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Gargano)] TJ ET 0.271 0.267 0.267 rg BT 98.322 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 103.743 663.247 Td /F1 9.8 Tf [(Robyn R. Gershon)] TJ ET 0.271 0.267 0.267 rg BT 184.483 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 189.904 663.247 Td /F1 9.8 Tf [(Robert M. Brackbill)] TJ ET 0.271 0.267 0.267 rg BT 272.252 667.135 Td /F1 8.7 Tf [(1)] TJ ET BT 26.250 652.075 Td /F4 9.0 Tf [(1)] TJ ET BT 31.254 652.075 Td /F1 9.0 Tf [( New York City Department of Health, World Trade Center Health Registry, New York, New York, USA)] TJ ET BT 26.250 640.353 Td /F1 9.8 Tf [(Gargano LM, Gershon RR, Brackbill RM. Quality of Life of Persons Injured on 9/11: Qualitative Analysis from the World Trade )] TJ ET BT 26.250 628.449 Td /F1 9.8 Tf [(Center Health Registry. PLOS Currents Disasters. 2016 Oct 27 . Edition 1. doi: )] TJ ET BT 26.250 616.544 Td /F1 9.8 Tf [(10.1371/currents.dis.7c70f66c1e6c5f41b43c797cb2a04793.)] TJ ET q 15.000 36.636 577.500 577.527 re W n 0.271 0.267 0.267 rg BT 26.250 587.441 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 567.487 Td /F1 9.8 Tf [(Introduction: A number of studies published by the World Trade Center Health Registry \(Registry\) document the prevalence of )] TJ ET BT 26.250 555.582 Td /F1 9.8 Tf [(injuries sustained by victims of the World Trade Center Disaster \(WTCD\) on 9/11. Injury occurrence during or in the immediate )] TJ ET BT 26.250 543.678 Td /F1 9.8 Tf [(aftermath of this event has been shown to be a risk factor for long-term adverse physical and mental health status. More recent )] TJ ET BT 26.250 531.773 Td /F1 9.8 Tf [(reports of ongoing physical health and mental health problems and overall poor quality of life among survivors led us to )] TJ ET BT 26.250 519.868 Td /F1 9.8 Tf [(undertake this qualitative study to explore the long-term impact of having both disaster-related injuries and peri-event traumatic )] TJ ET BT 26.250 507.963 Td /F1 9.8 Tf [(exposure on quality of life in disaster survivors.)] TJ ET BT 26.250 488.559 Td /F1 9.8 Tf [(Methods: Semi-structured, in-depth individual telephone interviews were conducted with 33 Registry enrollees who reported )] TJ ET BT 26.250 476.654 Td /F1 9.8 Tf [(being injured on 9/11/01. Topics included: extent and circumstance of the injury\(ies\), description of medical treatment for injury, )] TJ ET BT 26.250 464.749 Td /F1 9.8 Tf [(current health and functional status, and lifestyle changes resulting from the WTCD. The interviews were recorded, transcribed, )] TJ ET BT 26.250 452.844 Td /F1 9.8 Tf [(and inductively open-coded for thematic analysis.)] TJ ET BT 26.250 433.440 Td /F1 9.8 Tf [(Results: Six themes emerged with respect to long term recovery and quality of life: concurrent experience of injury with )] TJ ET BT 26.250 421.535 Td /F1 9.8 Tf [(exposure to peri-event traumatic exposure \(e.g., witnessing death or destruction, perceived life threat, etc.\); sub-optimal quality )] TJ ET BT 26.250 409.630 Td /F1 9.8 Tf [(and timeliness of short- and long-term medical care for the injury reported and mental health care; poor ongoing health status, )] TJ ET BT 26.250 397.725 Td /F1 9.8 Tf [(functional limitations, and disabilities; adverse impact on lifestyle; lack of social support; and adverse economic impact. Many )] TJ ET BT 26.250 385.821 Td /F1 9.8 Tf [(study participants, especially those reporting more serious injuries, also reported self-imposed social isolation, an inability to )] TJ ET BT 26.250 373.916 Td /F1 9.8 Tf [(participate in or take enjoyment from previously enjoyable leisure and social activities and greatly diminished overall quality of )] TJ ET BT 26.250 362.011 Td /F1 9.8 Tf [(life.)] TJ ET BT 26.250 342.606 Td /F1 9.8 Tf [(Discussion: This study provided unique insight into the long-term impact of disasters on survivors. Long after physical injuries )] TJ ET BT 26.250 330.702 Td /F1 9.8 Tf [(have healed, some injured disaster survivors report having serious health and mental health problems, economic problems due )] TJ ET BT 26.250 318.797 Td /F1 9.8 Tf [(to loss of livelihood, limited sources of social support, and profound social isolation. Strategies for addressing the long-term )] TJ ET BT 26.250 306.892 Td /F1 9.8 Tf [(health problems of disaster survivors are needed in order to support recovery.)] TJ ET BT 26.250 270.290 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 250.335 Td /F1 9.8 Tf [(This publication was supported by Cooperative Agreement Numbers 2U50/OH009739 and 5U50/OH009739 from the National )] TJ ET BT 26.250 238.431 Td /F1 9.8 Tf [(Institute for Occupational Safety and Health \(NIOSH\) of the Centers for Disease Control and Prevention \(CDC\); )] TJ ET BT 26.250 226.526 Td /F1 9.8 Tf [(U50/ATU272750 from the Agency for Toxic Substances and Disease Registry \(ATSDR\), CDC, which included support from the )] TJ ET BT 26.250 214.621 Td /F1 9.8 Tf [(National Center for Environmental Health, CDC; and by the New York City Department of Health and Mental Hygiene \(NYC )] TJ ET BT 26.250 202.716 Td /F1 9.8 Tf [(DOHMH\). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NIOSH, )] TJ ET BT 26.250 190.812 Td /F1 9.8 Tf [(CDC or the Department of Health and Human Services. The funders had no role in study design, data collection and analysis, )] TJ ET BT 26.250 178.907 Td /F1 9.8 Tf [(decision to publish, or preparation of the manuscript.)] TJ ET BT 26.250 149.804 Td /F4 12.0 Tf [(Introduction)] TJ ET Q q 15.000 684.354 577.500 53.646 re W n 0.267 0.267 0.267 rg BT 15.000 718.042 Td /F2 21.0 Tf [(Quality of Life of Persons Injured on 9/11: Qualitative Analysis )] TJ ET BT 15.000 693.094 Td /F2 21.0 Tf [(from the World Trade Center Health Registry)] TJ ET Q 0.271 0.267 0.267 rg BT 15.000 675.088 Td /F3 9.8 Tf [(October 27, 2016)] TJ ET BT 88.388 675.088 Td /F3 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 93.263 675.088 Td /F3 9.8 Tf [(Research Article)] TJ ET BT 26.250 663.247 Td /F1 9.8 Tf [(Lisa M. Gargano)] TJ ET 0.271 0.267 0.267 rg BT 98.322 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 103.743 663.247 Td /F1 9.8 Tf [(Robyn R. Gershon)] TJ ET 0.271 0.267 0.267 rg BT 184.483 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 189.904 663.247 Td /F1 9.8 Tf [(Robert M. Brackbill)] TJ ET 0.271 0.267 0.267 rg BT 272.252 667.135 Td /F1 8.7 Tf [(1)] TJ ET BT 26.250 652.075 Td /F4 9.0 Tf [(1)] TJ ET BT 31.254 652.075 Td /F1 9.0 Tf [( New York City Department of Health, World Trade Center Health Registry, New York, New York, USA)] TJ ET BT 26.250 640.353 Td /F1 9.8 Tf [(Gargano LM, Gershon RR, Brackbill RM. Quality of Life of Persons Injured on 9/11: Qualitative Analysis from the World Trade )] TJ ET BT 26.250 628.449 Td /F1 9.8 Tf [(Center Health Registry. PLOS Currents Disasters. 2016 Oct 27 . Edition 1. doi: )] TJ ET BT 26.250 616.544 Td /F1 9.8 Tf [(10.1371/currents.dis.7c70f66c1e6c5f41b43c797cb2a04793.)] TJ ET q 15.000 36.636 577.500 577.527 re W n 0.271 0.267 0.267 rg BT 26.250 587.441 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 567.487 Td /F1 9.8 Tf [(Introduction: A number of studies published by the World Trade Center Health Registry \(Registry\) document the prevalence of )] TJ ET BT 26.250 555.582 Td /F1 9.8 Tf [(injuries sustained by victims of the World Trade Center Disaster \(WTCD\) on 9/11. Injury occurrence during or in the immediate )] TJ ET BT 26.250 543.678 Td /F1 9.8 Tf [(aftermath of this event has been shown to be a risk factor for long-term adverse physical and mental health status. More recent )] TJ ET BT 26.250 531.773 Td /F1 9.8 Tf [(reports of ongoing physical health and mental health problems and overall poor quality of life among survivors led us to )] TJ ET BT 26.250 519.868 Td /F1 9.8 Tf [(undertake this qualitative study to explore the long-term impact of having both disaster-related injuries and peri-event traumatic )] TJ ET BT 26.250 507.963 Td /F1 9.8 Tf [(exposure on quality of life in disaster survivors.)] TJ ET BT 26.250 488.559 Td /F1 9.8 Tf [(Methods: Semi-structured, in-depth individual telephone interviews were conducted with 33 Registry enrollees who reported )] TJ ET BT 26.250 476.654 Td /F1 9.8 Tf [(being injured on 9/11/01. Topics included: extent and circumstance of the injury\(ies\), description of medical treatment for injury, )] TJ ET BT 26.250 464.749 Td /F1 9.8 Tf [(current health and functional status, and lifestyle changes resulting from the WTCD. The interviews were recorded, transcribed, )] TJ ET BT 26.250 452.844 Td /F1 9.8 Tf [(and inductively open-coded for thematic analysis.)] TJ ET BT 26.250 433.440 Td /F1 9.8 Tf [(Results: Six themes emerged with respect to long term recovery and quality of life: concurrent experience of injury with )] TJ ET BT 26.250 421.535 Td /F1 9.8 Tf [(exposure to peri-event traumatic exposure \(e.g., witnessing death or destruction, perceived life threat, etc.\); sub-optimal quality )] TJ ET BT 26.250 409.630 Td /F1 9.8 Tf [(and timeliness of short- and long-term medical care for the injury reported and mental health care; poor ongoing health status, )] TJ ET BT 26.250 397.725 Td /F1 9.8 Tf [(functional limitations, and disabilities; adverse impact on lifestyle; lack of social support; and adverse economic impact. Many )] TJ ET BT 26.250 385.821 Td /F1 9.8 Tf [(study participants, especially those reporting more serious injuries, also reported self-imposed social isolation, an inability to )] TJ ET BT 26.250 373.916 Td /F1 9.8 Tf [(participate in or take enjoyment from previously enjoyable leisure and social activities and greatly diminished overall quality of )] TJ ET BT 26.250 362.011 Td /F1 9.8 Tf [(life.)] TJ ET BT 26.250 342.606 Td /F1 9.8 Tf [(Discussion: This study provided unique insight into the long-term impact of disasters on survivors. Long after physical injuries )] TJ ET BT 26.250 330.702 Td /F1 9.8 Tf [(have healed, some injured disaster survivors report having serious health and mental health problems, economic problems due )] TJ ET BT 26.250 318.797 Td /F1 9.8 Tf [(to loss of livelihood, limited sources of social support, and profound social isolation. Strategies for addressing the long-term )] TJ ET BT 26.250 306.892 Td /F1 9.8 Tf [(health problems of disaster survivors are needed in order to support recovery.)] TJ ET BT 26.250 270.290 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 250.335 Td /F1 9.8 Tf [(This publication was supported by Cooperative Agreement Numbers 2U50/OH009739 and 5U50/OH009739 from the National )] TJ ET BT 26.250 238.431 Td /F1 9.8 Tf [(Institute for Occupational Safety and Health \(NIOSH\) of the Centers for Disease Control and Prevention \(CDC\); )] TJ ET BT 26.250 226.526 Td /F1 9.8 Tf [(U50/ATU272750 from the Agency for Toxic Substances and Disease Registry \(ATSDR\), CDC, which included support from the )] TJ ET BT 26.250 214.621 Td /F1 9.8 Tf [(National Center for Environmental Health, CDC; and by the New York City Department of Health and Mental Hygiene \(NYC )] TJ ET BT 26.250 202.716 Td /F1 9.8 Tf [(DOHMH\). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NIOSH, )] TJ ET BT 26.250 190.812 Td /F1 9.8 Tf [(CDC or the Department of Health and Human Services. The funders had no role in study design, data collection and analysis, )] TJ ET BT 26.250 178.907 Td /F1 9.8 Tf [(decision to publish, or preparation of the manuscript.)] TJ ET BT 26.250 149.804 Td /F4 12.0 Tf [(Introduction)] TJ ET Q q 15.000 684.354 577.500 53.646 re W n 0.267 0.267 0.267 rg BT 15.000 718.042 Td /F2 21.0 Tf [(Quality of Life of Persons Injured on 9/11: Qualitative Analysis )] TJ ET BT 15.000 693.094 Td /F2 21.0 Tf [(from the World Trade Center Health Registry)] TJ ET Q 0.271 0.267 0.267 rg BT 15.000 675.088 Td /F3 9.8 Tf [(October 27, 2016)] TJ ET BT 88.388 675.088 Td /F3 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 93.263 675.088 Td /F3 9.8 Tf [(Research Article)] TJ ET BT 26.250 663.247 Td /F1 9.8 Tf [(Lisa M. Gargano)] TJ ET 0.271 0.267 0.267 rg BT 98.322 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 103.743 663.247 Td /F1 9.8 Tf [(Robyn R. Gershon)] TJ ET 0.271 0.267 0.267 rg BT 184.483 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 189.904 663.247 Td /F1 9.8 Tf [(Robert M. Brackbill)] TJ ET 0.271 0.267 0.267 rg BT 272.252 667.135 Td /F1 8.7 Tf [(1)] TJ ET BT 26.250 652.075 Td /F4 9.0 Tf [(1)] TJ ET BT 31.254 652.075 Td /F1 9.0 Tf [( New York City Department of Health, World Trade Center Health Registry, New York, New York, USA)] TJ ET BT 26.250 640.353 Td /F1 9.8 Tf [(Gargano LM, Gershon RR, Brackbill RM. Quality of Life of Persons Injured on 9/11: Qualitative Analysis from the World Trade )] TJ ET BT 26.250 628.449 Td /F1 9.8 Tf [(Center Health Registry. PLOS Currents Disasters. 2016 Oct 27 . Edition 1. doi: )] TJ ET BT 26.250 616.544 Td /F1 9.8 Tf [(10.1371/currents.dis.7c70f66c1e6c5f41b43c797cb2a04793.)] TJ ET q 15.000 36.636 577.500 577.527 re W n 0.271 0.267 0.267 rg BT 26.250 587.441 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 567.487 Td /F1 9.8 Tf [(Introduction: A number of studies published by the World Trade Center Health Registry \(Registry\) document the prevalence of )] TJ ET BT 26.250 555.582 Td /F1 9.8 Tf [(injuries sustained by victims of the World Trade Center Disaster \(WTCD\) on 9/11. Injury occurrence during or in the immediate )] TJ ET BT 26.250 543.678 Td /F1 9.8 Tf [(aftermath of this event has been shown to be a risk factor for long-term adverse physical and mental health status. More recent )] TJ ET BT 26.250 531.773 Td /F1 9.8 Tf [(reports of ongoing physical health and mental health problems and overall poor quality of life among survivors led us to )] TJ ET BT 26.250 519.868 Td /F1 9.8 Tf [(undertake this qualitative study to explore the long-term impact of having both disaster-related injuries and peri-event traumatic )] TJ ET BT 26.250 507.963 Td /F1 9.8 Tf [(exposure on quality of life in disaster survivors.)] TJ ET BT 26.250 488.559 Td /F1 9.8 Tf [(Methods: Semi-structured, in-depth individual telephone interviews were conducted with 33 Registry enrollees who reported )] TJ ET BT 26.250 476.654 Td /F1 9.8 Tf [(being injured on 9/11/01. Topics included: extent and circumstance of the injury\(ies\), description of medical treatment for injury, )] TJ ET BT 26.250 464.749 Td /F1 9.8 Tf [(current health and functional status, and lifestyle changes resulting from the WTCD. The interviews were recorded, transcribed, )] TJ ET BT 26.250 452.844 Td /F1 9.8 Tf [(and inductively open-coded for thematic analysis.)] TJ ET BT 26.250 433.440 Td /F1 9.8 Tf [(Results: Six themes emerged with respect to long term recovery and quality of life: concurrent experience of injury with )] TJ ET BT 26.250 421.535 Td /F1 9.8 Tf [(exposure to peri-event traumatic exposure \(e.g., witnessing death or destruction, perceived life threat, etc.\); sub-optimal quality )] TJ ET BT 26.250 409.630 Td /F1 9.8 Tf [(and timeliness of short- and long-term medical care for the injury reported and mental health care; poor ongoing health status, )] TJ ET BT 26.250 397.725 Td /F1 9.8 Tf [(functional limitations, and disabilities; adverse impact on lifestyle; lack of social support; and adverse economic impact. Many )] TJ ET BT 26.250 385.821 Td /F1 9.8 Tf [(study participants, especially those reporting more serious injuries, also reported self-imposed social isolation, an inability to )] TJ ET BT 26.250 373.916 Td /F1 9.8 Tf [(participate in or take enjoyment from previously enjoyable leisure and social activities and greatly diminished overall quality of )] TJ ET BT 26.250 362.011 Td /F1 9.8 Tf [(life.)] TJ ET BT 26.250 342.606 Td /F1 9.8 Tf [(Discussion: This study provided unique insight into the long-term impact of disasters on survivors. Long after physical injuries )] TJ ET BT 26.250 330.702 Td /F1 9.8 Tf [(have healed, some injured disaster survivors report having serious health and mental health problems, economic problems due )] TJ ET BT 26.250 318.797 Td /F1 9.8 Tf [(to loss of livelihood, limited sources of social support, and profound social isolation. Strategies for addressing the long-term )] TJ ET BT 26.250 306.892 Td /F1 9.8 Tf [(health problems of disaster survivors are needed in order to support recovery.)] TJ ET BT 26.250 270.290 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 250.335 Td /F1 9.8 Tf [(This publication was supported by Cooperative Agreement Numbers 2U50/OH009739 and 5U50/OH009739 from the National )] TJ ET BT 26.250 238.431 Td /F1 9.8 Tf [(Institute for Occupational Safety and Health \(NIOSH\) of the Centers for Disease Control and Prevention \(CDC\); )] TJ ET BT 26.250 226.526 Td /F1 9.8 Tf [(U50/ATU272750 from the Agency for Toxic Substances and Disease Registry \(ATSDR\), CDC, which included support from the )] TJ ET BT 26.250 214.621 Td /F1 9.8 Tf [(National Center for Environmental Health, CDC; and by the New York City Department of Health and Mental Hygiene \(NYC )] TJ ET BT 26.250 202.716 Td /F1 9.8 Tf [(DOHMH\). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NIOSH, )] TJ ET BT 26.250 190.812 Td /F1 9.8 Tf [(CDC or the Department of Health and Human Services. 