rates of cancer than the general public. And many have died of cancers linked to the exposure to toxins in the air. But research suggests they're surviving at higher rates too. Gary Hershorn/Getty Images hide caption
On the morning of September 11, 2001, Elizabeth Cascio, an emergency medical technician with the New York City Fire Department, was in Queens directing a first responder training program, when the team got a call to mobilize to the World Trade Center. Her team arrived in a caravan of buses and ambulances just as the second tower collapsed.
Cascio spent about a month at ground zero assisting the recovery efforts, and she was among the first responders who developed a cough. Then, in 2019, she received a cancer diagnosis that her doctors determined was linked to her exposure.
\"The exposure [among first responders] was really dramatic,\" explains Dr. Michael Crane, a physician and environmental medicine professor at the Icahn School of Medicine at Mount Sinai, who also is the medical director of a clinic that delivers care to 9/11 first responders. \"There were all kinds of carcinogens and combustion products,\" Crane says.
It can take years, even decades, for cancers to develop. A study published in 2019 found that 9/11 first responders have an elevated risk of certain cancers, including a roughly 25% increased risk of prostate cancer, a doubling in the risk of thyroid cancer and a 41% increase in leukemia compared to the general population.
But recent research has found that first responders are also more likely than the general population to survive their cancers, according to the results of a study published this summer in the American Journal of Industrial Medicine. Researchers compared cancer deaths among the first responders to cancer deaths in the population in the New York area.
For one thing, \"it may be that they were healthier to begin with,\" says Zeig-Owens. The first responders were, on average, in their late 30s on the day of the September 11 attacks. And their jobs as firefighters and EMTS require a higher level of physical fitness, compared to people with sedentary jobs, she points out.
\"The 'healthy worker' effect is real,\" agrees Mt. Sinai's Crane. But, another possibility is that the first responders are benefiting from the comprehensive screening and medical care offered through the World Trade Center Health Program.
The big unknown is whether 9/11 first responders will continue to beat the odds and survive their cancers at significantly higher rates. Crane says the rescue and recovery workers who were present on 9/11 are, on average, in their late 50's, and the \"healthy worker\" effect that has worked to their advantage may begin to dissipate as they hit retirement age. 59ce067264