By 9:18 a.m., the first ambulances arrived, transporting victims who had sustained major traumatic injuries. To make room for these victims, we moved the patients with superficial lacerations from the emergency room to an adjacent outpatient clinic area. Within the next 10 minutes, ambulances were arriving with such great frequency that three triage teams were required. Overflow of critically injured patients from the emergency room was sent to a nearby intensive care unit. Those less seriously injured were sent to the clinic area.

Ambulances arrived in groups of three or four, some carrying single victims with severe multiple injuries, others containing two to four less severely injured victims. All victims had lacerations from flying glass. The ambulance floors were sticky from the blood. Because the blast occurred at a time when many of the active staff physicians were in or near the hospital, most of the large number of physicians in the emergency room were from St. Anthony or the adjacent Bone and Joint Hospital.

With his entire head and eyes covered with bloody bandages, a young man wearing only a blood-stained Tshirt and Marine Corps uniform pants was helped out of the back door of an ambulance. Hospital staff carefully supported his each step. As he was helped into a wheelchair, one of the staff members leaned over and whispered in his ear, "You're going to be OK now, son." As the Marine was wheeled into the emergency room, the triaging physician summoned waiting ophthalmologists and general surgeons to his aid. We later learned this Marine, father of two and soon to be three, would no longer be able to serve in the Marine Corps as a jet pilot because of a traumatic injury to his right eye. The young Marine had been on the eighth floor of the federal building visiting Marine friends, as he did each month. After the blast, the friends to whom he had been speaking were nowhere to be found. Their bodies were later recovered. His poise and composure were so remarkable, we developed a new appreciation for the Marine Corps slogan "A Few Good Men."

A woman arrived whose hand was on a doorknob at the time of the blast. Compound fractures of the ulna and radius had been wrapped at the blast site. She was wheeled into the emergency room to a waiting orthopedist. A young man whose back was turned against a pane of glass in the federal building at the time of the blast was brought into the emergency room. Four hours later, through the efforts of three surgeons, the nearly 200 lacerations of his back, shoulders, and head had been cleansed and sutured. Two days later, more glass fragments were removed from his body.

Half a block away, a woman was on the fifth floor of a building across from the federal building. She was facing a window at the time of the explosion. A shard of glass pierced her neck. She was brought off the ambulance with a paramedic applying direct pressure to the right side of her neck. Nonetheless, blood was pouring out of her neck wounds. Hemoptysis indicated that her airway was compromised. Waiting cardiovascular and general surgeons rushed her to the operating room. Forty minutes later, they had repaired her transsected esophagus and the injuries to her carotid artery and jugular vein.

Telephone lines to the emergency room and treatment areas were jammed. Handheld radios provided extra communication among the physicians directing each treatment area. Radio communication enabled us to continually allocate physicians, nurses, supplies, and equipment to various areas. More importantly, we could remain aware of the capacity of each area to accept additional patients.

Somehow, with the sense of urgency as great as it was, steps and movement were efficient, voices and emotions were under control. Professionalism and decorum were evident everywhere. Even though the three triage teams were evaluating patients who were arriving more rapidly than one per minute, patient distribution and treatment were organized.

Between 9:30 and 9:45 a.m., the clinic areas began to overflow with patients. One nurse recognized the need to open an additional treatment area to accept the overflow. She selected a medical-surgical floor. With the assistance of hospital support staff, the entire floor was soon available as a treatment area, complete with suture sets, dressings, appropriate lighting, physicians, and nurses. Another spontaneous decision was to place patients with ocular injuries and ophthalmologists into another area. Throughout the day, hospital staff made many similar decisions that deviated from the established and well-rehearsed disaster plan, a plan that had seemed so rational before the event. However, the decisions made after the actual disaster were instinctive responses based on the circumstances, the needs of the moment, and an awareness of the hospital's resources. In retrospect, it was these decisions, made more collectively than through a defined chain of command, that enabled the hospital to respond to the enormous challenge of this disaster.

Contingency plans were formulated to use other areas of the hospital and to use the Bone and Joint Hospital if other treatment areas would be needed. Another area being prepared was the family medicine residency clinic, located in a professional office building adjacent to the hospital. However, a bomb threat closed that building for the rest of the day.

Because nonemergency surgeries had been canceled at 9:15 a.m., the operating rooms were available and well prepared. Between 9:45 and 10:00 a.m., three victims were already in operating rooms, each with a team of surgeons. The surgical suite was instructed to keep "two ORs ahead." Transportation of the injured to the operating rooms required that the gurneys pass through hall-ways that were becoming crowded with medical personnel. Volunteers, blood donors, and family members from across the city, the county, and even other parts of Oklahoma were streaming into every hospital entrance.

Conference rooms designated for family members rapidly became overcrowded. Family members, clergy, social workers, and psychiatrists were relocated to a large conference center in the hospital's mental health center. Food service employees served as a human chain of guides for visitors unfamiliar with the hospital.

To maintain organization in the emergency room, identification tags were used to designate the volunteers as "RN" or "MD." Each group was assigned to wait in a specific area anticipating the arrival of more injured persons. In the street in front of the emergency room entrance was stationed an employee holding a long pole high in the air. Mounted on the pole was a large arrow inscribed with "injured" pointing toward the emergency room entrance.

Because enough staff were available for treating patients at the hospital, triage teams were dispatched to the blast site, complete with physicians, nurses, and supplies. They rode in ambulances returning to the federal building. Before sitting in the patient compartments, they had to wipe the blood from the benches and walls.