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672.2659 ] >> endobj 49 0 obj << /Type /Action /S /URI /URI (https://currents.plos.org/disasters/author/rbrackbihealth-nyc-gov/) >> endobj 50 0 obj << /Type /Page /Parent 3 0 R /Annots [ 52 0 R 54 0 R 56 0 R 58 0 R 60 0 R 62 0 R 64 0 R 66 0 R 68 0 R 70 0 R 72 0 R 74 0 R 76 0 R 78 0 R 80 0 R 82 0 R 84 0 R 86 0 R 88 0 R 90 0 R 92 0 R 94 0 R 96 0 R 98 0 R 100 0 R 102 0 R 104 0 R 106 0 R 108 0 R 110 0 R 112 0 R 114 0 R 116 0 R 118 0 R 120 0 R 122 0 R 124 0 R 126 0 R 128 0 R 130 0 R 132 0 R 134 0 R 136 0 R 138 0 R 140 0 R 142 0 R 144 0 R 146 0 R ] /Contents 51 0 R >> endobj 51 0 obj << /Length 33589 >> stream 0.271 0.267 0.267 rg q 15.000 44.491 577.500 732.509 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(A large number of studies have shown that victims of natural and human-made disasters experience both adverse physical and )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(mental health effects, with survivors especially at risk of post-traumatic stress disorder \(PTSD\) and depression.)] TJ ET 0.267 0.267 0.267 rg BT 504.156 757.079 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 508.975 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 511.384 757.079 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 516.203 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 518.612 757.079 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 523.431 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 525.840 757.079 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 530.659 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 533.068 757.079 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 537.887 755.571 Td /F1 9.8 Tf [( The )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(World Trade Center Health Registry \(Registry\) was developed to understand the short, medium, and long-term public health )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(impacts of the attacks on people exposed to the World Trade Center \(WTC\) disaster on September 11, 2001 \(9/11\). The )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(Registry enrolled more than 70,000 people who were members of populations at risk, including: those in the vicinity of the )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(attacks in lower Manhattan on 9/11/01 either in buildings \(including the WTC Towers\) or passing through the area; residents )] TJ ET BT 26.250 696.048 Td /F1 9.8 Tf [(who lived in the immediate area surrounding the WTC site; rescue, recovery and ancillary workers working at the site on 9/11 or )] TJ ET BT 26.250 684.143 Td /F1 9.8 Tf [(on later clean-up and recovery operations; and children who were enrolled in schools in the vicinity of the WTC.)] TJ ET 0.267 0.267 0.267 rg BT 505.823 685.650 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 510.642 688.031 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 513.051 685.650 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 26.250 664.738 Td /F1 9.8 Tf [(A study published by the Registry found that over 9,000 \(13%\) enrollees reported being injured on 9/11.6 The most common )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(injury reported was a sprain or strain.)] TJ ET 0.267 0.267 0.267 rg BT 186.637 654.341 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 191.456 652.833 Td /F1 9.8 Tf [( Some groups were more likely to be more seriously injured; for instance, while 3,672 )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(\(44%\) of Registry enrollee survivors were injured, 474 \(13%\) reported an injury involving a fracture or dislocation, burn, or head )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(injury.)] TJ ET 0.267 0.267 0.267 rg BT 52.253 630.531 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 57.072 629.024 Td /F1 9.8 Tf [( These and other Registry studies have also found injury to be a significant risk factor for mental health disorders, )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(including a two-fold higher likelihood of PTSD, after controlling for other risk factors.)] TJ ET 0.267 0.267 0.267 rg BT 386.054 618.626 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 390.873 621.007 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 393.282 618.626 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 398.101 617.119 Td /F1 9.8 Tf [( The occurrence of any injury was also )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(found to be independently associated with new onset heart disease post-9/11.)] TJ ET BT 362.274 609.103 Td /F1 8.7 Tf [(8)] TJ ET BT 367.093 605.214 Td /F1 9.8 Tf [( In addition to well-documented on-going health )] TJ ET BT 26.250 593.310 Td /F1 9.8 Tf [(and mental health problems noted by Registry enrollees who were injured, there have also been numerous anecdotal reports of )] TJ ET BT 26.250 581.405 Td /F1 9.8 Tf [(poor quality of life reported by survivors. Whether this is related to injuries sustained on 9/11 or to peri-traumatic exposure to the )] TJ ET BT 26.250 569.500 Td /F1 9.8 Tf [(disaster, or both, is an open question, as it is hard to disentangle the long-term effects of injuries from long-term effects of the )] TJ ET BT 26.250 557.595 Td /F1 9.8 Tf [(traumatic exposure.)] TJ ET BT 26.250 538.191 Td /F1 9.8 Tf [(After the attacks, the New York State Office of Mental Health collaborated with New York City and county mental health )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(departments to address mental health needs using two related but distinct response strategies.)] TJ ET 0.267 0.267 0.267 rg BT 435.409 527.793 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 440.227 526.286 Td /F1 9.8 Tf [( The first, named Project )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(Liberty, aimed at the general population consisted of public education concerning traumatic stress reactions and appropriate )] TJ ET BT 26.250 502.476 Td /F1 9.8 Tf [(coping strategies, outreach to all affected communities, and short-term supportive counseling for anyone affected by September )] TJ ET BT 26.250 490.572 Td /F1 9.8 Tf [(11th. The second response strategy was aimed at a subset of the affected population: individuals whose traumatic symptoms )] TJ ET BT 26.250 478.667 Td /F1 9.8 Tf [(persisted and were of sufficient severity to meet diagnostic criteria for PTSD and/or other mental disorder. From mid-October )] TJ ET BT 26.250 466.762 Td /F1 9.8 Tf [(2001 through March 2002, Project Liberty staff provided over 42,000 service encounters, representing service to over 91,000 )] TJ ET BT 26.250 454.857 Td /F1 9.8 Tf [(unique individuals. An evaluation of Project Liberty showed that counselors were able to identify which individuals might require )] TJ ET BT 26.250 442.953 Td /F1 9.8 Tf [(more intensive mental health treatment. Overall, about 9% of individuals encountered through Project Liberty were referred for )] TJ ET BT 26.250 431.048 Td /F1 9.8 Tf [(mental health treatment. These individuals experienced about twice as many traumatic symptoms as those not referred, and )] TJ ET BT 26.250 419.143 Td /F1 9.8 Tf [(rates of referral were higher for highly traumatized groups such as families of the deceased and WTC evacuees.)] TJ ET 0.267 0.267 0.267 rg BT 509.616 420.650 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 26.250 399.738 Td /F1 9.8 Tf [(Information on disaster-related factors that may influence long-term quality of life of survivors can inform the development of )] TJ ET BT 26.250 387.834 Td /F1 9.8 Tf [(strategies to ensure the best possible outcome and recovery for seriously injured disaster survivors. The goals of this qualitative )] TJ ET BT 26.250 375.929 Td /F1 9.8 Tf [(study were to 1\) fill in the gaps in knowledge concerning the circumstances surrounding the injuries, 2\) determine the short and )] TJ ET BT 26.250 364.024 Td /F1 9.8 Tf [(long term mental and physical health effects of being injured, and 3\) assess the social and economic impacts of being injured.)] TJ ET BT 26.250 327.422 Td /F4 12.0 Tf [(Methods)] TJ ET BT 26.250 307.467 Td /F1 9.8 Tf [(A semi-structured interview script, which was informed by a conceptual model of long-term health impacts in disaster survivors, )] TJ ET BT 26.250 295.563 Td /F1 9.8 Tf [(was used to conduct the interviews. Telephone interviews were conducted on 33 eligible Registry enrollees between March and )] TJ ET BT 26.250 283.658 Td /F1 9.8 Tf [(June 2015 \(83% of those contacted by phone agreed to be interviewed\). Up to 50 interviews were planned, but saturation)] TJ ET 0.267 0.267 0.267 rg BT 549.240 285.165 Td /F4 8.7 Tf [(10)] TJ ET 0.271 0.267 0.267 rg BT 26.250 271.753 Td /F1 9.8 Tf [(was reached with 33 interviews and therefore, in order to minimize respondent burden, no further recruitment was conducted. )] TJ ET BT 26.250 259.848 Td /F1 9.8 Tf [(These interviewees met the study criteria eligibility: a\) completion of registry survey waves 1, 2, and 3; b\) report of sustaining )] TJ ET BT 26.250 247.944 Td /F1 9.8 Tf [(any one or more of five types of injuries on 9/11 \(sprain/strain, cut/laceration, burn, fracture, or head injury\) on the Registrys )] TJ ET BT 26.250 236.039 Td /F1 9.8 Tf [(Wave 1 \(2002-2003\) interview; c\) report of being present south of Chambers Street on the morning of 9/11; d\) aged 17 years or )] TJ ET BT 26.250 224.134 Td /F1 9.8 Tf [(older on 9/11; e\) English language preference; f\) and current address in U.S. We maximized representation of persons who )] TJ ET BT 26.250 212.229 Td /F1 9.8 Tf [(either reported multiple types of injuries or more severe types of injuries by including those with head/concussion, burns, or )] TJ ET BT 26.250 200.325 Td /F1 9.8 Tf [(bone fractures or dislocation injuries, while also including persons with less severe types of injuries, such as sprain/strain or )] TJ ET BT 26.250 188.420 Td /F1 9.8 Tf [(lacerations. For the first 10 interviews, we did not recruit persons with a history of probable PTSD, which is defined as attaining )] TJ ET BT 26.250 176.515 Td /F1 9.8 Tf [(a score of 44 or greater on the PCL-17)] TJ ET 0.267 0.267 0.267 rg BT 193.170 178.022 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 197.989 180.403 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 200.398 178.022 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 210.035 176.515 Td /F1 9.8 Tf [( in order to assess the degree of distress during the interview that might occur. In )] TJ ET BT 26.250 164.610 Td /F1 9.8 Tf [(subsequent batches we recruited persons with probable PTSD at Waves 1 or 2 and then Wave 3. Recruiters and the interviewer )] TJ ET BT 26.250 152.706 Td /F1 9.8 Tf [(were blinded to the PTSD scores of all participants in order to minimize the risk of interviewer bias.)] TJ ET BT 26.250 133.301 Td /F1 9.8 Tf [(Potential study participants were first sent an invitation letter with a description of the study, its purpose and the benefits and )] TJ ET BT 26.250 121.396 Td /F1 9.8 Tf [(risks of participation. Registry recruitment staff called all potential participants to schedule an interview and to obtain verbal )] TJ ET BT 26.250 109.491 Td /F1 9.8 Tf [(consent prior to conducting the interview. Participants were sent a $50 gift card as compensation for their time.)] TJ ET BT 26.250 90.087 Td /F1 9.8 Tf [(Each interview lasted approximately one hour. The interviewers guide was developed by all authors with input from other )] TJ ET BT 26.250 78.182 Td /F1 9.8 Tf [(Registry staff. Table 1 displays topics and sample questions from the guide. All interviews were recorded with enrollee )] TJ ET BT 26.250 66.277 Td /F1 9.8 Tf [(permission and transcribed verbatim by a professional transcriptionist. This study was approved by the institutional review board )] TJ ET BT 26.250 54.372 Td /F1 9.8 Tf [(of the NYC Department of Health and Mental Hygiene.)] TJ ET Q q 15.000 44.491 577.500 732.509 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(A large number of studies have shown that victims of natural and human-made disasters experience both adverse physical and )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(mental health effects, with survivors especially at risk of post-traumatic stress disorder \(PTSD\) and depression.)] TJ ET 0.267 0.267 0.267 rg BT 504.156 757.079 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 508.975 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 511.384 757.079 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 516.203 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 518.612 757.079 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 523.431 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 525.840 757.079 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 530.659 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 533.068 757.079 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 537.887 755.571 Td /F1 9.8 Tf [( The )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(World Trade Center Health Registry \(Registry\) was developed to understand the short, medium, and long-term public health )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(impacts of the attacks on people exposed to the World Trade Center \(WTC\) disaster on September 11, 2001 \(9/11\). The )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(Registry enrolled more than 70,000 people who were members of populations at risk, including: those in the vicinity of the )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(attacks in lower Manhattan on 9/11/01 either in buildings \(including the WTC Towers\) or passing through the area; residents )] TJ ET BT 26.250 696.048 Td /F1 9.8 Tf [(who lived in the immediate area surrounding the WTC site; rescue, recovery and ancillary workers working at the site on 9/11 or )] TJ ET BT 26.250 684.143 Td /F1 9.8 Tf [(on later clean-up and recovery operations; and children who were enrolled in schools in the vicinity of the WTC.)] TJ ET 0.267 0.267 0.267 rg BT 505.823 685.650 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 510.642 688.031 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 513.051 685.650 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 26.250 664.738 Td /F1 9.8 Tf [(A study published by the Registry found that over 9,000 \(13%\) enrollees reported being injured on 9/11.6 The most common )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(injury reported was a sprain or strain.)] TJ ET 0.267 0.267 0.267 rg BT 186.637 654.341 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 191.456 652.833 Td /F1 9.8 Tf [( Some groups were more likely to be more seriously injured; for instance, while 3,672 )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(\(44%\) of Registry enrollee survivors were injured, 474 \(13%\) reported an injury involving a fracture or dislocation, burn, or head )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(injury.)] TJ ET 0.267 0.267 0.267 rg BT 52.253 630.531 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 57.072 629.024 Td /F1 9.8 Tf [( These and other Registry studies have also found injury to be a significant risk factor for mental health disorders, )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(including a two-fold higher likelihood of PTSD, after controlling for other risk factors.)] TJ ET 0.267 0.267 0.267 rg BT 386.054 618.626 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 390.873 621.007 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 393.282 618.626 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 398.101 617.119 Td /F1 9.8 Tf [( The occurrence of any injury was also )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(found to be independently associated with new onset heart disease post-9/11.)] TJ ET BT 362.274 609.103 Td /F1 8.7 Tf [(8)] TJ ET BT 367.093 605.214 Td /F1 9.8 Tf [( In addition to well-documented on-going health )] TJ ET BT 26.250 593.310 Td /F1 9.8 Tf [(and mental health problems noted by Registry enrollees who were injured, there have also been numerous anecdotal reports of )] TJ ET BT 26.250 581.405 Td /F1 9.8 Tf [(poor quality of life reported by survivors. Whether this is related to injuries sustained on 9/11 or to peri-traumatic exposure to the )] TJ ET BT 26.250 569.500 Td /F1 9.8 Tf [(disaster, or both, is an open question, as it is hard to disentangle the long-term effects of injuries from long-term effects of the )] TJ ET BT 26.250 557.595 Td /F1 9.8 Tf [(traumatic exposure.)] TJ ET BT 26.250 538.191 Td /F1 9.8 Tf [(After the attacks, the New York State Office of Mental Health collaborated with New York City and county mental health )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(departments to address mental health needs using two related but distinct response strategies.)] TJ ET 0.267 0.267 0.267 rg BT 435.409 527.793 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 440.227 526.286 Td /F1 9.8 Tf [( The first, named Project )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(Liberty, aimed at the general population consisted of public education concerning traumatic stress reactions and appropriate )] TJ ET BT 26.250 502.476 Td /F1 9.8 Tf [(coping strategies, outreach to all affected communities, and short-term supportive counseling for anyone affected by September )] TJ ET BT 26.250 490.572 Td /F1 9.8 Tf [(11th. The second response strategy was aimed at a subset of the affected population: individuals whose traumatic symptoms )] TJ ET BT 26.250 478.667 Td /F1 9.8 Tf [(persisted and were of sufficient severity to meet diagnostic criteria for PTSD and/or other mental disorder. From mid-October )] TJ ET BT 26.250 466.762 Td /F1 9.8 Tf [(2001 through March 2002, Project Liberty staff provided over 42,000 service encounters, representing service to over 91,000 )] TJ ET BT 26.250 454.857 Td /F1 9.8 Tf [(unique individuals. An evaluation of Project Liberty showed that counselors were able to identify which individuals might require )] TJ ET BT 26.250 442.953 Td /F1 9.8 Tf [(more intensive mental health treatment. Overall, about 9% of individuals encountered through Project Liberty were referred for )] TJ ET BT 26.250 431.048 Td /F1 9.8 Tf [(mental health treatment. These individuals experienced about twice as many traumatic symptoms as those not referred, and )] TJ ET BT 26.250 419.143 Td /F1 9.8 Tf [(rates of referral were higher for highly traumatized groups such as families of the deceased and WTC evacuees.)] TJ ET 0.267 0.267 0.267 rg BT 509.616 420.650 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 26.250 399.738 Td /F1 9.8 Tf [(Information on disaster-related factors that may influence long-term quality of life of survivors can inform the development of )] TJ ET BT 26.250 387.834 Td /F1 9.8 Tf [(strategies to ensure the best possible outcome and recovery for seriously injured disaster survivors. The goals of this qualitative )] TJ ET BT 26.250 375.929 Td /F1 9.8 Tf [(study were to 1\) fill in the gaps in knowledge concerning the circumstances surrounding the injuries, 2\) determine the short and )] TJ ET BT 26.250 364.024 Td /F1 9.8 Tf [(long term mental and physical health effects of being injured, and 3\) assess the social and economic impacts of being injured.)] TJ ET BT 26.250 327.422 Td /F4 12.0 Tf [(Methods)] TJ ET BT 26.250 307.467 Td /F1 9.8 Tf [(A semi-structured interview script, which was informed by a conceptual model of long-term health impacts in disaster survivors, )] TJ ET BT 26.250 295.563 Td /F1 9.8 Tf [(was used to conduct the interviews. Telephone interviews were conducted on 33 eligible Registry enrollees between March and )] TJ ET BT 26.250 283.658 Td /F1 9.8 Tf [(June 2015 \(83% of those contacted by phone agreed to be interviewed\). Up to 50 interviews were planned, but saturation)] TJ ET 0.267 0.267 0.267 rg BT 549.240 285.165 Td /F4 8.7 Tf [(10)] TJ ET 0.271 0.267 0.267 rg BT 26.250 271.753 Td /F1 9.8 Tf [(was reached with 33 interviews and therefore, in order to minimize respondent burden, no further recruitment was conducted. )] TJ ET BT 26.250 259.848 Td /F1 9.8 Tf [(These interviewees met the study criteria eligibility: a\) completion of registry survey waves 1, 2, and 3; b\) report of sustaining )] TJ ET BT 26.250 247.944 Td /F1 9.8 Tf [(any one or more of five types of injuries on 9/11 \(sprain/strain, cut/laceration, burn, fracture, or head injury\) on the Registrys )] TJ ET BT 26.250 236.039 Td /F1 9.8 Tf [(Wave 1 \(2002-2003\) interview; c\) report of being present south of Chambers Street on the morning of 9/11; d\) aged 17 years or )] TJ ET BT 26.250 224.134 Td /F1 9.8 Tf [(older on 9/11; e\) English language preference; f\) and current address in U.S. We maximized representation of persons who )] TJ ET BT 26.250 212.229 Td /F1 9.8 Tf [(either reported multiple types of injuries or more severe types of injuries by including those with head/concussion, burns, or )] TJ ET BT 26.250 200.325 Td /F1 9.8 Tf [(bone fractures or dislocation injuries, while also including persons with less severe types of injuries, such as sprain/strain or )] TJ ET BT 26.250 188.420 Td /F1 9.8 Tf [(lacerations. For the first 10 interviews, we did not recruit persons with a history of probable PTSD, which is defined as attaining )] TJ ET BT 26.250 176.515 Td /F1 9.8 Tf [(a score of 44 or greater on the PCL-17)] TJ ET 0.267 0.267 0.267 rg BT 193.170 178.022 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 197.989 180.403 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 200.398 178.022 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 210.035 176.515 Td /F1 9.8 Tf [( in order to assess the degree of distress during the interview that might occur. In )] TJ ET BT 26.250 164.610 Td /F1 9.8 Tf [(subsequent batches we recruited persons with probable PTSD at Waves 1 or 2 and then Wave 3. Recruiters and the interviewer )] TJ ET BT 26.250 152.706 Td /F1 9.8 Tf [(were blinded to the PTSD scores of all participants in order to minimize the risk of interviewer bias.)] TJ ET BT 26.250 133.301 Td /F1 9.8 Tf [(Potential study participants were first sent an invitation letter with a description of the study, its purpose and the benefits and )] TJ ET BT 26.250 121.396 Td /F1 9.8 Tf [(risks of participation. Registry recruitment staff called all potential participants to schedule an interview and to obtain verbal )] TJ ET BT 26.250 109.491 Td /F1 9.8 Tf [(consent prior to conducting the interview. Participants were sent a $50 gift card as compensation for their time.)] TJ ET BT 26.250 90.087 Td /F1 9.8 Tf [(Each interview lasted approximately one hour. The interviewers guide was developed by all authors with input from other )] TJ ET BT 26.250 78.182 Td /F1 9.8 Tf [(Registry staff. Table 1 displays topics and sample questions from the guide. All interviews were recorded with enrollee )] TJ ET BT 26.250 66.277 Td /F1 9.8 Tf [(permission and transcribed verbatim by a professional transcriptionist. This study was approved by the institutional review board )] TJ ET BT 26.250 54.372 Td /F1 9.8 Tf [(of the NYC Department of Health and Mental Hygiene.)] TJ ET Q q 15.000 44.491 577.500 732.509 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(A large number of studies have shown that victims of natural and human-made disasters experience both adverse physical and )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(mental health effects, with survivors especially at risk of post-traumatic stress disorder \(PTSD\) and depression.)] TJ ET 0.267 0.267 0.267 rg BT 504.156 757.079 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 508.975 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 511.384 757.079 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 516.203 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 518.612 757.079 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 523.431 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 525.840 757.079 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 530.659 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 533.068 757.079 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 537.887 755.571 Td /F1 9.8 Tf [( The )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(World Trade Center Health Registry \(Registry\) was developed to understand the short, medium, and long-term public health )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(impacts of the attacks on people exposed to the World Trade Center \(WTC\) disaster on September 11, 2001 \(9/11\). The )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(Registry enrolled more than 70,000 people who were members of populations at risk, including: those in the vicinity of the )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(attacks in lower Manhattan on 9/11/01 either in buildings \(including the WTC Towers\) or passing through the area; residents )] TJ ET BT 26.250 696.048 Td /F1 9.8 Tf [(who lived in the immediate area surrounding the WTC site; rescue, recovery and ancillary workers working at the site on 9/11 or )] TJ ET BT 26.250 684.143 Td /F1 9.8 Tf [(on later clean-up and recovery operations; and children who were enrolled in schools in the vicinity of the WTC.)] TJ ET 0.267 0.267 0.267 rg BT 505.823 685.650 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 510.642 688.031 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 513.051 685.650 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 26.250 664.738 Td /F1 9.8 Tf [(A study published by the Registry found that over 9,000 \(13%\) enrollees reported being injured on 9/11.6 The most common )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(injury reported was a sprain or strain.)] TJ ET 0.267 0.267 0.267 rg BT 186.637 654.341 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 191.456 652.833 Td /F1 9.8 Tf [( Some groups were more likely to be more seriously injured; for instance, while 3,672 )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(\(44%\) of Registry enrollee survivors were injured, 474 \(13%\) reported an injury involving a fracture or dislocation, burn, or head )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(injury.)] TJ ET 0.267 0.267 0.267 rg BT 52.253 630.531 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 57.072 629.024 Td /F1 9.8 Tf [( These and other Registry studies have also found injury to be a significant risk factor for mental health disorders, )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(including a two-fold higher likelihood of PTSD, after controlling for other risk factors.)] TJ ET 0.267 0.267 0.267 rg BT 386.054 618.626 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 390.873 621.007 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 393.282 618.626 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 398.101 617.119 Td /F1 9.8 Tf [( The occurrence of any injury was also )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(found to be independently associated with new onset heart disease post-9/11.)] TJ ET BT 362.274 609.103 Td /F1 8.7 Tf [(8)] TJ ET BT 367.093 605.214 Td /F1 9.8 Tf [( In addition to well-documented on-going health )] TJ ET BT 26.250 593.310 Td /F1 9.8 Tf [(and mental health problems noted by Registry enrollees who were injured, there have also been numerous anecdotal reports of )] TJ ET BT 26.250 581.405 Td /F1 9.8 Tf [(poor quality of life reported by survivors. Whether this is related to injuries sustained on 9/11 or to peri-traumatic exposure to the )] TJ ET BT 26.250 569.500 Td /F1 9.8 Tf [(disaster, or both, is an open question, as it is hard to disentangle the long-term effects of injuries from long-term effects of the )] TJ ET BT 26.250 557.595 Td /F1 9.8 Tf [(traumatic exposure.)] TJ ET BT 26.250 538.191 Td /F1 9.8 Tf [(After the attacks, the New York State Office of Mental Health collaborated with New York City and county mental health )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(departments to address mental health needs using two related but distinct response strategies.)] TJ ET 0.267 0.267 0.267 rg BT 435.409 527.793 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 440.227 526.286 Td /F1 9.8 Tf [( The first, named Project )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(Liberty, aimed at the general population consisted of public education concerning traumatic stress reactions and appropriate )] TJ ET BT 26.250 502.476 Td /F1 9.8 Tf [(coping strategies, outreach to all affected communities, and short-term supportive counseling for anyone affected by September )] TJ ET BT 26.250 490.572 Td /F1 9.8 Tf [(11th. The second response strategy was aimed at a subset of the affected population: individuals whose traumatic symptoms )] TJ ET BT 26.250 478.667 Td /F1 9.8 Tf [(persisted and were of sufficient severity to meet diagnostic criteria for PTSD and/or other mental disorder. From mid-October )] TJ ET BT 26.250 466.762 Td /F1 9.8 Tf [(2001 through March 2002, Project Liberty staff provided over 42,000 service encounters, representing service to over 91,000 )] TJ ET BT 26.250 454.857 Td /F1 9.8 Tf [(unique individuals. An evaluation of Project Liberty showed that counselors were able to identify which individuals might require )] TJ ET BT 26.250 442.953 Td /F1 9.8 Tf [(more intensive mental health treatment. Overall, about 9% of individuals encountered through Project Liberty were referred for )] TJ ET BT 26.250 431.048 Td /F1 9.8 Tf [(mental health treatment. These individuals experienced about twice as many traumatic symptoms as those not referred, and )] TJ ET BT 26.250 419.143 Td /F1 9.8 Tf [(rates of referral were higher for highly traumatized groups such as families of the deceased and WTC evacuees.)] TJ ET 0.267 0.267 0.267 rg BT 509.616 420.650 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 26.250 399.738 Td /F1 9.8 Tf [(Information on disaster-related factors that may influence long-term quality of life of survivors can inform the development of )] TJ ET BT 26.250 387.834 Td /F1 9.8 Tf [(strategies to ensure the best possible outcome and recovery for seriously injured disaster survivors. The goals of this qualitative )] TJ ET BT 26.250 375.929 Td /F1 9.8 Tf [(study were to 1\) fill in the gaps in knowledge concerning the circumstances surrounding the injuries, 2\) determine the short and )] TJ ET BT 26.250 364.024 Td /F1 9.8 Tf [(long term mental and physical health effects of being injured, and 3\) assess the social and economic impacts of being injured.)] TJ ET BT 26.250 327.422 Td /F4 12.0 Tf [(Methods)] TJ ET BT 26.250 307.467 Td /F1 9.8 Tf [(A semi-structured interview script, which was informed by a conceptual model of long-term health impacts in disaster survivors, )] TJ ET BT 26.250 295.563 Td /F1 9.8 Tf [(was used to conduct the interviews. Telephone interviews were conducted on 33 eligible Registry enrollees between March and )] TJ ET BT 26.250 283.658 Td /F1 9.8 Tf [(June 2015 \(83% of those contacted by phone agreed to be interviewed\). Up to 50 interviews were planned, but saturation)] TJ ET 0.267 0.267 0.267 rg BT 549.240 285.165 Td /F4 8.7 Tf [(10)] TJ ET 0.271 0.267 0.267 rg BT 26.250 271.753 Td /F1 9.8 Tf [(was reached with 33 interviews and therefore, in order to minimize respondent burden, no further recruitment was conducted. )] TJ ET BT 26.250 259.848 Td /F1 9.8 Tf [(These interviewees met the study criteria eligibility: a\) completion of registry survey waves 1, 2, and 3; b\) report of sustaining )] TJ ET BT 26.250 247.944 Td /F1 9.8 Tf [(any one or more of five types of injuries on 9/11 \(sprain/strain, cut/laceration, burn, fracture, or head injury\) on the Registrys )] TJ ET BT 26.250 236.039 Td /F1 9.8 Tf [(Wave 1 \(2002-2003\) interview; c\) report of being present south of Chambers Street on the morning of 9/11; d\) aged 17 years or )] TJ ET BT 26.250 224.134 Td /F1 9.8 Tf [(older on 9/11; e\) English language preference; f\) and current address in U.S. We maximized representation of persons who )] TJ ET BT 26.250 212.229 Td /F1 9.8 Tf [(either reported multiple types of injuries or more severe types of injuries by including those with head/concussion, burns, or )] TJ ET BT 26.250 200.325 Td /F1 9.8 Tf [(bone fractures or dislocation injuries, while also including persons with less severe types of injuries, such as sprain/strain or )] TJ ET BT 26.250 188.420 Td /F1 9.8 Tf [(lacerations. For the first 10 interviews, we did not recruit persons with a history of probable PTSD, which is defined as attaining )] TJ ET BT 26.250 176.515 Td /F1 9.8 Tf [(a score of 44 or greater on the PCL-17)] TJ ET 0.267 0.267 0.267 rg BT 193.170 178.022 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 197.989 180.403 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 200.398 178.022 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 210.035 176.515 Td /F1 9.8 Tf [( in order to assess the degree of distress during the interview that might occur. In )] TJ ET BT 26.250 164.610 Td /F1 9.8 Tf [(subsequent batches we recruited persons with probable PTSD at Waves 1 or 2 and then Wave 3. Recruiters and the interviewer )] TJ ET BT 26.250 152.706 Td /F1 9.8 Tf [(were blinded to the PTSD scores of all participants in order to minimize the risk of interviewer bias.)] TJ ET BT 26.250 133.301 Td /F1 9.8 Tf [(Potential study participants were first sent an invitation letter with a description of the study, its purpose and the benefits and )] TJ ET BT 26.250 121.396 Td /F1 9.8 Tf [(risks of participation. Registry recruitment staff called all potential participants to schedule an interview and to obtain verbal )] TJ ET BT 26.250 109.491 Td /F1 9.8 Tf [(consent prior to conducting the interview. Participants were sent a $50 gift card as compensation for their time.)] TJ ET BT 26.250 90.087 Td /F1 9.8 Tf [(Each interview lasted approximately one hour. The interviewers guide was developed by all authors with input from other )] TJ ET BT 26.250 78.182 Td /F1 9.8 Tf [(Registry staff. Table 1 displays topics and sample questions from the guide. All interviews were recorded with enrollee )] TJ ET BT 26.250 66.277 Td /F1 9.8 Tf [(permission and transcribed verbatim by a professional transcriptionist. 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0 291.000 35.250 437.441 cm /I3 Do Q q 35.250 410.204 537.000 21.236 re W n 0.271 0.267 0.267 rg BT 35.250 420.451 Td /F4 9.8 Tf [(Table 1. )] TJ ET BT 74.269 420.451 Td /F1 9.8 Tf [(Interview topic and sample questions)] TJ ET Q BT 26.250 381.930 Td /F4 9.8 Tf [(Data Analysis)] TJ ET BT 26.250 362.526 Td /F1 9.8 Tf [(Using a pre-set list of major themes that were based on the conceptual models embedded in the interview script, two members )] TJ ET BT 26.250 350.621 Td /F1 9.8 Tf [(of the research team read and coded the first five transcripts of the recorded data. The analysis was conducted using the block )] TJ ET BT 26.250 338.716 Td /F1 9.8 Tf [(of data for each of the major categories as described in the interview guide. The researchers then met to achieve consensus on )] TJ ET BT 26.250 326.811 Td /F1 9.8 Tf [(the major themes and sub-themes, and to identify and discuss any new themes that emerged from the data. At this stage, the )] TJ ET BT 26.250 314.907 Td /F1 9.8 Tf [(researchers also agreed upon the terminology that would be used for the themes. For example, originally, one researcher listed )] TJ ET BT 26.250 303.002 Td /F1 9.8 Tf [(Changes in Work Status as a separate theme, the two researchers agreed to fold this into the Lifestyle Impacts theme. One )] TJ ET BT 26.250 291.097 Td /F1 9.8 Tf [(researcher initially referred to any new health problems as New Health Problems, which was then changed to Current Health )] TJ ET BT 26.250 279.192 Td /F1 9.8 Tf [(Status, Functional Physical Status Impairments and Disability. Once the new terminology was in place, the two researchers )] TJ ET BT 26.250 267.288 Td /F1 9.8 Tf [(then read the next 5 transcripts to ensure that they were coding using the same terminology and pre-set themes similarly. After )] TJ ET BT 26.250 255.383 Td /F1 9.8 Tf [(thorough discussion of the identified themes by all three researchers, further adjustments to terminology were again made at )] TJ ET BT 26.250 243.478 Td /F1 9.8 Tf [(this point to keep the themes to a manageable number \(resulting in the final six themes identified\). Disagreements about )] TJ ET BT 26.250 231.573 Td /F1 9.8 Tf [(themes were discussed and resolved among coders until 100% agreement on themes was achieved. Two researchers then )] TJ ET BT 26.250 219.669 Td /F1 9.8 Tf [(reread all 33 transcripts and coded them separately. They then met to compare their results and at this point the third )] TJ ET BT 26.250 207.764 Td /F1 9.8 Tf [(researcher assessed the coding and determined an interrater reliability of 0.97.)] TJ ET BT 26.250 188.359 Td /F1 9.8 Tf [(The authors used thematic analysis)] TJ ET 0.267 0.267 0.267 rg BT 179.608 189.866 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 189.245 188.359 Td /F1 9.8 Tf [( as the analytic framework to identify themes relevant to participants post-9/11 health and )] TJ ET BT 26.250 176.454 Td /F1 9.8 Tf [(mental health \(short- and long-term\), health care utilization, social support, and everyday functioning. Coders were unaware of )] TJ ET BT 26.250 164.550 Td /F1 9.8 Tf [(the PTSD scores during this analysis phase. The analysis included line-by-line coding of statements and responses by two )] TJ ET BT 26.250 152.645 Td /F1 9.8 Tf [(independent researchers \(LMG and RG\).)] TJ ET 0.267 0.267 0.267 rg BT 203.446 154.152 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 213.084 152.645 Td /F1 9.8 Tf [( The researchers reviewed the codes and evaluated their meaning. The coded data )] TJ ET BT 26.250 140.740 Td /F1 9.8 Tf [(were organized to identify themes. These themes were cross-referenced among the coders and percent agreement was )] TJ ET BT 26.250 128.835 Td /F1 9.8 Tf [(determined.)] TJ ET BT 26.250 92.233 Td /F4 12.0 Tf [(Results)] TJ ET BT 26.250 72.279 Td /F4 9.8 Tf [(Participant characteristics)] TJ ET BT 26.250 52.874 Td /F1 9.8 Tf [(Demographic characteristics of the participants are described in Table 2. Over half \(57.6%\) were male and 48.5% were age 25-)] TJ ET BT 26.250 40.969 Td /F1 9.8 Tf [(44 years on 9/11. The largest proportion \(75.8%\) of participants was white and 12.1% were Hispanic. Almost half \(45.5%\) had a )] TJ ET Q q 15.000 26.683 577.500 750.317 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F4 9.8 Tf [(Ethics Statement)] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(This study was approved by the institutional review board