Two nurses from one of the teams rescued a grandmother from a middle floor of the destroyed federal building. They wheeled her carrier out of an ambulance. It was reassuring to see them return safely. The woman's fractured hip was surgically repaired. A young woman arrived in an ambulance with endotracheal tube in place, pupils dilated and fixed. The immediate computed tomographic scan showed multiple skull fractures, intraventricular hemorrhage, and marked cerebral edema. When her body was subsequently taken from the hospital to the medical examiner's office, we did not even know her name. During the day, five other Jane Does and one John Doe were treated and eventually identified.

All victims had glass embedded in their bodies, hair, and clothing. It was difficult to walk anywhere in the treatment areas without crunching glass underfoot. Once treatment was completed, victims searched for their families and asked about the status of other injured coworkers.

At 10:30 a.m., radio communication with the emergency medical service was lost, and television reports became the source of information. A police officer dispatched to the emergency medical service office located one block from the hospital complex learned that the service's broadcast frequency had been changed. Communication was eventually restored. Short-wave radio operators who were parked on the street outside the emergency room aided our security department in maintaining communication.

By now, six hospital areas, including the operating rooms, were being used for treatment. Each treatment area contained a portable radiograph unit. Pneumatic tubes provided laboratory results to the emergency room. Telephone lines remained overloaded. Radios and runners were still being used for internal communication. All nonemergency laboratory testing was postponed during the crisis, and qualified laboratory personnel were reassigned to blood-banking functions.

At 10:40 a.m., we were informed that a second bomb had been found at the federal building and that all rescuers had been instructed to evacuate the blast site. We were told to expect a second wave of as many as 200 casualties after deactivation of the bomb. While we anxiously waited, the hospital's food service staff began providing the first of 1700 sack lunches to the volunteers and family members. Local restaurants also pitched in with pizzas, sandwiches, and hamburgers for the waiting volunteers.

At approximately 11:30 a.m., in response to requests for updated information from the media and in an effort to stem the overwhelming flow of volunteers and blood donors, a news conference was held in front of the hospital.

By 1:00 p.m., the second bomb threat was determined to be a hoax. No second wave had materialized. Only a few injured survivors still trickled in, then there were none. Our anticipation yielded to frustration and helplessness as calls were received for body bags. Additional security officers were strategically placed at all entrances to prevent media access to the injured or to the families. As the disaster response was downgraded, most hospital personnel returned to their regular duties. Residents from the St. Anthony Hospital family practice residency program who were no longer actively involved in treatment were dispatched throughout the hospital to systematically reevaluate and coordinate the care of the injured persons admitted to the hospital. In the emergency room, however, extra staff maintained a heightened state of readiness throughout the afternoon and evening. Some treatment areas were busy late into the night.

More than 400 family members had crowded into the conference room designated as the family center. Throughout the day, families were provided information as our hospital staff communicated with other hospitals through fax machines. Taped to the walls of the family members' conference room were large poster-sized lists containing handwritten names of injured persons being treated at St. Anthony and other area hospitals. Hospital staff constantly updated the lists. As the afternoon wore on, family members who could not find their loved ones' names on the lists grew more anxious and despondent.

A bank of telephones was installed for use by family members. After the local media broadcast these numbers, the telephones never ceased ringing with inquiries from across Oklahoma, the United States, and the world. St. Anthony staff researched each of these hundreds of inquiries and returned each telephone call, working late into the night.

With darkness descending on the bomb site, hundreds of visitors anxiously searched for their missing loved ones, circulating among hospital emergency rooms with pictures clutched in their hands. One family wanted to search the entire hospital, room by room, to find a missing family member.

Simultaneously, media from across the country descended on Oklahoma City. Most were overwhelmed by the enormity of the human carnage, and some were looking for an expose. Hospital officials were especially careful to ensure the privacy of the victims and their families.

Late in the evening, instructions were received from the state medical examiner's office that all remaining family members were to proceed to a local church, which had become the official information site for families. By this time, many of the families had established a bond with the hospital staff or with some of the volunteer staff. We reluctantly complied with the instructions and announced that families were to proceed to the church. Even more reluctantly, they departed.

During the first day, eight patients were treated in the operating rooms. Multiple procedures were done by 36 surgeons. At one point, five patients were having surgical procedures simultaneously. During the first day, six ruptured globes were repaired, 50 units of blood were transfused, and the hospital's entire supply of plasma expanders (hetastarch) was used.

One patient whom we later learned was almost declared dead at the scene had 9.5 hours of surgery, performed by 11 surgeons. Her husband had been to each area hospital with her photograph several times. No one could identify his wife as a victim being treated. On his fourth visit to St. Anthony, a hospital nurse could not identify her photo as one of our Jane Does. However, she noticed that the man's wedding band was identical to that of a Jane Doe. Two days later, the patient had another 7.5 hours of plastic surgery. Five days later, she awakened from a coma. Three weeks later, appearing miraculously improved but still disfigured, she was discharged from the hospital.

Within 24 hours of the disaster, crisis intervention teams were mobilized to provide assistance to hospital staff who were deemed to be at the highest risk for psychological trauma from the disaster.

***

In subsequent days, individual counseling was provided to all hospitalized victims and to most of those treated and released, as well as their families. More than 600 hospital employees underwent debriefing.

In subsequent days, physicians counseled each other. Each of us felt an uncomfortable gnawing sense of not having done enough.

In subsequent days, we treated injured firefighters and rescue workers from around the country. They often delayed their treatment because of their reluctance to interrupt their teams' rescue efforts. By interacting with them, we developed a new appreciation for the words "dedication" and "bravery."

In subsequent days, our tears reflected both compassionate sorrow and admiration for the bravery and generosity of the community and the country.

In subsequent days, we learned that caring and kindness were stronger than hatred and destruction.