of the NYC Department of Health and Mental Hygiene.)] TJ ET 0.965 0.965 0.965 rg 26.250 398.954 555.000 339.236 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 738.191 m 581.250 738.191 l 581.250 737.441 l 26.250 737.441 l f 26.250 398.954 m 581.250 398.954 l 581.250 399.704 l 26.250 399.704 l f q 450.000 0 0 291.000 35.250 437.441 cm /I3 Do Q q 35.250 410.204 537.000 21.236 re W n 0.271 0.267 0.267 rg BT 35.250 420.451 Td /F4 9.8 Tf [(Table 1. )] TJ ET BT 74.269 420.451 Td /F1 9.8 Tf [(Interview topic and sample questions)] TJ ET Q BT 26.250 381.930 Td /F4 9.8 Tf [(Data Analysis)] TJ ET BT 26.250 362.526 Td /F1 9.8 Tf [(Using a pre-set list of major themes that were based on the conceptual models embedded in the interview script, two members )] TJ ET BT 26.250 350.621 Td /F1 9.8 Tf [(of the research team read and coded the first five transcripts of the recorded data. The analysis was conducted using the block )] TJ ET BT 26.250 338.716 Td /F1 9.8 Tf [(of data for each of the major categories as described in the interview guide. The researchers then met to achieve consensus on )] TJ ET BT 26.250 326.811 Td /F1 9.8 Tf [(the major themes and sub-themes, and to identify and discuss any new themes that emerged from the data. At this stage, the )] TJ ET BT 26.250 314.907 Td /F1 9.8 Tf [(researchers also agreed upon the terminology that would be used for the themes. For example, originally, one researcher listed )] TJ ET BT 26.250 303.002 Td /F1 9.8 Tf [(Changes in Work Status as a separate theme, the two researchers agreed to fold this into the Lifestyle Impacts theme. One )] TJ ET BT 26.250 291.097 Td /F1 9.8 Tf [(researcher initially referred to any new health problems as New Health Problems, which was then changed to Current Health )] TJ ET BT 26.250 279.192 Td /F1 9.8 Tf [(Status, Functional Physical Status Impairments and Disability. Once the new terminology was in place, the two researchers )] TJ ET BT 26.250 267.288 Td /F1 9.8 Tf [(then read the next 5 transcripts to ensure that they were coding using the same terminology and pre-set themes similarly. After )] TJ ET BT 26.250 255.383 Td /F1 9.8 Tf [(thorough discussion of the identified themes by all three researchers, further adjustments to terminology were again made at )] TJ ET BT 26.250 243.478 Td /F1 9.8 Tf [(this point to keep the themes to a manageable number \(resulting in the final six themes identified\). Disagreements about )] TJ ET BT 26.250 231.573 Td /F1 9.8 Tf [(themes were discussed and resolved among coders until 100% agreement on themes was achieved. Two researchers then )] TJ ET BT 26.250 219.669 Td /F1 9.8 Tf [(reread all 33 transcripts and coded them separately. They then met to compare their results and at this point the third )] TJ ET BT 26.250 207.764 Td /F1 9.8 Tf [(researcher assessed the coding and determined an interrater reliability of 0.97.)] TJ ET BT 26.250 188.359 Td /F1 9.8 Tf [(The authors used thematic analysis)] TJ ET 0.267 0.267 0.267 rg BT 179.608 189.866 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 189.245 188.359 Td /F1 9.8 Tf [( as the analytic framework to identify themes relevant to participants post-9/11 health and )] TJ ET BT 26.250 176.454 Td /F1 9.8 Tf [(mental health \(short- and long-term\), health care utilization, social support, and everyday functioning. Coders were unaware of )] TJ ET BT 26.250 164.550 Td /F1 9.8 Tf [(the PTSD scores during this analysis phase. The analysis included line-by-line coding of statements and responses by two )] TJ ET BT 26.250 152.645 Td /F1 9.8 Tf [(independent researchers \(LMG and RG\).)] TJ ET 0.267 0.267 0.267 rg BT 203.446 154.152 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 213.084 152.645 Td /F1 9.8 Tf [( The researchers reviewed the codes and evaluated their meaning. The coded data )] TJ ET BT 26.250 140.740 Td /F1 9.8 Tf [(were organized to identify themes. These themes were cross-referenced among the coders and percent agreement was )] TJ ET BT 26.250 128.835 Td /F1 9.8 Tf [(determined.)] TJ ET BT 26.250 92.233 Td /F4 12.0 Tf [(Results)] TJ ET BT 26.250 72.279 Td /F4 9.8 Tf [(Participant characteristics)] TJ ET BT 26.250 52.874 Td /F1 9.8 Tf [(Demographic characteristics of the participants are described in Table 2. Over half \(57.6%\) were male and 48.5% were age 25-)] TJ ET BT 26.250 40.969 Td /F1 9.8 Tf [(44 years on 9/11. The largest proportion \(75.8%\) of participants was white and 12.1% were Hispanic. Almost half \(45.5%\) had a )] TJ ET Q q 15.000 26.683 577.500 750.317 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F4 9.8 Tf [(Ethics Statement)] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(This study was approved by the institutional review board of the NYC Department of Health and Mental Hygiene.)] TJ ET 0.965 0.965 0.965 rg 26.250 398.954 555.000 339.236 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 738.191 m 581.250 738.191 l 581.250 737.441 l 26.250 737.441 l f 26.250 398.954 m 581.250 398.954 l 581.250 399.704 l 26.250 399.704 l f q 450.000 0 0 291.000 35.250 437.441 cm /I3 Do Q q 35.250 410.204 537.000 21.236 re W n 0.271 0.267 0.267 rg BT 35.250 420.451 Td /F4 9.8 Tf [(Table 1. )] TJ ET BT 74.269 420.451 Td /F1 9.8 Tf [(Interview topic and sample questions)] TJ ET Q BT 26.250 381.930 Td /F4 9.8 Tf [(Data Analysis)] TJ ET BT 26.250 362.526 Td /F1 9.8 Tf [(Using a pre-set list of major themes that were based on the conceptual models embedded in the interview script, two members )] TJ ET BT 26.250 350.621 Td /F1 9.8 Tf [(of the research team read and coded the first five transcripts of the recorded data. The analysis was conducted using the block )] TJ ET BT 26.250 338.716 Td /F1 9.8 Tf [(of data for each of the major categories as described in the interview guide. The researchers then met to achieve consensus on )] TJ ET BT 26.250 326.811 Td /F1 9.8 Tf [(the major themes and sub-themes, and to identify and discuss any new themes that emerged from the data. At this stage, the )] TJ ET BT 26.250 314.907 Td /F1 9.8 Tf [(researchers also agreed upon the terminology that would be used for the themes. For example, originally, one researcher listed )] TJ ET BT 26.250 303.002 Td /F1 9.8 Tf [(Changes in Work Status as a separate theme, the two researchers agreed to fold this into the Lifestyle Impacts theme. One )] TJ ET BT 26.250 291.097 Td /F1 9.8 Tf [(researcher initially referred to any new health problems as New Health Problems, which was then changed to Current Health )] TJ ET BT 26.250 279.192 Td /F1 9.8 Tf [(Status, Functional Physical Status Impairments and Disability. Once the new terminology was in place, the two researchers )] TJ ET BT 26.250 267.288 Td /F1 9.8 Tf [(then read the next 5 transcripts to ensure that they were coding using the same terminology and pre-set themes similarly. After )] TJ ET BT 26.250 255.383 Td /F1 9.8 Tf [(thorough discussion of the identified themes by all three researchers, further adjustments to terminology were again made at )] TJ ET BT 26.250 243.478 Td /F1 9.8 Tf [(this point to keep the themes to a manageable number \(resulting in the final six themes identified\). Disagreements about )] TJ ET BT 26.250 231.573 Td /F1 9.8 Tf [(themes were discussed and resolved among coders until 100% agreement on themes was achieved. Two researchers then )] TJ ET BT 26.250 219.669 Td /F1 9.8 Tf [(reread all 33 transcripts and coded them separately. They then met to compare their results and at this point the third )] TJ ET BT 26.250 207.764 Td /F1 9.8 Tf [(researcher assessed the coding and determined an interrater reliability of 0.97.)] TJ ET BT 26.250 188.359 Td /F1 9.8 Tf [(The authors used thematic analysis)] TJ ET 0.267 0.267 0.267 rg BT 179.608 189.866 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 189.245 188.359 Td /F1 9.8 Tf [( as the analytic framework to identify themes relevant to participants post-9/11 health and )] TJ ET BT 26.250 176.454 Td /F1 9.8 Tf [(mental health \(short- and long-term\), health care utilization, social support, and everyday functioning. Coders were unaware of )] TJ ET BT 26.250 164.550 Td /F1 9.8 Tf [(the PTSD scores during this analysis phase. The analysis included line-by-line coding of statements and responses by two )] TJ ET BT 26.250 152.645 Td /F1 9.8 Tf [(independent researchers \(LMG and RG\).)] TJ ET 0.267 0.267 0.267 rg BT 203.446 154.152 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 213.084 152.645 Td /F1 9.8 Tf [( The researchers reviewed the codes and evaluated their meaning. The coded data )] TJ ET BT 26.250 140.740 Td /F1 9.8 Tf [(were organized to identify themes. These themes were cross-referenced among the coders and percent agreement was )] TJ ET BT 26.250 128.835 Td /F1 9.8 Tf [(determined.)] TJ ET BT 26.250 92.233 Td /F4 12.0 Tf [(Results)] TJ ET BT 26.250 72.279 Td /F4 9.8 Tf [(Participant characteristics)] TJ ET BT 26.250 52.874 Td /F1 9.8 Tf [(Demographic characteristics of the participants are described in Table 2. Over half \(57.6%\) were male and 48.5% were age 25-)] TJ ET BT 26.250 40.969 Td /F1 9.8 Tf [(44 years on 9/11. The largest proportion \(75.8%\) of participants was white and 12.1% were Hispanic. 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Over half \(51.7%\) reported an annual household income of over $75,000 in 2002. Almost 40% )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(participated in rescue and recovery work on 9/11. Almost half \(48.5%\) did not screen positive for probable PTSD on any of the 3 )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(waves, 27.3% had probable PTSD at Wave 1 and/or Wave 2, and 24.2% had probable PTSD at Wave 3. Three-quarters of )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(participants had more severe injuries, of these, 69.7% had two or more injuries, and 24.2% were categorized as having less )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(severe injuries.)] TJ ET 0.965 0.965 0.965 rg 26.250 104.490 555.000 605.486 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 709.976 m 581.250 709.976 l 581.250 709.226 l 26.250 709.226 l f 26.250 104.490 m 581.250 104.490 l 581.250 105.240 l 26.250 105.240 l f q 438.750 0 0 557.250 35.250 142.976 cm /I5 Do Q q 35.250 115.740 537.000 21.236 re W n 0.271 0.267 0.267 rg BT 35.250 125.987 Td /F4 9.8 Tf [(Table 2. )] TJ ET BT 74.269 125.987 Td /F1 9.8 Tf [(Characteristics of participants interviewed \(n=33\))] TJ ET Q BT 26.250 87.466 Td /F4 9.8 Tf [(Thematic analysis)] TJ ET BT 26.250 68.061 Td /F1 9.8 Tf [(Thematic analysis yielded six themes related to exposure to WTCD and current quality of life: \(1\) concurrent peri-event injuries )] TJ ET BT 26.250 56.157 Td /F1 9.8 Tf [(and traumatic exposures on 9/11; \(2\) timeliness of short- and long-term medical care for injury and mental health care; \(3\) )] TJ ET BT 26.250 44.252 Td /F1 9.8 Tf [(current health status, functional limitations, and disabilities; \(4\) lifestyle impact; \(5\) availability of social support; and \(6\) )] TJ ET Q q 15.000 29.966 577.500 747.034 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(college or post-graduate degree. Over half \(51.7%\) reported an annual household income of over $75,000 in 2002. Almost 40% )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(participated in rescue and recovery work on 9/11. Almost half \(48.5%\) did not screen positive for probable PTSD on any of the 3 )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(waves, 27.3% had probable PTSD at Wave 1 and/or Wave 2, and 24.2% had probable PTSD at Wave 3. Three-quarters of )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(participants had more severe injuries, of these, 69.7% had two or more injuries, and 24.2% were categorized as having less )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(severe injuries.)] TJ ET 0.965 0.965 0.965 rg 26.250 104.490 555.000 605.486 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 709.976 m 581.250 709.976 l 581.250 709.226 l 26.250 709.226 l f 26.250 104.490 m 581.250 104.490 l 581.250 105.240 l 26.250 105.240 l f q 438.750 0 0 557.250 35.250 142.976 cm /I7 Do Q q 35.250 115.740 537.000 21.236 re W n 0.271 0.267 0.267 rg BT 35.250 125.987 Td /F4 9.8 Tf [(Table 2. )] TJ ET BT 74.269 125.987 Td /F1 9.8 Tf [(Characteristics of participants interviewed \(n=33\))] TJ ET Q BT 26.250 87.466 Td /F4 9.8 Tf [(Thematic analysis)] TJ ET BT 26.250 68.061 Td /F1 9.8 Tf [(Thematic analysis yielded six themes related to exposure to WTCD and current quality of life: \(1\) concurrent peri-event injuries )] TJ ET BT 26.250 56.157 Td /F1 9.8 Tf [(and traumatic exposures on 9/11; \(2\) timeliness of short- and long-term medical care for injury and mental health care; \(3\) )] TJ ET BT 26.250 44.252 Td /F1 9.8 Tf [(current health status, functional limitations, and disabilities; \(4\) lifestyle impact; \(5\) availability of social support; and \(6\) )] TJ ET Q q 15.000 29.966 577.500 747.034 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(college or post-graduate degree. Over half \(51.7%\) reported an annual household income of over $75,000 in 2002. Almost 40% )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(participated in rescue and recovery work on 9/11. Almost half \(48.5%\) did not screen positive for probable PTSD on any of the 3 )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(waves, 27.3% had probable PTSD at Wave 1 and/or Wave 2, and 24.2% had probable PTSD at Wave 3. Three-quarters of )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(participants had more severe injuries, of these, 69.7% had two or more injuries, and 24.2% were categorized as having less )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(severe injuries.)] TJ ET 0.965 0.965 0.965 rg 26.250 104.490 555.000 605.486 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 709.976 m 581.250 709.976 l 581.250 709.226 l 26.250 709.226 l f 26.250 104.490 m 581.250 104.490 l 581.250 105.240 l 26.250 105.240 l f q 438.750 0 0 557.250 35.250 142.976 cm /I9 Do Q q 35.250 115.740 537.000 21.236 re W n 0.271 0.267 0.267 rg BT 35.250 125.987 Td /F4 9.8 Tf [(Table 2. )] TJ ET BT 74.269 125.987 Td /F1 9.8 Tf [(Characteristics of participants interviewed \(n=33\))] TJ ET Q BT 26.250 87.466 Td /F4 9.8 Tf [(Thematic analysis)] TJ ET BT 26.250 68.061 Td /F1 9.8 Tf [(Thematic analysis yielded six themes related to exposure to WTCD and current quality of life: \(1\) concurrent peri-event injuries )] TJ ET BT 26.250 56.157 Td /F1 9.8 Tf [(and traumatic exposures on 9/11; 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DB#xqy: "XIJJݻc*$ d0:Քرc0⒖_}}=[7 Ņ...$I.AӧOWUUHKK?{իFFF...)u刈ܚpJLL|𡤤y\\\SSG}ĝFnݺ5 iΝMjra l"nk֬hL&.00p``[~=CellBII=f߼y 4.$$$00 +6ѣG̙emm矏*+z޼ymmm;p+WwU[[ի˗/c519qPSSm+\qrrr>n:9fkk5j󜜜V P6l}娦#_lXX؞={j\QUU9s&6`ZZ :Qg0OCCC/] HMM͌3/_#hGr*,6mmmh0n[n,Y$<<|ٰ Q(>̙3b˖-QQQ0!bnnnffL!hd2W\YUU \XXegg!L/++۞c*!thqihh耷] jR^c":WW*a B) ]NNwTCYYYf2m,_`bb0E\l6<͛Ѡ(m'm2,))A zEj+NͫN>t@gg'q5=عs Drttr劓.QQQvvv| r޽~M ;u/"`}OΝ;`Alǔŋ+Vٳ#eʹʂ]+B9qDooO~,fSWWo;8^tle˖qѣGw={F঻{ڴi_8ypBє .^mqK,`XbԂ <bqCCxU6JJJk׮?0Ȝ8q^"@lc ZZZ ,,,\]];;; YnjjmmmCCCuRYY^*UHRׯ_U`^XXb5ĶhLq󪓏 WQQzV?)))fff䜒LbLP|~BUČy7[p3pD]YYm۶}Vd?3q+B@~ `64{xxQ^H$P)))1@(ѝ_;3"888.eaaa$ jcTC$[[[yyA744㦺:##CVVJEEMlmmQGSϟ?{LOOu}5:neexb"mmmEEE}}}h+-555&&QVVʕ+yyyGe٥>" l$''رCEEJNNիVFFFPP2G;L1jkko߾f͚۷O6 &۷o_$%%s`E(۬yGoE?v|W__M"~ڔFӿoc`+//䉎]zԙ3gy:::UTTeddjjjD(񤠥STT_SS4<}$ `Jh"쭪̙39b /ZYA P]]=---YTT-󧦦JIIBtzzz|򉊊ʃbbbЕm(JllG;vXbEQQѬY8jٳx eesP)7oޜ={v֭3g TSS;x𠟟7|<<<\GG'::˗˗/>^SS3""˗񇇇ѣG%%%a'Ohl&\a\ 5)۷o HTT|­%.]Bddd A:NP>|󷷷r'֭[a<==5ɔ@CȌ655o122RTT"v˖-ƫ PBCCť,K.N> o ee庺:A233eeexUݭ122" =!Wk__t|mΝ;VVV{ٳfս>G=|IIIH$L&譼<S%%%h4 hjjbTouuuu᭽:WڼysFFࠥ%DK  (;;O>#YY٠7o ^1zzz۬Y~~iܹk׮UUJJvHB&K~SN٭YF]]6mVd@~~>=?"`!` ,<{,`Rw+))}7e .̞={ZZZϟ?oN/))111\zl}(VVVgϦR֭ܶmۯ?500066R###xqq/G%|!244$ 1 r}}}ooȲBܹP3gdfffff޿J8qbdd$77CW GJJ*((()) oL&=yꕫkBB_|Snܸ͓fkk++ZPj{zzh4ڜ9sۇR`?mll400Xz5Jurrx"l7o D6VV:;;9033+(((((0 +D,bW ƍXpՀHٳ#11Q2{ݰaիWݯ_Y,Vee/3l~+++]633SxB8-~x%twwS(2 oBVUU hkk,`!Hl6lsΝpLH.ݍk.ltww777/\퟇JJJϟX>BS?3ao sppG`2oC(9QBlC᢫t ;|G5Un)L^QQQQQ"e/ DAmSYO$A]]IZLFTUUŭ 500Ĝ$TF@@@@0?P endstream endobj 185 0 obj << /Type /Page /Parent 3 0 R /Annots [ 188 0 R 191 0 R 193 0 R ] /Contents 186 0 R >> endobj 186 0 obj << /Length 22933 >> stream 0.271 0.267 0.267 rg q 15.000 31.514 577.500 745.486 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(economic impact. Interrater reliability for each theme was good \(kappa = 0.97\). Themes are presented below, with )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(representative quotations selected to highlight key results.)] TJ ET 0.965 0.965 0.965 rg 26.250 560.204 555.000 185.486 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 745.691 m 581.250 745.691 l 581.250 744.941 l 26.250 744.941 l f 26.250 560.204 m 581.250 560.204 l 581.250 560.954 l 26.250 560.954 l f q 326.250 0 0 137.250 35.250 598.691 cm /I12 Do Q q 35.250 571.454 537.000 21.236 re W n 0.271 0.267 0.267 rg BT 35.250 581.701 Td /F4 9.8 Tf [(Table 3. )] TJ ET BT 74.269 581.701 Td /F1 9.8 Tf [(Study Themes)] TJ ET Q BT 26.250 543.180 Td /F4 9.8 Tf [(Peri-event traumatic exposures and injuries)] TJ ET BT 26.250 523.776 Td /F1 9.8 Tf [(The first awareness of the event varied greatly and was dependent upon the participants location when the event first began at )] TJ ET BT 26.250 511.871 Td /F1 9.8 Tf [(8:46am. Some participants were already at their desks, located in either of the towers or in surrounding buildings. Others were )] TJ ET BT 26.250 499.966 Td /F1 9.8 Tf [(at the street level and were about to enter one of the seven WTC complex buildings or other nearby buildings. Unless the )] TJ ET BT 26.250 488.061 Td /F1 9.8 Tf [(participant had a direct view of an airplane making impact, making sense of the situation was initially, at least, virtually )] TJ ET BT 26.250 476.157 Td /F1 9.8 Tf [(impossible. Even participants who heard the first explosion as the plane made impact and reported seeing debris from their )] TJ ET BT 26.250 464.252 Td /F1 9.8 Tf [(office windows could not understand what had just happened. Almost no one initially understood the gravity of the situation or )] TJ ET BT 26.250 452.347 Td /F1 9.8 Tf [(the precariousness of their own personal safety. In these first few minutes, there was a sense of confusion and uncertainty )] TJ ET BT 26.250 440.442 Td /F1 9.8 Tf [(regarding what had happened and how they should respond.)] TJ ET BT 26.250 421.038 Td /F1 9.8 Tf [(Sensory exposure was common. Participants reported seeing and hearing the planes impact the buildings, and seeing the )] TJ ET BT 26.250 409.133 Td /F1 9.8 Tf [(collapse of either the WTC Tower One \(WTC 1\) or WTC Tower Two \(WTC 2\), or both. Participants saw people on high floors in )] TJ ET BT 26.250 397.228 Td /F1 9.8 Tf [(WTC 1 waving tablecloths and then jumping out of windows. Participants saw and felt debris from the towers and the impact of )] TJ ET BT 26.250 385.323 Td /F1 9.8 Tf [(the dust clouds. Participants smelled smoke and other odors of building materials caught up in the dust cloud. Participants )] TJ ET BT 26.250 373.419 Td /F1 9.8 Tf [(heard screaming of others when they were in their work area, in the stairwells, and on the street.)] TJ ET BT 26.250 354.014 Td /F1 9.8 Tf [(Participants experienced a wide range of injuries, including, most commonly, eye injury, foot injuries, skin burns, head injuries, )] TJ ET BT 26.250 342.109 Td /F1 9.8 Tf [(contusions, sprains, strains, and broken bones. Several participants experienced injuries almost immediately after the first )] TJ ET BT 26.250 330.204 Td /F1 9.8 Tf [(impact, generally because of resultant damage to their work area \(falling ceilings and walls\). Others who were at street level )] TJ ET BT 26.250 318.300 Td /F1 9.8 Tf [(were injured by falling debris. Still others were injured in the lobby of WTC 1 when a fire ball exploded out of the bank of )] TJ ET BT 26.250 306.395 Td /F1 9.8 Tf [(elevators. Other victims were not injured until they began to evacuate, either from WTC 1 or WTC 2 or from other WTC complex )] TJ ET BT 26.250 294.490 Td /F1 9.8 Tf [(buildings or buildings in the vicinity. Several participants were injured later on, during and immediately after the collapse of WTC )] TJ ET BT 26.250 282.585 Td /F1 9.8 Tf [(2, at 9:59am, or later still, when WTC 1 collapsed at 10:28am. Participants who were not injured either immediately or shortly )] TJ ET BT 26.250 270.681 Td /F1 9.8 Tf [(after the attacks reported that their injuries occurred during their sometimes extended journey towards home or to another )] TJ ET BT 26.250 258.776 Td /F1 9.8 Tf [(destination.)] TJ ET BT 26.250 239.371 Td /F1 9.8 Tf [(The participants location at the start of the attacks at 8:46am also affected the intensity of their peri-event traumatic exposure. )] TJ ET BT 26.250 227.466 Td /F1 9.8 Tf [(As described by one participant, )] TJ ET BT 167.693 227.466 Td /F5 9.8 Tf [(then I just heard this horrible, indescribable sound. It sounded like the biggest thing you ever )] TJ ET BT 26.250 215.562 Td /F5 9.8 Tf [(heard was tearing through a jungle. And I turned around and I saw it [the plane impacting WTC 1].)] TJ ET BT 448.425 215.562 Td /F1 9.8 Tf [()] TJ ET BT 26.250 196.157 Td /F1 9.8 Tf [(The initial thought of many participants was that they were going to die, as reported by one participant, )] TJ ET BT 470.099 196.157 Td /F5 9.8 Tf [(I said, listen God, make )] TJ ET BT 26.250 184.252 Td /F5 9.8 Tf [(it quick. I dont want to suffer.)] TJ ET BT 155.769 184.252 Td /F1 9.8 Tf [( Many participants reported feeling the experience was other worldly, as one participant noted, )] TJ ET BT 26.250 172.347 Td /F5 9.8 Tf [(I experienced an alien abduction feeling.)] TJ ET BT 207.259 172.347 Td /F1 9.8 Tf [( For many participants, a sense of disbelief was common; they tried to make sense of )] TJ ET BT 26.250 160.443 Td /F1 9.8 Tf [(what they were seeing. Dust, darkness, smoke and confusion were commonly reported. One participant, a first responder )] TJ ET BT 26.250 148.538 Td /F1 9.8 Tf [(heading to the complex, reported that when he emerged from the Holland Tunnel, the scene was)] TJ ET BT 443.004 148.538 Td /F5 9.8 Tf [( a nuclear winter; I just )] TJ ET BT 26.250 136.633 Td /F5 9.8 Tf [(remember the dust and smoke, and the confusion.)] TJ ET BT 246.815 136.633 Td /F1 9.8 Tf [( There was also a sense of disbelief for some that they were still alive, as )] TJ ET BT 26.250 124.728 Td /F1 9.8 Tf [(one participant, buried in the rubble after the collapse of WTC 2 stated, )] TJ ET BT 334.613 124.728 Td /F5 9.8 Tf [(I realized, Im alive.)] TJ ET BT 424.547 124.728 Td /F1 9.8 Tf [( For some participants, the reality )] TJ ET BT 26.250 112.824 Td /F1 9.8 Tf [(of what they had experienced did not become clear for quite some time after the event. One participant, who woke up later in an )] TJ ET BT 26.250 100.919 Td /F1 9.8 Tf [(intensive care unit, reported, )] TJ ET BT 151.976 100.919 Td /F5 9.8 Tf [([The nurse] looked at me and said, you know, you are the luckiest person in the entire world.)] TJ ET BT 26.250 81.514 Td /F1 9.8 Tf [(Part of the traumatic exposure was related to witnessing people getting injured or killed, in some cases, quite near them. It was )] TJ ET BT 26.250 69.609 Td /F1 9.8 Tf [(clear from the participants reports that the traumatic event was a combination of both witnessing the unfolding events, including )] TJ ET BT 26.250 57.705 Td /F1 9.8 Tf [(escaping past corpses in the tower lobby and on the street \(remains of jumpers from high floors\), as well as getting caught up )] TJ ET BT 26.250 45.800 Td /F1 9.8 Tf [(and injured in the event itself. For instance, several participants were traumatized during their efforts to run away from the )] TJ ET Q q 15.000 31.514 577.500 745.486 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(economic impact. Interrater reliability for each theme was good \(kappa = 0.97\). Themes are presented below, with )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(representative quotations selected to highlight key results.)] TJ ET 0.965 0.965 0.965 rg 26.250 560.204 555.000 185.486 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 745.691 m 581.250 745.691 l 581.250 744.941 l 26.250 744.941 l f 26.250 560.204 m 581.250 560.204 l 581.250 560.954 l 26.250 560.954 l f q 326.250 0 0 137.250 35.250 598.691 cm /I12 Do Q q 35.250 571.454 537.000 21.236 re W n 0.271 0.267 0.267 rg BT 35.250 581.701 Td /F4 9.8 Tf [(Table 3. )] TJ ET BT 74.269 581.701 Td /F1 9.8 Tf [(Study Themes)] TJ ET Q BT 26.250 543.180 Td /F4 9.8 Tf [(Peri-event traumatic exposures and injuries)] TJ ET BT 26.250 523.776 Td /F1 9.8 Tf [(The first awareness of the event varied greatly and was dependent upon the participants location when the event first began at )] TJ ET BT 26.250 511.871 Td /F1 9.8 Tf [(8:46am. Some participants were already at their desks, located in either of the towers or in surrounding buildings. Others were )] TJ ET BT 26.250 499.966 Td /F1 9.8 Tf [(at the street level and were about to enter one of the seven WTC complex buildings or other nearby buildings. Unless the )] TJ ET BT 26.250 488.061 Td /F1 9.8 Tf [(participant had a direct view of an airplane making impact, making sense of the situation was initially, at least, virtually )] TJ ET BT 26.250 476.157 Td /F1 9.8 Tf [(impossible. Even participants who heard the first explosion as the plane made impact and reported seeing debris from their )] TJ ET BT 26.250 464.252 Td /F1 9.8 Tf [(office windows could not understand what had just happened. Almost no one initially understood the gravity of the situation or )] TJ ET BT 26.250 452.347 Td /F1 9.8 Tf [(the precariousness of their own personal safety. In these first few minutes, there was a sense of confusion and uncertainty )] TJ ET BT 26.250 440.442 Td /F1 9.8 Tf [(regarding what had happened and how they should respond.)] TJ ET BT 26.250 421.038 Td /F1 9.8 Tf [(Sensory exposure was common. Participants reported seeing and hearing the planes impact the buildings, and seeing the )] TJ ET BT 26.250 409.133 Td /F1 9.8 Tf [(collapse of either the WTC Tower One \(WTC 1\) or WTC Tower Two \(WTC 2\), or both. Participants saw people on high floors in )] TJ ET BT 26.250 397.228 Td /F1 9.8 Tf [(WTC 1 waving tablecloths and then jumping out of windows. Participants saw and felt debris from the towers and the impact of )] TJ ET BT 26.250 385.323 Td /F1 9.8 Tf [(the dust clouds. Participants smelled smoke and other odors of building materials caught up in the dust cloud. Participants )] TJ ET BT 26.250 373.419 Td /F1 9.8 Tf [(heard screaming of others when they were in their work area, in the stairwells, and on the street.)] TJ ET BT 26.250 354.014 Td /F1 9.8 Tf [(Participants experienced a wide range of injuries, including, most commonly, eye injury, foot injuries, skin burns, head injuries, )] TJ ET BT 26.250 342.109 Td /F1 9.8 Tf [(contusions, sprains, strains, and broken bones. Several participants experienced injuries almost immediately after the first )] TJ ET BT 26.250 330.204 Td /F1 9.8 Tf [(impact, generally because of resultant damage to their work area \(falling ceilings and walls\). Others who were at street level )] TJ ET BT 26.250 318.300 Td /F1 9.8 Tf [(were injured by falling debris. Still others were injured in the lobby of WTC 1 when a fire ball exploded out of the bank of )] TJ ET BT 26.250 306.395 Td /F1 9.8 Tf [(elevators. Other victims were not injured until they began to evacuate, either from WTC 1 or WTC 2 or from other WTC complex )] TJ ET BT 26.250 294.490 Td /F1 9.8 Tf [(buildings or buildings in the vicinity. Several participants were injured later on, during and immediately after the collapse of WTC )] TJ ET BT 26.250 282.585 Td /F1 9.8 Tf [(2, at 9:59am, or later still, when WTC 1 collapsed at 10:28am. Participants who were not injured either immediately or shortly )] TJ ET BT 26.250 270.681 Td /F1 9.8 Tf [(after the attacks reported that their injuries occurred during their sometimes extended journey towards home or to another )] TJ ET BT 26.250 258.776 Td /F1 9.8 Tf [(destination.)] TJ ET BT 26.250 239.371 Td /F1 9.8 Tf [(The participants location at the start of the attacks at 8:46am also affected the intensity of their peri-event traumatic exposure. )] TJ ET BT 26.250 227.466 Td /F1 9.8 Tf [(As described by one participant, )] TJ ET BT 167.693 227.466 Td /F5 9.8 Tf [(then I just heard this horrible, indescribable sound. It sounded like the biggest thing you ever )] TJ ET BT 26.250 215.562 Td /F5 9.8 Tf [(heard was tearing through a jungle. And I turned around and I saw it [the plane impacting WTC 1].)] TJ ET BT 448.425 215.562 Td /F1 9.8 Tf [()] TJ ET BT 26.250 196.157 Td /F1 9.8 Tf [(The initial thought of many participants was that they were going to die, as reported by one participant, )] TJ ET BT 470.099 196.157 Td /F5 9.8 Tf [(I said, listen God, make )] TJ ET BT 26.250 184.252 Td /F5 9.8 Tf [(it quick. I dont want to suffer.)] TJ ET BT 155.769 184.252 Td /F1 9.8 Tf [( Many participants reported feeling the experience was other worldly, as one participant noted, )] TJ ET BT 26.250 172.347 Td /F5 9.8 Tf [(I experienced an alien abduction feeling.)] TJ ET BT 207.259 172.347 Td /F1 9.8 Tf [( For many participants, a sense of disbelief was common; they tried to make sense of )] TJ ET BT 26.250 160.443 Td /F1 9.8 Tf [(what they were seeing. Dust, darkness, smoke and confusion were commonly reported. One participant, a first responder )] TJ ET BT 26.250 148.538 Td /F1 9.8 Tf [(heading to the complex, reported that when he emerged from the Holland Tunnel, the scene was)] TJ ET BT 443.004 148.538 Td /F5 9.8 Tf [( a nuclear winter; I just )] TJ ET BT 26.250 136.633 Td /F5 9.8 Tf [(remember the dust and smoke, and the confusion.)] TJ ET BT 246.815 136.633 Td /F1 9.8 Tf [( There was also a sense of disbelief for some that they were still alive, as )] TJ ET BT 26.250 124.728 Td /F1 9.8 Tf [(one participant, buried in the rubble after the collapse of WTC 2 stated, )] TJ ET BT 334.613 124.728 Td /F5 9.8 Tf [(I realized, Im alive.)] TJ ET BT 424.547 124.728 Td /F1 9.8 Tf [( For some participants, the reality )] TJ ET BT 26.250 112.824 Td /F1 9.8 Tf [(of what they had experienced did not become clear for quite some time after the event. One participant, who woke up later in an )] TJ ET BT 26.250 100.919 Td /F1 9.8 Tf [(intensive care unit, reported, )] TJ ET BT 151.976 100.919 Td /F5 9.8 Tf [([The nurse] looked at me and said, you know, you are the luckiest person in the entire world.)] TJ ET BT 26.250 81.514 Td /F1 9.8 Tf [(Part of the traumatic exposure was related to witnessing people getting injured or killed, in some cases, quite near them. It was )] TJ ET BT 26.250 69.609 Td /F1 9.8 Tf [(clear from the participants reports that the traumatic event was a combination of both witnessing the unfolding events, including )] TJ ET BT 26.250 57.705 Td /F1 9.8 Tf [(escaping past corpses in the tower lobby and on the street \(remains of jumpers from high floors\), as well as getting caught up )] TJ ET BT 26.250 45.800 Td /F1 9.8 Tf [(and injured in the event itself. For instance, several participants were traumatized during their efforts to run away from the )] TJ ET Q q 15.000 31.514 577.500 745.486 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(economic impact. Interrater reliability for each theme was good \(kappa = 0.97\). Themes are presented below, with )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(representative quotations selected to highlight key results.)] TJ ET 0.965 0.965 0.965 rg 26.250 560.204 555.000 185.486 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 745.691 m 581.250 745.691 l 581.250 744.941 l 26.250 744.941 l f 26.250 560.204 m 581.250 560.204 l 581.250 560.954 l 26.250 560.954 l f q 326.250 0 0 137.250 35.250 598.691 cm /I12 Do Q q 35.250 571.454 537.000 21.236 re W n 0.271 0.267 0.267 rg BT 35.250 581.701 Td /F4 9.8 Tf [(Table 3. )] TJ ET BT 74.269 581.701 Td /F1 9.8 Tf [(Study Themes)] TJ ET Q BT 26.250 543.180 Td /F4 9.8 Tf [(Peri-event traumatic exposures and injuries)] TJ ET BT 26.250 523.776 Td /F1 9.8 Tf [(The first awareness of the event varied greatly and was dependent upon the participants location when the event first began at )] TJ ET BT 26.250 511.871 Td /F1 9.8 Tf [(8:46am. Some participants were already at their desks, located in either of the towers or in surrounding buildings. Others were )] TJ ET BT 26.250 499.966 Td /F1 9.8 Tf [(at the street level and were about to enter one of the seven WTC complex buildings or other nearby buildings. Unless the )] TJ ET BT 26.250 488.061 Td /F1 9.8 Tf [(participant had a direct view of an airplane making impact, making sense of the situation was initially, at least, virtually )] TJ ET BT 26.250 476.157 Td /F1 9.8 Tf [(impossible. Even participants who heard the first explosion as the plane made impact and reported seeing debris from their )] TJ ET BT 26.250 464.252 Td /F1 9.8 Tf [(office windows could not understand what had just happened. Almost no one initially understood the gravity of the situation or )] TJ ET BT 26.250 452.347 Td /F1 9.8 Tf [(the precariousness of their own personal safety. In these first few minutes, there was a sense of confusion and uncertainty )] TJ ET BT 26.250 440.442 Td /F1 9.8 Tf [(regarding what had happened and how they should respond.)] TJ ET BT 26.250 421.038 Td /F1 9.8 Tf [(Sensory exposure was common. Participants reported seeing and hearing the planes impact the buildings, and seeing the )] TJ ET BT 26.250 409.133 Td /F1 9.8 Tf [(collapse of either the WTC Tower One \(WTC 1\) or WTC Tower Two \(WTC 2\), or both. Participants saw people on high floors in )] TJ ET BT 26.250 397.228 Td /F1 9.8 Tf [(WTC 1 waving tablecloths and then jumping out of windows. Participants saw and felt debris from the towers and the impact of )] TJ ET BT 26.250 385.323 Td /F1 9.8 Tf [(the dust clouds. Participants smelled smoke and other odors of building materials caught up in the dust cloud. Participants )] TJ ET BT 26.250 373.419 Td /F1 9.8 Tf [(heard screaming of others when they were in their work area, in the stairwells, and on the street.)] TJ ET BT 26.250 354.014 Td /F1 9.8 Tf [(Participants experienced a wide range of injuries, including, most commonly, eye injury, foot injuries, skin burns, head injuries, )] TJ ET BT 26.250 342.109 Td /F1 9.8 Tf [(contusions, sprains, strains, and broken bones. Several participants experienced injuries almost immediately after the first )] TJ ET BT 26.250 330.204 Td /F1 9.8 Tf [(impact, generally because of resultant damage to their work area \(falling ceilings and walls\). Others who were at street level )] TJ ET BT 26.250 318.300 Td /F1 9.8 Tf [(were injured by falling debris. Still others were injured in the lobby of WTC 1 when a fire ball exploded out of the bank of )] TJ ET BT 26.250 306.395 Td /F1 9.8 Tf [(elevators. Other victims were not injured until they began to evacuate, either from WTC 1 or WTC 2 or from other WTC complex )] TJ ET BT 26.250 294.490 Td /F1 9.8 Tf [(buildings or buildings in the vicinity. Several participants were injured later on, during and immediately after the collapse of WTC )] TJ ET BT 26.250 282.585 Td /F1 9.8 Tf [(2, at 9:59am, or later still, when WTC 1 collapsed at 10:28am. Participants who were not injured either immediately or shortly )] TJ ET BT 26.250 270.681 Td /F1 9.8 Tf [(after the attacks reported that their injuries occurred during their sometimes extended journey towards home or to another )] TJ ET BT 26.250 258.776 Td /F1 9.8 Tf [(destination.)] TJ ET BT 26.250 239.371 Td /F1 9.8 Tf [(The participants location at the start of the attacks at 8:46am also affected the intensity of their peri-event traumatic exposure. )] TJ ET BT 26.250 227.466 Td /F1 9.8 Tf [(As described by one participant, )] TJ ET BT 167.693 227.466 Td /F5 9.8 Tf [(then I just heard this horrible, indescribable sound. It sounded like the biggest thing you ever )] TJ ET BT 26.250 215.562 Td /F5 9.8 Tf [(heard was tearing through a jungle. And I turned around and I saw it [the plane impacting WTC 1].)] TJ ET BT 448.425 215.562 Td /F1 9.8 Tf [()] TJ ET BT 26.250 196.157 Td /F1 9.8 Tf [(The initial thought of many participants was that they were going to die, as reported by one participant, )] TJ ET BT 470.099 196.157 Td /F5 9.8 Tf [(I said, listen God, make )] TJ ET BT 26.250 184.252 Td /F5 9.8 Tf [(it quick. I dont want to suffer.)] TJ ET BT 155.769 184.252 Td /F1 9.8 Tf [( Many participants reported feeling the experience was other worldly, as one participant noted, )] TJ ET BT 26.250 172.347 Td /F5 9.8 Tf [(I experienced an alien abduction feeling.)] TJ ET BT 207.259 172.347 Td /F1 9.8 Tf [( For many participants, a sense of disbelief was common; they tried to make sense of )] TJ ET BT 26.250 160.443 Td /F1 9.8 Tf [(what they were seeing. Dust, darkness, smoke and confusion were commonly reported. One participant, a first responder )] TJ ET BT 26.250 148.538 Td /F1 9.8 Tf [(heading to the complex, reported that when he emerged from the Holland Tunnel, the scene was)] TJ ET BT 443.004 148.538 Td /F5 9.8 Tf [( a nuclear winter; I just )] TJ ET BT 26.250 136.633 Td /F5 9.8 Tf [(remember the dust and smoke, and the confusion.)] TJ ET BT 246.815 136.633 Td /F1 9.8 Tf [( There was also a sense of disbelief for some that they were still alive, as )] TJ ET BT 26.250 124.728 Td /F1 9.8 Tf [(one participant, buried in the rubble after the collapse of WTC 2 stated, )] TJ ET BT 334.613 124.728 Td /F5 9.8 Tf [(I realized, Im alive.)] TJ ET BT 424.547 124.728 Td /F1 9.8 Tf [( For some participants, the reality )] TJ ET BT 26.250 112.824 Td /F1 9.8 Tf [(of what they had experienced did not become clear for quite some time after the event. One participant, who woke up later in an )] TJ ET BT 26.250 100.919 Td /F1 9.8 Tf [(intensive care unit, reported, )] TJ ET BT 151.976 100.919 Td /F5 9.8 Tf [([The nurse] looked at me and said, you know, you are the luckiest person in the entire world.)] TJ ET BT 26.250 81.514 Td /F1 9.8 Tf [(Part of the traumatic exposure was related to witnessing people getting injured or killed, in some cases, quite near them. It was )] TJ ET BT 26.250 69.609 Td /F1 9.8 Tf [(clear from the participants reports that the traumatic event was a combination of both witnessing the unfolding events, including )] TJ ET BT 26.250 57.705 Td /F1 9.8 Tf [(escaping past corpses in the tower lobby and on the street \(remains of jumpers from high floors\), as well as getting caught up )] TJ ET BT 26.250 45.800 Td /F1 9.8 Tf [(and injured in the event itself. For instance, several participants were traumatized during their efforts to run away from the )] TJ ET Q q 326.250 0 0 137.250 35.250 598.691 cm /I12 Do Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(5)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 187 0 obj << /Type /Font /Subtype /Type1 /Name /F5 /BaseFont /Helvetica-Oblique /Encoding /WinAnsiEncoding >> endobj 188 0 obj << /Type /Annot /Subtype /Link /A 189 0 R /Border [0 0 0] /H /I /Rect [ 35.2500 598.6905 361.5000 735.9405 ] >> endobj 189 0 obj << /Type /Action /S /URI /URI (https://currents.plos.org/disasters/files/2016/09/Table-3-RR-600x776-1.jpg) >> endobj 190 0 obj << /Type /XObject /Subtype /Image /Width 435 /Height 183 /ColorSpace /DeviceRGB /Filter /DCTDecode /BitsPerComponent 8 /Length 13648>> stream JFIF``;CREATOR: gd-jpeg v1.0 (using IJG JPEG v80), quality = 82 C   %# , #&')*)-0-(0%()(C   ((((((((((((((((((((((((((((((((((((((((((((((((((("R !1T"AQV#2a3q%5B$Su4CDRb6FUcrt ?)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@)@y[qa ̌K$]ξ-q uR?e+mhC*pJ|k#*+ᷚt4Pv$iun!#qO~tt H {襥 RdpsJim.4ڹI9ĉqmgw,'?4ԯ;Sbd2݊P)LdP)LҁJRJRJRJRJRJRJRJRJRJRJRJRJRJRJRJRJRJRJR_*N}R 7kdC@O !lxRd`nԚV=kodE*ZqN{\ HDtq_u_}~pӦkMjݪ1Am-I)m YFP_o:y뎣#qa*\Dq/x) <˩ȯ$`L(?ѳYkmG|/M\%E icˊ#IPp灚Ҕ R R R R R R R R R R R R R R R R R R R 'T[؛*&ˋFXmRxܔʁ?5F9h==L.Ly"WXm4}j[#-q-JR\*~ybg?k"7i~'F`{sKS;=y#>@ן%yuj`[2>n`48T!+Dh{r~di<Ӊm2,icm\ )߄e;@9VH 0{^]sژ=D.P~О^6OH !P]m*JJJ@QI!\*rSHӵ0{^]].%ytLy"WWiA 0{^];SHPBLy"WN%yuvSHӵ0{^]].%ytLy"WWiA 0{^];SHPBLy"WN%yuvSHӵ0{^]].%ytLy"WWiA 0{^];SHPBLy"WN%yuvSHӵ0{^]].%ytLy"WWiA 0{^];SHPBLy"WN%yuvSHӵ0{^]].%ytLy"WWiA 0{^];SHPBLy"W_)Ֆ2Wqanۤ4iV7)IQ}~:GhÿA((((oQjaeerKkg[#k{P4=k>O/z }Wi7sq4;9(!GVҕmˆk:cƿSULT}w5CRgRtR pBy qq7s#>yWd}}iA)\Fe$m(*ޞ+ W]w1_]Lx@n"NW8'c##"]uL7&qouCn0 R2:)@TkyY5s.~#L5a)[[iVvFv_Qn:[j\f4JR'@ZR˨P q*kpȲc->%qPX<#TW XB|mAm0Tc}= cWff>[=[QHP .G~ s&vҭ2J>ItYw:gxH}rjZKiNqX'Fs m$ۯn&nԤ@$sBsy攖u-[ef2ƒ!Š=80=Bͥ"꯷ƖV^M<Ⱦ]"!C`-#vi5Dvs)uIA´#dl 66[NF!+jOjS27N-]Fv:Ҿ->j{m.\h$A+3Aj(%m~JPsy\h j8k# qkiLeĩV(BHH2Bq.1sL}CZbJ[ 5*aHP*AQB"2#N/Ѷ%i-f$)D:sxngqi]Y |kuOR}HZVr)n7>E+s"]_oqkS*+@X)!0TUڎ3F^uN/TϹKd28},+p$-=G/wQwbl^u1 ˮw4e8;I-!*ppt Gw+H<ӗAi򡷪nk)[Y%*>YN?!XDd2T̡*rL4[u6 Bwd`K^sIL1N%9$W‚9)#659wac. ~mdx wrHX+ɗv+j`IStFBԝ䀾G 0+ܝ!Bn4o \(w Cipc`^!'Q³+g$ǨJ7Iv'n?cm5V.ǎYJ p:8:rZtα![/^ye\aBĒr9 ɲ-DK9q?:'I j; ֹ:óf15bڑ*!%.ূ0h?W'V2,Muf[L>V-%-xݒEk \S:詪kKppd^i oY_rsNۉ[7p'frw @7X"#7d(8IG p$0+ߦtߩM+Rf䕯XE8,[/Խ4 YRN0y>XJ[rR~I̕$ݛvUt1T!~D3uըfc6UmI8HCN=h)mypda\씅E{lo1]Lj%Դ*ځq^bԅƿ_ZS[[YB##Z*kyV +zyƒ:`s xGnHL8KSo)hc=G* Ol~7mⵜ|g\ "BC_ƳdCvIO,8җY(JpN+ ,]5Mr#Lu+XX ; }a.tqa.q  9N¼WuK)#9P>NZ}vGw~aJRJRJRJRXeq \ O)= PO3[FԬZu(V} A?LA -7@pG$waX;}<08| 1d֕nD8mrJI-epnn)2Iۻ9Tvm&#!k Ŏg'|T2@y41&hiج2.62Ck iqK=qOA]*h AM-Ckiy N?JOPVޝ9cr;CmM-$aA@A$WDi \8ZͩeJ ]Jԭj' (=fo|V/j"Ra8a[1#E4=b&2+i ,7Rs<‰vi{՚!7/)iI׌y׎H=%H[HLmJZ{?w)P#*׈fe 2"zn]@$C!@jlN3)+hnK).Sa|43CTw.bhCJRAU ARKQDڃ!AO"ҦU.ϸtFhWuY-C)6 rIǿ8wKp sT𷴣 8FG:wBNշX%kY9)kޠ=` 'H\[ X,DH36jZRK'irzшޗ$B5)S p1P%XKMF^ q P Kvl<]I,bɰGA#qʹv=ڕnғ;`ǵ-Aͭ#8A4枋o$iSԾb5`gbt;v_lV-.<6};G0HPߜrΫGԀDFW:̕7C@NԞn9=OZ&~C-AjܭƚX[{H1u N0$fH.l Fc\:ia]u)PJ[s#~B6OƱICʵkGusjpzPã!sk2!vǝc]*܇-k܍*?]F])mCo1dZBx߳RA(zxu fՆ(̗Uhӡ#fdc5ło >TvƌkD0uG=+ȶU0uִͤn]9 {ǻ a9qȖHJ7Ci8=>n)%9Np8j:b%ݞhMiw&ؐh`e*LPH5瀋D Du\mt q:P kQ8VFyםVG5.Be2S+ͱd/N2rpyl%oCa.dThډ RRU{Ӝt'!Ǹhor!IB{KᡗKjRAdtI<{z"ٵbiq(C Jd+)΢MdmT!kWIV8^I C$dA R˚Nw*\6;GV^\k[\KLHu2PfihSݸU/)qԭ.'xڭ?}ib=nv-X|tŌN6[Ka)AIʰ 9H[orȳ@q1e8%.- XX²Ny5`YK eJVR?uUWU[u2X e B@ 9j :u,bD\6{v]Q'9˖(5Ү-tm5)*)(m6)*nN+>,,d)f{Lf-; @3R Yn"M[%s8Z d6(JR#{]K lQqi^ ތcO/w{얐ԗ… ;7 z9|O*^'h @yr6,)zC|EJٕd`ydS@Rcǿ9sw]#z.DKuG[ᨩʝEy wi!u >\ Ҩ 7PD(AB20/#}&ulTePAo IHP) `(tr:QZ(nxX/-0EP]m6xcՁSWyT)[w{)Q2yM㵧9-8MMܣ$-*KuIy[k8x5TFqɶ8~k[0* AA#'2{vILfy 9ip4wȄ Z6emқ(/i2-شPFI#985lxktYjF~НI]`g8pc"k-MKehk[.Ky8{̻W\W=9 }Pg0g=I4T}֞>vI95ӗ nSF3ZUMmvrϣօRH'~ݑ  [CQzeIJ%\A@uzfL3Q]ǜJ86!9l3cїFd=JTڝ͡ăF@}1Pq\?1-b3d-mi˙*8励/ 2ڰI''+%*%**%zʧ%zʠJ 2^ 2^/R_̗z_̗ Ԩ>%*%**%zʧ%zʠJ 2^ 2^/R_̷ɧ%zQ Ԩ>-Fi 2޿o&*%zQz_̷ɠJ 2޿o&-Gh/VG^x?ߪ-Fk9o¼\f$RI|h?A)@)@)@)@sSc7LrT-T'^֬` 3(14%+)&R#KМ=)$;J.9^Rؑs*@N0SIZ.鏗,nrZh0L}]c>ӊ1ev8xѕ R}s*vfab#^_rېۜu< rw<9ct˖_N鏗,BˉwD[gOt*J[= Jy:Rl6Hّbʼn<,GYd66IQ8ެ>\v7L|e-}4}knwLˋ%Ng#:v`Ɵ/ \V301)_v7L|e-}5Ѻg7k١LƑmnb4qv1YH#\ =-| _M;>\ Ԩ].Y| _Mq/ݗ^AnrZk鏗,*ctv_N鏗,*ct˖_\v7Ke-}4P{>\籺c/k頻J/ݗӱ_/k頽J/ݗӱ_/k頽J/ݗӱ_/k頽J/ݗӱ_/k頽Yy㣹T;[0eT+%4sKm IȄr'X(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((? endstream endobj 191 0 obj << /Type /Annot /Subtype /Link /A 192 0 R /Border [0 0 0] /H /I /Rect [ 35.2500 598.6905 361.5000 735.9405 ] >> endobj 192 0 obj << /Type /Action /S /URI /URI (https://currents.plos.org/disasters/files/2016/09/Table-3-RR-600x776-1.jpg) >> endobj 193 0 obj << /Type /Annot /Subtype /Link /A 194 0 R /Border [0 0 0] /H /I /Rect [ 35.2500 598.6905 361.5000 735.9405 ] >> endobj 194 0 obj << /Type /Action /S /URI /URI (https://currents.plos.org/disasters/files/2016/09/Table-3-RR-600x776-1.jpg) >> endobj 195 0 obj << /Type /Page /Parent 3 0 R /Contents 196 0 R >> endobj 196 0 obj << /Length 29461 >> stream 0.271 0.267 0.267 rg q 15.000 30.929 577.500 746.071 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(collapsing buildings amid the flying debris and resultant dust clouds, not only because they were injured during these efforts, but )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(because they were caught up in stampeding crowds of people who were similarly trying to flee. As noted by one participant, as )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(WTC 1 started to collapse, )] TJ ET BT 143.835 743.667 Td /F5 9.8 Tf [(It was every man for himself. We just started running.)] TJ ET BT 380.077 743.667 Td /F1 9.8 Tf [( Another survivor reported a similar situation )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(when WTC 2 collapsed,)] TJ ET BT 129.200 731.762 Td /F5 9.8 Tf [( I started running and there were just hundreds of people running. And somebody just completely )] TJ ET BT 26.250 719.857 Td /F5 9.8 Tf [(knocked the wind out of me and knocked me across the street itself. And I really thought that I was just going to die there.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(Although first responders were on the scene early to direct people out and away from the buildings, many interviewees reported )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(that once WTC 2 collapsed, conditions on the ground rapidly deteriorated, making escape especially traumatic. Visibility )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(became exceptionally poor; as noted by one participant,)] TJ ET BT 267.416 676.643 Td /F5 9.8 Tf [( It was the darkest- it was darker than nighttime. It was indescribable )] TJ ET BT 26.250 664.738 Td /F5 9.8 Tf [(really.)] TJ ET BT 55.500 664.738 Td /F1 9.8 Tf [( In the darkness, people became disoriented, and several of them experienced injuries at this point.)] TJ ET BT 26.250 645.333 Td /F1 9.8 Tf [(As the evacuation inside of the buildings proceeded, conditions in the stairwells degraded. At one point, in WTC 2, shortly )] TJ ET BT 26.250 633.429 Td /F1 9.8 Tf [(before the collapse of the building, several participants reported chaos in the stairwell; large cracks appeared in the stairwell )] TJ ET BT 26.250 621.524 Td /F1 9.8 Tf [(walls, all the emergency lights went out, water from broken standpipes was filling in and reached up to the knees of some )] TJ ET BT 26.250 609.619 Td /F1 9.8 Tf [(people, and people began to panic and run down the stairs. Several participants also noted that it was at this point or shortly )] TJ ET BT 26.250 597.714 Td /F1 9.8 Tf [(after they exited the stairwells, they were now without their shoes and experienced foot injuries.)] TJ ET BT 26.250 578.310 Td /F1 9.8 Tf [(The collapse of the towers was harrowing for several participants as the force of the implosion caused them to be thrown. As )] TJ ET BT 26.250 566.405 Td /F1 9.8 Tf [(noted by one survivor,)] TJ ET BT 122.171 566.405 Td /F5 9.8 Tf [( [I was] about 30 feet Id say from the North Tower when it collapsed. And I was blown about 40 feet in )] TJ ET BT 26.250 554.500 Td /F5 9.8 Tf [(the air. I smacked into a cement wall. I was able to crawl into a room in WTC Tower 6.)] TJ ET BT 400.123 554.500 Td /F1 9.8 Tf [( Other survivors similarly reported getting )] TJ ET BT 26.250 542.595 Td /F1 9.8 Tf [(thrown in the air as they were hit by flying debris. As noted by one first responder running away from the collapsing WTC 1,)] TJ ET BT 26.250 530.691 Td /F5 9.8 Tf [(I got maybe about two blocks, 2 1/2 blocks up, and I got hit on the head and I went flying and I think I fell into what was an )] TJ ET BT 26.250 518.786 Td /F5 9.8 Tf [(excavation pitI was buried over with concrete and debris.)] TJ ET BT 284.186 518.786 Td /F1 9.8 Tf [( Other participants also reported getting buried under debris, as )] TJ ET BT 26.250 506.881 Td /F1 9.8 Tf [(noted by one survivor, )] TJ ET BT 124.881 506.881 Td /F5 9.8 Tf [(Since we were so close, you know the force just moved me I dont know like 20 feet or however. It )] TJ ET BT 26.250 494.976 Td /F5 9.8 Tf [(definitely blew me a distance. And we were all flattened out. Everybody who was in the area. And then there was that huge gray-)] TJ ET BT 26.250 483.072 Td /F5 9.8 Tf [(black cloud. You couldnt see any sunlight like just a tad, just a smidgen. And after we were all knocked down .somebody )] TJ ET BT 26.250 471.167 Td /F5 9.8 Tf [(was on top of me because of the weight of everything coming down. Thats when I fractured my rib. And I had my leg pulled up )] TJ ET BT 26.250 459.262 Td /F5 9.8 Tf [(behind me and I had an injury to my knee.)] TJ ET BT 26.250 439.857 Td /F1 9.8 Tf [(Participants reported getting buried under debris and losing consciousness as the towers collapsed. As one survivor of WTC 1 )] TJ ET BT 26.250 427.953 Td /F1 9.8 Tf [(collapse stated, )] TJ ET BT 96.704 427.953 Td /F5 9.8 Tf [(I ran towards building five [WTC Tower 5]. Thats the shortest entrance you can run to in order to get out of the )] TJ ET BT 26.250 416.048 Td /F5 9.8 Tf [(staircase when the building [started to] collapse. I blacked out and the next thing I know I was on a stretcher and getting medical )] TJ ET BT 26.250 404.143 Td /F5 9.8 Tf [(attention.)] TJ ET BT 26.250 384.738 Td /F4 9.8 Tf [(Timeliness of short and long-term medical and mental health care)] TJ ET BT 26.250 365.334 Td /F1 9.8 Tf [(Immediate medical care for injuries fell into three categories none, immediate, and delayed. Most, though not all, of those who )] TJ ET BT 26.250 353.429 Td /F1 9.8 Tf [(did not seek any medical care \(either immediate or delayed\) had less severe injuries, mostly cuts and scrapes, foot injuries, )] TJ ET BT 26.250 341.524 Td /F1 9.8 Tf [(and eye irritation. Those with more severe injuries received either immediate or delayed medical care for their injuries, with the )] TJ ET BT 26.250 329.619 Td /F1 9.8 Tf [(majority generally receiving care by the end of the day, although some waited days to weeks before receiving care. The reasons )] TJ ET BT 26.250 317.715 Td /F1 9.8 Tf [(for delaying care included,)] TJ ET BT 140.052 317.715 Td /F5 9.8 Tf [( did not realize how badly I was injured, could not/would not leave my home/apartment,)] TJ ET BT 528.043 317.715 Td /F1 9.8 Tf [( and,)] TJ ET BT 26.250 305.810 Td /F5 9.8 Tf [(wanted to be alone/not think about the event.)] TJ ET BT 26.250 286.405 Td /F1 9.8 Tf [(Many of the more severely injured people first had to be evacuated from the immediate vicinity of the WTC to another location. )] TJ ET BT 26.250 274.500 Td /F1 9.8 Tf [(In some cases, this took quite an extended period of time because they were first evacuated by boat to a triage site, usually in )] TJ ET BT 26.250 262.596 Td /F1 9.8 Tf [(Staten Island or New Jersey, and from there they were then taken by bus, ambulance, or private car to a nearby hospital. Even )] TJ ET BT 26.250 250.691 Td /F1 9.8 Tf [(though many of these more severely injured people were in great pain, they self- evacuated or were assisted by Good )] TJ ET BT 26.250 238.786 Td /F1 9.8 Tf [(Samaritans to these more distant locations without benefit of immediate first aid care \(by Emergency Medical Services\) or )] TJ ET BT 26.250 226.881 Td /F1 9.8 Tf [(pain medications. As one participant reported, )] TJ ET BT 227.305 226.881 Td /F5 9.8 Tf [(They got me into triage- I remember screaming, somebody give me some )] TJ ET BT 26.250 214.977 Td /F5 9.8 Tf [(morphine.)] TJ ET BT 72.845 214.977 Td /F1 9.8 Tf [( When they finally arrived at the distant hospital, hours after they had initially sustained their injuries, many of these )] TJ ET BT 26.250 203.072 Td /F1 9.8 Tf [(participants reported that they basically were in shock, with many completely unaware of how they had even gotten there. In )] TJ ET BT 26.250 191.167 Td /F1 9.8 Tf [(addition to receiving care and treatment of their injuries, many of the participants who presented to either local or more distant )] TJ ET BT 26.250 179.262 Td /F1 9.8 Tf [(hospitals reported that in addition to treatment of their injuries, they also received pulmonary therapy treatments to help them )] TJ ET BT 26.250 167.358 Td /F1 9.8 Tf [(breathe. No one in our sample reported that the hospital provider recommended that they seek follow-up psychological care, )] TJ ET BT 26.250 155.453 Td /F1 9.8 Tf [(although several were urged to see other medical specialists and/or their family provider.)] TJ ET BT 26.250 136.048 Td /F1 9.8 Tf [(Some study participants who were first responders reported that even though they had been badly injured that day, they still )] TJ ET BT 26.250 124.143 Td /F1 9.8 Tf [(refused medical care. Most felt they were needed on the job and did not want to stop working, others were clearly in shock \(they )] TJ ET BT 26.250 112.239 Td /F1 9.8 Tf [(afterward said they could not remember details of how they had continued to perform their duties\), some had received head )] TJ ET BT 26.250 100.334 Td /F1 9.8 Tf [(injuries \(and may also have been in shock\), and others felt it was unseemly to complain about their injuries when so many fellow )] TJ ET BT 26.250 88.429 Td /F1 9.8 Tf [(rescuers had been killed. Other \(non-responder\) participants declined any offers of care that day as they wanted to reach their )] TJ ET BT 26.250 76.524 Td /F1 9.8 Tf [(own provider near where they lived. However, several did not get to see their own provider for many days, and when they did, )] TJ ET BT 26.250 64.620 Td /F1 9.8 Tf [(the provider also did not discuss the potential need for follow-up mental health care.)] TJ ET BT 26.250 45.215 Td /F1 9.8 Tf [(Among those with more severe injuries, long-term care and continued health problems were commonly reported. Almost all )] TJ ET Q q 15.000 30.929 577.500 746.071 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(collapsing buildings amid the flying debris and resultant dust clouds, not only because they were injured during these efforts, but )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(because they were caught up in stampeding crowds of people who were similarly trying to flee. As noted by one participant, as )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(WTC 1 started to collapse, )] TJ ET BT 143.835 743.667 Td /F5 9.8 Tf [(It was every man for himself. We just started running.)] TJ ET BT 380.077 743.667 Td /F1 9.8 Tf [( Another survivor reported a similar situation )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(when WTC 2 collapsed,)] TJ ET BT 129.200 731.762 Td /F5 9.8 Tf [( I started running and there were just hundreds of people running. And somebody just completely )] TJ ET BT 26.250 719.857 Td /F5 9.8 Tf [(knocked the wind out of me and knocked me across the street itself. And I really thought that I was just going to die there.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(Although first responders were on the scene early to direct people out and away from the buildings, many interviewees reported )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(that once WTC 2 collapsed, conditions on the ground rapidly deteriorated, making escape especially traumatic. Visibility )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(became exceptionally poor; as noted by one participant,)] TJ ET BT 267.416 676.643 Td /F5 9.8 Tf [( It was the darkest- it was darker than nighttime. It was indescribable )] TJ ET BT 26.250 664.738 Td /F5 9.8 Tf [(really.)] TJ ET BT 55.500 664.738 Td /F1 9.8 Tf [( In the darkness, people became disoriented, and several of them experienced injuries at this point.)] TJ ET BT 26.250 645.333 Td /F1 9.8 Tf [(As the evacuation inside of the buildings proceeded, conditions in the stairwells degraded. At one point, in WTC 2, shortly )] TJ ET BT 26.250 633.429 Td /F1 9.8 Tf [(before the collapse of the building, several participants reported chaos in the stairwell; large cracks appeared in the stairwell )] TJ ET BT 26.250 621.524 Td /F1 9.8 Tf [(walls, all the emergency lights went out, water from broken standpipes was filling in and reached up to the knees of some )] TJ ET BT 26.250 609.619 Td /F1 9.8 Tf [(people, and people began to panic and run down the stairs. Several participants also noted that it was at this point or shortly )] TJ ET BT 26.250 597.714 Td /F1 9.8 Tf [(after they exited the stairwells, they were now without their shoes and experienced foot injuries.)] TJ ET BT 26.250 578.310 Td /F1 9.8 Tf [(The collapse of the towers was harrowing for several participants as the force of the implosion caused them to be thrown. As )] TJ ET BT 26.250 566.405 Td /F1 9.8 Tf [(noted by one survivor,)] TJ ET BT 122.171 566.405 Td /F5 9.8 Tf [( [I was] about 30 feet Id say from the North Tower when it collapsed. And I was blown about 40 feet in )] TJ ET BT 26.250 554.500 Td /F5 9.8 Tf [(the air. I smacked into a cement wall. I was able to crawl into a room in WTC Tower 6.)] TJ ET BT 400.123 554.500 Td /F1 9.8 Tf [( Other survivors similarly reported getting )] TJ ET BT 26.250 542.595 Td /F1 9.8 Tf [(thrown in the air as they were hit by flying debris. As noted by one first responder running away from the collapsing WTC 1,)] TJ ET BT 26.250 530.691 Td /F5 9.8 Tf [(I got maybe about two blocks, 2 1/2 blocks up, and I got hit on the head and I went flying and I think I fell into what was an )] TJ ET BT 26.250 518.786 Td /F5 9.8 Tf [(excavation pitI was buried over with concrete and debris.)] TJ ET BT 284.186 518.786 Td /F1 9.8 Tf [( Other participants also reported getting buried under debris, as )] TJ ET BT 26.250 506.881 Td /F1 9.8 Tf [(noted by one survivor, )] TJ ET BT 124.881 506.881 Td /F5 9.8 Tf [(Since we were so close, you know the force just moved me I dont know like 20 feet or however. It )] TJ ET BT 26.250 494.976 Td /F5 9.8 Tf [(definitely blew me a distance. And we were all flattened out. Everybody who was in the area. And then there was that huge gray-)] TJ ET BT 26.250 483.072 Td /F5 9.8 Tf [(black cloud. You couldnt see any sunlight like just a tad, just a smidgen. And after we were all knocked down .somebody )] TJ ET BT 26.250 471.167 Td /F5 9.8 Tf [(was on top of me because of the weight of everything coming down. Thats when I fractured my rib. And I had my leg pulled up )] TJ ET BT 26.250 459.262 Td /F5 9.8 Tf [(behind me and I had an injury to my knee.)] TJ ET BT 26.250 439.857 Td /F1 9.8 Tf [(Participants reported getting buried under debris and losing consciousness as the towers collapsed. As one survivor of WTC 1 )] TJ ET BT 26.250 427.953 Td /F1 9.8 Tf [(collapse stated, )] TJ ET BT 96.704 427.953 Td /F5 9.8 Tf [(I ran towards building five [WTC Tower 5]. Thats the shortest entrance you can run to in order to get out of the )] TJ ET BT 26.250 416.048 Td /F5 9.8 Tf [(staircase when the building [started to] collapse. I blacked out and the next thing I know I was on a stretcher and getting medical )] TJ ET BT 26.250 404.143 Td /F5 9.8 Tf [(attention.)] TJ ET BT 26.250 384.738 Td /F4 9.8 Tf [(Timeliness of short and long-term medical and mental health care)] TJ ET BT 26.250 365.334 Td /F1 9.8 Tf [(Immediate medical care for injuries fell into three categories none, immediate, and delayed. Most, though not all, of those who )] TJ ET BT 26.250 353.429 Td /F1 9.8 Tf [(did not seek any medical care \(either immediate or delayed\) had less severe injuries, mostly cuts and scrapes, foot injuries, )] TJ ET BT 26.250 341.524 Td /F1 9.8 Tf [(and eye irritation. Those with more severe injuries received either immediate or delayed medical care for their injuries, with the )] TJ ET BT 26.250 329.619 Td /F1 9.8 Tf [(majority generally receiving care by the end of the day, although some waited days to weeks before receiving care. The reasons )] TJ ET BT 26.250 317.715 Td /F1 9.8 Tf [(for delaying care included,)] TJ ET BT 140.052 317.715 Td /F5 9.8 Tf [( did not realize how badly I was injured, could not/would not leave my home/apartment,)] TJ ET BT 528.043 317.715 Td /F1 9.8 Tf [( and,)] TJ ET BT 26.250 305.810 Td /F5 9.8 Tf [(wanted to be alone/not think about the event.)] TJ ET BT 26.250 286.405 Td /F1 9.8 Tf [(Many of the more severely injured people first had to be evacuated from the immediate vicinity of the WTC to another location. )] TJ ET BT 26.250 274.500 Td /F1 9.8 Tf [(In some cases, this took quite an extended period of time because they were first evacuated by boat to a triage site, usually in )] TJ ET BT 26.250 262.596 Td /F1 9.8 Tf [(Staten Island or New Jersey, and from there they were then taken by bus, ambulance, or private car to a nearby hospital. Even )] TJ ET BT 26.250 250.691 Td /F1 9.8 Tf [(though many of these more severely injured people were in great pain, they self- evacuated or were assisted by Good )] TJ ET BT 26.250 238.786 Td /F1 9.8 Tf [(Samaritans to these more distant locations without benefit of immediate first aid care \(by Emergency Medical Services\) or )] TJ ET BT 26.250 226.881 Td /F1 9.8 Tf [(pain medications. As one participant reported, )] TJ ET BT 227.305 226.881 Td /F5 9.8 Tf [(They got me into triage- I remember screaming, somebody give me some )] TJ ET BT 26.250 214.977 Td /F5 9.8 Tf [(morphine.)] TJ ET BT 72.845 214.977 Td /F1 9.8 Tf [( When they finally arrived at the distant hospital, hours after they had initially sustained their injuries, many of these )] TJ ET BT 26.250 203.072 Td /F1 9.8 Tf [(participants reported that they basically were in shock, with many completely unaware of how they had even gotten there. In )] TJ ET BT 26.250 191.167 Td /F1 9.8 Tf [(addition to receiving care and treatment of their injuries, many of the participants who presented to either local or more distant )] TJ ET BT 26.250 179.262 Td /F1 9.8 Tf [(hospitals reported that in addition to treatment of their injuries, they also received pulmonary therapy treatments to help them )] TJ ET BT 26.250 167.358 Td /F1 9.8 Tf [(breathe. No one in our sample reported that the hospital provider recommended that they seek follow-up psychological care, )] TJ ET BT 26.250 155.453 Td /F1 9.8 Tf [(although several were urged to see other medical specialists and/or their family provider.)] TJ ET BT 26.250 136.048 Td /F1 9.8 Tf [(Some study participants who were first responders reported that even though they had been badly injured that day, they still )] TJ ET BT 26.250 124.143 Td /F1 9.8 Tf [(refused medical care. Most felt they were needed on the job and did not want to stop working, others were clearly in shock \(they )] TJ ET BT 26.250 112.239 Td /F1 9.8 Tf [(afterward said they could not remember details of how they had continued to perform their duties\), some had received head )] TJ ET BT 26.250 100.334 Td /F1 9.8 Tf [(injuries \(and may also have been in shock\), and others felt it was unseemly to complain about their injuries when so many fellow )] TJ ET BT 26.250 88.429 Td /F1 9.8 Tf [(rescuers had been killed. Other \(non-responder\) participants declined any offers of care that day as they wanted to reach their )] TJ ET BT 26.250 76.524 Td /F1 9.8 Tf [(own provider near where they lived. However, several did not get to see their own provider for many days, and when they did, )] TJ ET BT 26.250 64.620 Td /F1 9.8 Tf [(the provider also did not discuss the potential need for follow-up mental health care.)] TJ ET BT 26.250 45.215 Td /F1 9.8 Tf [(Among those with more severe injuries, long-term care and continued health problems were commonly reported. Almost all )] TJ ET Q q 15.000 30.929 577.500 746.071 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(collapsing buildings amid the flying debris and resultant dust clouds, not only because they were injured during these efforts, but )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(because they were caught up in stampeding crowds of people who were similarly trying to flee. As noted by one participant, as )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(WTC 1 started to collapse, )] TJ ET BT 143.835 743.667 Td /F5 9.8 Tf [(It was every man for himself. We just started running.)] TJ ET BT 380.077 743.667 Td /F1 9.8 Tf [( Another survivor reported a similar situation )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(when WTC 2 collapsed,)] TJ ET BT 129.200 731.762 Td /F5 9.8 Tf [( I started running and there were just hundreds of people running. And somebody just completely )] TJ ET BT 26.250 719.857 Td /F5 9.8 Tf [(knocked the wind out of me and knocked me across the street itself. And I really thought that I was just going to die there.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(Although first responders were on the scene early to direct people out and away from the buildings, many interviewees reported )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(that once WTC 2 collapsed, conditions on the ground rapidly deteriorated, making escape especially traumatic. Visibility )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(became exceptionally poor; as noted by one participant,)] TJ ET BT 267.416 676.643 Td /F5 9.8 Tf [( It was the darkest- it was darker than nighttime. It was indescribable )] TJ ET BT 26.250 664.738 Td /F5 9.8 Tf [(really.)] TJ ET BT 55.500 664.738 Td /F1 9.8 Tf [( In the darkness, people became disoriented, and several of them experienced injuries at this point.)] TJ ET BT 26.250 645.333 Td /F1 9.8 Tf [(As the evacuation inside of the buildings proceeded, conditions in the stairwells degraded. At one point, in WTC 2, shortly )] TJ ET BT 26.250 633.429 Td /F1 9.8 Tf [(before the collapse of the building, several participants reported chaos in the stairwell; large cracks appeared in the stairwell )] TJ ET BT 26.250 621.524 Td /F1 9.8 Tf [(walls, all the emergency lights went out, water from broken standpipes was filling in and reached up to the knees of some )] TJ ET BT 26.250 609.619 Td /F1 9.8 Tf [(people, and people began to panic and run down the stairs. Several participants also noted that it was at this point or shortly )] TJ ET BT 26.250 597.714 Td /F1 9.8 Tf [(after they exited the stairwells, they were now without their shoes and experienced foot injuries.)] TJ ET BT 26.250 578.310 Td /F1 9.8 Tf [(The collapse of the towers was harrowing for several participants as the force of the implosion caused them to be thrown. As )] TJ ET BT 26.250 566.405 Td /F1 9.8 Tf [(noted by one survivor,)] TJ ET BT 122.171 566.405 Td /F5 9.8 Tf [( [I was] about 30 feet Id say from the North Tower when it collapsed. And I was blown about 40 feet in )] TJ ET BT 26.250 554.500 Td /F5 9.8 Tf [(the air. I smacked into a cement wall. I was able to crawl into a room in WTC Tower 6.)] TJ ET BT 400.123 554.500 Td /F1 9.8 Tf [( Other survivors similarly reported getting )] TJ ET BT 26.250 542.595 Td /F1 9.8 Tf [(thrown in the air as they were hit by flying debris. As noted by one first responder running away from the collapsing WTC 1,)] TJ ET BT 26.250 530.691 Td /F5 9.8 Tf [(I got maybe about two blocks, 2 1/2 blocks up, and I got hit on the head and I went flying and I think I fell into what was an )] TJ ET BT 26.250 518.786 Td /F5 9.8 Tf [(excavation pitI was buried over with concrete and debris.)] TJ ET BT 284.186 518.786 Td /F1 9.8 Tf [( Other participants also reported getting buried under debris, as )] TJ ET BT 26.250 506.881 Td /F1 9.8 Tf [(noted by one survivor, )] TJ ET BT 124.881 506.881 Td /F5 9.8 Tf [(Since we were so close, you know the force just moved me I dont know like 20 feet or however. It )] TJ ET BT 26.250 494.976 Td /F5 9.8 Tf [(definitely blew me a distance. And we were all flattened out. Everybody who was in the area. And then there was that huge gray-)] TJ ET BT 26.250 483.072 Td /F5 9.8 Tf [(black cloud. You couldnt see any sunlight like just a tad, just a smidgen. And after we were all knocked down .somebody )] TJ ET BT 26.250 471.167 Td /F5 9.8 Tf [(was on top of me because of the weight of everything coming down. Thats when I fractured my rib. And I had my leg pulled up )] TJ ET BT 26.250 459.262 Td /F5 9.8 Tf [(behind me and I had an injury to my knee.)] TJ ET BT 26.250 439.857 Td /F1 9.8 Tf [(Participants reported getting buried under debris and losing consciousness as the towers collapsed. As one survivor of WTC 1 )] TJ ET BT 26.250 427.953 Td /F1 9.8 Tf [(collapse stated, )] TJ ET BT 96.704 427.953 Td /F5 9.8 Tf [(I ran towards building five [WTC Tower 5]. Thats the shortest entrance you can run to in order to get out of the )] TJ ET BT 26.250 416.048 Td /F5 9.8 Tf [(staircase when the building [started to] collapse. I blacked out and the next thing I know I was on a stretcher and getting medical )] TJ ET BT 26.250 404.143 Td /F5 9.8 Tf [(attention.)] TJ ET BT 26.250 384.738 Td /F4 9.8 Tf [(Timeliness of short and long-term medical and mental health care)] TJ ET BT 26.250 365.334 Td /F1 9.8 Tf [(Immediate medical care for injuries fell into three categories none, immediate, and delayed. Most, though not all, of those who )] TJ ET BT 26.250 353.429 Td /F1 9.8 Tf [(did not seek any medical care \(either immediate or delayed\) had less severe injuries, mostly cuts and scrapes, foot injuries, )] TJ ET BT 26.250 341.524 Td /F1 9.8 Tf [(and eye irritation. Those with more severe injuries received either immediate or delayed medical care for their injuries, with the )] TJ ET BT 26.250 329.619 Td /F1 9.8 Tf [(majority generally receiving care by the end of the day, although some waited days to weeks before receiving care. The reasons )] TJ ET BT 26.250 317.715 Td /F1 9.8 Tf [(for delaying care included,)] TJ ET BT 140.052 317.715 Td /F5 9.8 Tf [( did not realize how badly I was injured, could not/would not leave my home/apartment,)] TJ ET BT 528.043 317.715 Td /F1 9.8 Tf [( and,)] TJ ET BT 26.250 305.810 Td /F5 9.8 Tf [(wanted to be alone/not think about the event.)] TJ ET BT 26.250 286.405 Td /F1 9.8 Tf [(Many of the more severely injured people first had to be evacuated from the immediate vicinity of the WTC to another location. )] TJ ET BT 26.250 274.500 Td /F1 9.8 Tf [(In some cases, this took quite an extended period of time because they were first evacuated by boat to a triage site, usually in )] TJ ET BT 26.250 262.596 Td /F1 9.8 Tf [(Staten Island or New Jersey, and from there they were then taken by bus, ambulance, or private car to a nearby hospital. Even )] TJ ET BT 26.250 250.691 Td /F1 9.8 Tf [(though many of these more severely injured people were in great pain, they self- evacuated or were assisted by Good )] TJ ET BT 26.250 238.786 Td /F1 9.8 Tf [(Samaritans to these more distant locations without benefit of immediate first aid care \(by Emergency Medical Services\) or )] TJ ET BT 26.250 226.881 Td /F1 9.8 Tf [(pain medications. As one participant reported, )] TJ ET BT 227.305 226.881 Td /F5 9.8 Tf [(They got me into triage- I remember screaming, somebody give me some )] TJ ET BT 26.250 214.977 Td /F5 9.8 Tf [(morphine.)] TJ ET BT 72.845 214.977 Td /F1 9.8 Tf [( When they finally arrived at the distant hospital, hours after they had initially sustained their injuries, many of these )] TJ ET BT 26.250 203.072 Td /F1 9.8 Tf [(participants reported that they basically were in shock, with many completely unaware of how they had even gotten there. In )] TJ ET BT 26.250 191.167 Td /F1 9.8 Tf [(addition to receiving care and treatment of their injuries, many of the participants who presented to either local or more distant )] TJ ET BT 26.250 179.262 Td /F1 9.8 Tf [(hospitals reported that in addition to treatment of their injuries, they also received pulmonary therapy treatments to help them )] TJ ET BT 26.250 167.358 Td /F1 9.8 Tf [(breathe. No one in our sample reported that the hospital provider recommended that they seek follow-up psychological care, )] TJ ET BT 26.250 155.453 Td /F1 9.8 Tf [(although several were urged to see other medical specialists and/or their family provider.)] TJ ET BT 26.250 136.048 Td /F1 9.8 Tf [(Some study participants who were first responders reported that even though they had been badly injured that day, they still )] TJ ET BT 26.250 124.143 Td /F1 9.8 Tf [(refused medical care. Most felt they were needed on the job and did not want to stop working, others were clearly in shock \(they )] TJ ET BT 26.250 112.239 Td /F1 9.8 Tf [(afterward said they could not remember details of how they had continued to perform their duties\), some had received head )] TJ ET BT 26.250 100.334 Td /F1 9.8 Tf [(injuries \(and may also have been in shock\), and others felt it was unseemly to complain about their injuries when so many fellow )] TJ ET BT 26.250 88.429 Td /F1 9.8 Tf [(rescuers had been killed. Other \(non-responder\) participants declined any offers of care that day as they wanted to reach their )] TJ ET BT 26.250 76.524 Td /F1 9.8 Tf [(own provider near where they lived. However, several did not get to see their own provider for many days, and when they did, )] TJ ET BT 26.250 64.620 Td /F1 9.8 Tf [(the provider also did not discuss the potential need for follow-up mental health care.)] TJ ET BT 26.250 45.215 Td /F1 9.8 Tf [(Among those with more severe injuries, long-term care and continued health problems were commonly reported. Almost all )] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(6)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 197 0 obj << /Type /Page /Parent 3 0 R /Contents 198 0 R >> endobj 198 0 obj << /Length 29596 >> stream 0.271 0.267 0.267 rg q 15.000 30.929 577.500 746.071 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(participants who had sustained serious injuries spoke of the continued need for physical therapy as well as continuing )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(assessment and treatment by medical specialists on a regular basis, such as orthopedists and pulmonologists. Several )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(participants mentioned that long after they had sustained their injuries, they required surgery, sometimes multiple surgeries. )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(Several mentioned that additional future surgeries would be needed to repair ongoing problems, most typically on the knees, )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(shoulders, and back. A few of these participants also discussed being in chronic pain and having a constant need for pain )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(medications. Several participants also mentioned self-medicating after 9/11, including the use of herbal preparations. Persons in )] TJ ET BT 26.250 696.048 Td /F1 9.8 Tf [(the interviews often mentioned heavy alcohol consumption for a short time after 9/11. Participants who reported current self-)] TJ ET BT 26.250 684.143 Td /F1 9.8 Tf [(medicating all had current probable PTSD. One participant discussed problems sleeping because of nightmares and when )] TJ ET BT 26.250 672.238 Td /F1 9.8 Tf [(asked how they managed this, they replied, )] TJ ET BT 216.472 672.238 Td /F5 9.8 Tf [(I take some NyQuil and a glass of wine.)] TJ ET BT 26.250 652.833 Td /F4 9.8 Tf [(Current health status, functional physical status impairments and disability)] TJ ET BT 26.250 633.429 Td /F1 9.8 Tf [(Long term disability in those who had suffered orthopedic injuries was not uncommon. In some cases, participants stated that )] TJ ET BT 26.250 621.524 Td /F1 9.8 Tf [(they were partially or fully disabled as a result of their injuries. Some participants stated that they are now disfigured, as noted )] TJ ET BT 26.250 609.619 Td /F1 9.8 Tf [(one participant who had sustained serious burns, and who did not like to go out in public because, as he said, )] TJ ET BT 501.007 609.619 Td /F5 9.8 Tf [(Kids say, )] TJ ET BT 26.250 597.714 Td /F5 9.8 Tf [(mommy look at that mans hands.)] TJ ET BT 26.250 578.310 Td /F1 9.8 Tf [(Some participants described mobility impairments that required the use of wheelchairs, walkers, or canes. Others had chronic )] TJ ET BT 26.250 566.405 Td /F1 9.8 Tf [(injury-related health problems \(such as loss of range of motion in injured limbs or chronic pain\). One participant who reported )] TJ ET BT 26.250 554.500 Td /F1 9.8 Tf [(broken bones in his fingers, reported now having arthritis in those fingers, saying)] TJ ET BT 373.613 554.500 Td /F5 9.8 Tf [( [Its] so bad that I cant even barely tie my )] TJ ET BT 26.250 542.595 Td /F5 9.8 Tf [(shoes or anything like that.)] TJ ET BT 145.473 542.595 Td /F1 9.8 Tf [( One participant who had suffered severe burns spoke of loss of dexterity in hands and loss of )] TJ ET BT 26.250 530.691 Td /F1 9.8 Tf [(sensitivity in finger tips. Physical symptoms and diseases described less frequently included hearing loss, dermatological )] TJ ET BT 26.250 518.786 Td /F1 9.8 Tf [(conditions, autoimmune diseases, and cancer. When discussing his current health and hearing loss, one participant said, )] TJ ET BT 26.250 506.881 Td /F5 9.8 Tf [([The doctor] said your hearing loss is remarkably advanced for a man your age.)] TJ ET BT 26.250 487.476 Td /F1 9.8 Tf [(Several participants stated that their injuries resulted in a diminution in their ability to physically perform their normal activities of )] TJ ET BT 26.250 475.572 Td /F1 9.8 Tf [(daily living, such as bathing, dressing, cooking, cleaning, etc. As noted one participant, )] TJ ET BT 402.356 475.572 Td /F5 9.8 Tf [(Ive got to accept the fact that I cant do )] TJ ET BT 26.250 463.667 Td /F5 9.8 Tf [(nothing like I used to.)] TJ ET BT 121.634 463.667 Td /F1 9.8 Tf [( Many seriously injured participants who had previously been very physically active \(playing sports, going )] TJ ET BT 26.250 451.762 Td /F1 9.8 Tf [(to the gym, participating in outdoor activities\) now reported that they could no longer do these things, as one person noted, )] TJ ET BT 26.250 439.857 Td /F5 9.8 Tf [(Life has certainly changed.)] TJ ET BT 26.250 420.453 Td /F1 9.8 Tf [(In addition to the long-term effect of physical injuries, almost all of the participants reported a variety of respiratory symptoms )] TJ ET BT 26.250 408.548 Td /F1 9.8 Tf [(and conditions, including asthma, reactive airway disease, sleep apnea, bronchitis, chronic pneumonia, and lung problems. )] TJ ET BT 26.250 396.643 Td /F1 9.8 Tf [(These respiratory problems also negatively impacted their current functional status. One participant said)] TJ ET BT 474.389 396.643 Td /F5 9.8 Tf [( I cant do any [type of] )] TJ ET BT 26.250 384.738 Td /F5 9.8 Tf [(work for any length of time without literally sitting down and trying to catch my breath.)] TJ ET BT 395.814 384.738 Td /F1 9.8 Tf [( Similarly, another participant stated )] TJ ET BT 26.250 372.834 Td /F5 9.8 Tf [(Even now, when I start to do anything strenuous, bingo, forget it, it takes me a while to recover from it)] TJ ET BT 469.534 372.834 Td /F1 9.8 Tf [( Many participants also )] TJ ET BT 26.250 360.929 Td /F1 9.8 Tf [(reported sinus and throat problems such as allergies, throat irritation, and acid reflux/gastroesophageal reflux diseases \(GERD\). )] TJ ET BT 26.250 349.024 Td /F1 9.8 Tf [(After one participant had an endoscopy, he said he was told that )] TJ ET BT 306.455 349.024 Td /F5 9.8 Tf [(it looked like I had swallowed some red hot coals.)] TJ ET BT 26.250 329.619 Td /F1 9.8 Tf [(In addition to physical ailments, many of the participants described a range of ongoing mental health symptoms related to the )] TJ ET BT 26.250 317.715 Td /F1 9.8 Tf [(event, including anxiety, depression, panic attacks, and sleep disturbances. Several had been diagnosed with PTSD, anxiety )] TJ ET BT 26.250 305.810 Td /F1 9.8 Tf [(disorder and/or depression by a clinician. Serious mental health problems were noted, as recalled by one person who said, )] TJ ET BT 26.250 293.905 Td /F5 9.8 Tf [([after 911], I would look at people and I would see their skeleton.)] TJ ET BT 310.774 293.905 Td /F1 9.8 Tf [( When asked how often this happened, the response was,)] TJ ET BT 26.250 282.000 Td /F5 9.8 Tf [(All the time.)] TJ ET BT 83.678 282.000 Td /F1 9.8 Tf [( For most participants reporting mental health symptoms, these generally became evident shortly after the WTC )] TJ ET BT 26.250 270.096 Td /F1 9.8 Tf [(event, although others reported that symptoms did not manifest until weeks or months later. Several participants reported that )] TJ ET BT 26.250 258.191 Td /F1 9.8 Tf [(their mental health symptoms have persisted for years. Anxiety symptoms included reluctance to fly, fear of being in crowds or )] TJ ET BT 26.250 246.286 Td /F1 9.8 Tf [(public spaces, other phobias, and nervousness. Some participants reported that they were generally now more emotional than )] TJ ET BT 26.250 234.381 Td /F1 9.8 Tf [(they were before 9/11. One participant stated, )] TJ ET BT 226.778 234.381 Td /F5 9.8 Tf [(Im very emotional now. Yeah. I am, [I] mean anything, it has me crying.)] TJ ET BT 542.152 234.381 Td /F1 9.8 Tf [( While )] TJ ET BT 26.250 222.477 Td /F1 9.8 Tf [(another said, )] TJ ET BT 85.325 222.477 Td /F5 9.8 Tf [(Some days Im fine and then theres other days where I get totally upset.)] TJ ET BT 403.975 222.477 Td /F1 9.8 Tf [( Participants also mentioned having )] TJ ET BT 26.250 210.572 Td /F1 9.8 Tf [(sleep problems, restlessness, nightmares, and insomnia. One participant described )] TJ ET BT 388.228 210.572 Td /F5 9.8 Tf [(My wife was telling me that half a dozen )] TJ ET BT 26.250 198.667 Td /F5 9.8 Tf [(times Id be crying in my sleep, yelling in my sleep. She said Im worried about you. Youre not right, youre not yourself. And I )] TJ ET BT 26.250 186.762 Td /F5 9.8 Tf [(knew I wasnt myself. I didnt want my kids going out, I didnt want them going anywhere.)] TJ ET BT 410.995 186.762 Td /F1 9.8 Tf [( Some, but not all, of the participants )] TJ ET BT 26.250 174.858 Td /F1 9.8 Tf [(with these types of symptoms eventually received mental health services such as counseling therapy and prescription )] TJ ET BT 26.250 162.953 Td /F1 9.8 Tf [(medications. Several participants reported that they had moved away from New York City to avoid any reminders of the event, )] TJ ET BT 26.250 151.048 Td /F1 9.8 Tf [(but that even after the relocation, their symptoms persisted.)] TJ ET BT 26.250 131.643 Td /F4 9.8 Tf [(Lifestyle impact)] TJ ET BT 26.250 112.239 Td /F1 9.8 Tf [(Almost all participants reported major changes in their lifestyle after 9/11. Some lifestyle changes were related to the loss of )] TJ ET BT 26.250 100.334 Td /F1 9.8 Tf [(their jobs, and in other cases, changes resulted because of their injuries and subsequent disabilities, as illustrated by this quote,)] TJ ET BT 26.250 88.429 Td /F5 9.8 Tf [(I left [or rather] I would say, that I was forced to take early \(disability\) retirement as a result of it. My wife works now and I just )] TJ ET BT 26.250 76.524 Td /F5 9.8 Tf [(take care of the kids.)] TJ ET BT 26.250 57.120 Td /F1 9.8 Tf [(Several participants reported that they now had little or no enjoyment in life and that they no longer had any interest in )] TJ ET BT 26.250 45.215 Td /F1 9.8 Tf [(participating in activities they had previously \(prior to 9/11\) found enjoyable. Examples of these activities included socializing )] TJ ET Q q 15.000 30.929 577.500 746.071 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(participants who had sustained serious injuries spoke of the continued need for physical therapy as well as continuing )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(assessment and treatment by medical specialists on a regular basis, such as orthopedists and pulmonologists. Several )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(participants mentioned that long after they had sustained their injuries, they required surgery, sometimes multiple surgeries. )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(Several mentioned that additional future surgeries would be needed to repair ongoing problems, most typically on the knees, )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(shoulders, and back. A few of these participants also discussed being in chronic pain and having a constant need for pain )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(medications. Several participants also mentioned self-medicating after 9/11, including the use of herbal preparations. Persons in )] TJ ET BT 26.250 696.048 Td /F1 9.8 Tf [(the interviews often mentioned heavy alcohol consumption for a short time after 9/11. Participants who reported current self-)] TJ ET BT 26.250 684.143 Td /F1 9.8 Tf [(medicating all had current probable PTSD. One participant discussed problems sleeping because of nightmares and when )] TJ ET BT 26.250 672.238 Td /F1 9.8 Tf [(asked how they managed this, they replied, )] TJ ET BT 216.472 672.238 Td /F5 9.8 Tf [(I take some NyQuil and a glass of wine.)] TJ ET BT 26.250 652.833 Td /F4 9.8 Tf [(Current health status, functional physical status impairments and disability)] TJ ET BT 26.250 633.429 Td /F1 9.8 Tf [(Long term disability in those who had suffered orthopedic injuries was not uncommon. In some cases, participants stated that )] TJ ET BT 26.250 621.524 Td /F1 9.8 Tf [(they were partially or fully disabled as a result of their injuries. Some participants stated that they are now disfigured, as noted )] TJ ET BT 26.250 609.619 Td /F1 9.8 Tf [(one participant who had sustained serious burns, and who did not like to go out in public because, as he said, )] TJ ET BT 501.007 609.619 Td /F5 9.8 Tf [(Kids say, )] TJ ET BT 26.250 597.714 Td /F5 9.8 Tf [(mommy look at that mans hands.)] TJ ET BT 26.250 578.310 Td /F1 9.8 Tf [(Some participants described mobility impairments that required the use of wheelchairs, walkers, or canes. Others had chronic )] TJ ET BT 26.250 566.405 Td /F1 9.8 Tf [(injury-related health problems \(such as loss of range of motion in injured limbs or chronic pain\). One participant who reported )] TJ ET BT 26.250 554.500 Td /F1 9.8 Tf [(broken bones in his fingers, reported now having arthritis in those fingers, saying)] TJ ET BT 373.613 554.500 Td /F5 9.8 Tf [( [Its] so bad that I cant even barely tie my )] TJ ET BT 26.250 542.595 Td /F5 9.8 Tf [(shoes or anything like that.)] TJ ET BT 145.473 542.595 Td /F1 9.8 Tf [( One participant who had suffered severe burns spoke of loss of dexterity in hands and loss of )] TJ ET BT 26.250 530.691 Td /F1 9.8 Tf [(sensitivity in finger tips. Physical symptoms and diseases described less frequently included hearing loss, dermatological )] TJ ET BT 26.250 518.786 Td /F1 9.8 Tf [(conditions, autoimmune diseases, and cancer. When discussing his current health and hearing loss, one participant said, )] TJ ET BT 26.250 506.881 Td /F5 9.8 Tf [([The doctor] said your hearing loss is remarkably advanced for a man your age.)] TJ ET BT 26.250 487.476 Td /F1 9.8 Tf [(Several participants stated that their injuries resulted in a diminution in their ability to physically perform their normal activities of )] TJ ET BT 26.250 475.572 Td /F1 9.8 Tf [(daily living, such as bathing, dressing, cooking, cleaning, etc. As noted one participant, )] TJ ET BT 402.356 475.572 Td /F5 9.8 Tf [(Ive got to accept the fact that I cant do )] TJ ET BT 26.250 463.667 Td /F5 9.8 Tf [(nothing like I used to.)] TJ ET BT 121.634 463.667 Td /F1 9.8 Tf [( Many seriously injured participants who had previously been very physically active \(playing sports, going )] TJ ET BT 26.250 451.762 Td /F1 9.8 Tf [(to the gym, participating in outdoor activities\) now reported that they could no longer do these things, as one person noted, )] TJ ET BT 26.250 439.857 Td /F5 9.8 Tf [(Life has certainly changed.)] TJ ET BT 26.250 420.453 Td /F1 9.8 Tf [(In addition to the long-term effect of physical injuries, almost all of the participants reported a variety of respiratory symptoms )] TJ ET BT 26.250 408.548 Td /F1 9.8 Tf [(and conditions, including asthma, reactive airway disease, sleep apnea, bronchitis, chronic pneumonia, and lung problems. )] TJ ET BT 26.250 396.643 Td /F1 9.8 Tf [(These respiratory problems also negatively impacted their current functional status. One participant said)] TJ ET BT 474.389 396.643 Td /F5 9.8 Tf [( I cant do any [type of] )] TJ ET BT 26.250 384.738 Td /F5 9.8 Tf [(work for any length of time without literally sitting down and trying to catch my breath.)] TJ ET BT 395.814 384.738 Td /F1 9.8 Tf [( Similarly, another participant stated )] TJ ET BT 26.250 372.834 Td /F5 9.8 Tf [(Even now, when I start to do anything strenuous, bingo, forget it, it takes me a while to recover from it)] TJ ET BT 469.534 372.834 Td /F1 9.8 Tf [( Many participants also )] TJ ET BT 26.250 360.929 Td /F1 9.8 Tf [(reported sinus and throat problems such as allergies, throat irritation, and acid reflux/gastroesophageal reflux diseases \(GERD\). )] TJ ET BT 26.250 349.024 Td /F1 9.8 Tf [(After one participant had an endoscopy, he said he was told that )] TJ ET BT 306.455 349.024 Td /F5 9.8 Tf [(it looked like I had swallowed some red hot coals.)] TJ ET BT 26.250 329.619 Td /F1 9.8 Tf [(In addition to physical ailments, many of the participants described a range of ongoing mental health symptoms related to the )] TJ ET BT 26.250 317.715 Td /F1 9.8 Tf [(event, including anxiety, depression, panic attacks, and sleep disturbances. Several had been diagnosed with PTSD, anxiety )] TJ ET BT 26.250 305.810 Td /F1 9.8 Tf [(disorder and/or depression by a clinician. Serious mental health problems were noted, as recalled by one person who said, )] TJ ET BT 26.250 293.905 Td /F5 9.8 Tf [([after 911], I would look at people and I would see their skeleton.)] TJ ET BT 310.774 293.905 Td /F1 9.8 Tf [( When asked how often this happened, the response was,)] TJ ET BT 26.250 282.000 Td /F5 9.8 Tf [(All the time.)] TJ ET BT 83.678 282.000 Td /F1 9.8 Tf [( For most participants reporting mental health symptoms, these generally became evident shortly after the WTC )] TJ ET BT 26.250 270.096 Td /F1 9.8 Tf [(event, although others reported that symptoms did not manifest until weeks or months later. Several participants reported that )] TJ ET BT 26.250 258.191 Td /F1 9.8 Tf [(their mental health symptoms have persisted for years. Anxiety symptoms included reluctance to fly, fear of being in crowds or )] TJ ET BT 26.250 246.286 Td /F1 9.8 Tf [(public spaces, other phobias, and nervousness. Some participants reported that they were generally now more emotional than )] TJ ET BT 26.250 234.381 Td /F1 9.8 Tf [(they were before 9/11. One participant stated, )] TJ ET BT 226.778 234.381 Td /F5 9.8 Tf [(Im very emotional now. Yeah. I am, [I] mean anything, it has me crying.)] TJ ET BT 542.152 234.381 Td /F1 9.8 Tf [( While )] TJ ET BT 26.250 222.477 Td /F1 9.8 Tf [(another said, )] TJ ET BT 85.325 222.477 Td /F5 9.8 Tf [(Some days Im fine and then theres other days where I get totally upset.)] TJ ET BT 403.975 222.477 Td /F1 9.8 Tf [( Participants also mentioned having )] TJ ET BT 26.250 210.572 Td /F1 9.8 Tf [(sleep problems, restlessness, nightmares, and insomnia. One participant described )] TJ ET BT 388.228 210.572 Td /F5 9.8 Tf [(My wife was telling me that half a dozen )] TJ ET BT 26.250 198.667 Td /F5 9.8 Tf [(times Id be crying in my sleep, yelling in my sleep. She said Im worried about you. Youre not right, youre not yourself. And I )] TJ ET BT 26.250 186.762 Td /F5 9.8 Tf [(knew I wasnt myself. I didnt want my kids going out, I didnt want them going anywhere.)] TJ ET BT 410.995 186.762 Td /F1 9.8 Tf [( Some, but not all, of the participants )] TJ ET BT 26.250 174.858 Td /F1 9.8 Tf [(with these types of symptoms eventually received mental health services such as counseling therapy and prescription )] TJ ET BT 26.250 162.953 Td /F1 9.8 Tf [(medications. Several participants reported that they had moved away from New York City to avoid any reminders of the event, )] TJ ET BT 26.250 151.048 Td /F1 9.8 Tf [(but that even after the relocation, their symptoms persisted.)] TJ ET BT 26.250 131.643 Td /F4 9.8 Tf [(Lifestyle impact)] TJ ET BT 26.250 112.239 Td /F1 9.8 Tf [(Almost all participants reported major changes in their lifestyle after 9/11. Some lifestyle changes were related to the loss of )] TJ ET BT 26.250 100.334 Td /F1 9.8 Tf [(their jobs, and in other cases, changes resulted because of their injuries and subsequent disabilities, as illustrated by this quote,)] TJ ET BT 26.250 88.429 Td /F5 9.8 Tf [(I left [or rather] I would say, that I was forced to take early \(disability\) retirement as a result of it. My wife works now and I just )] TJ ET BT 26.250 76.524 Td /F5 9.8 Tf [(take care of the kids.)] TJ ET BT 26.250 57.120 Td /F1 9.8 Tf [(Several participants reported that they now had little or no enjoyment in life and that they no longer had any interest in )] TJ ET BT 26.250 45.215 Td /F1 9.8 Tf [(participating in activities they had previously \(prior to 9/11\) found enjoyable. Examples of these activities included socializing )] TJ ET Q q 15.000 30.929 577.500 746.071 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(participants who had sustained serious injuries spoke of the continued need for physical therapy as well as continuing )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(assessment and treatment by medical specialists on a regular basis, such as orthopedists and pulmonologists. Several )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(participants mentioned that long after they had sustained their injuries, they required surgery, sometimes multiple surgeries. )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(Several mentioned that additional future surgeries would be needed to repair ongoing problems, most typically on the knees, )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(shoulders, and back. A few of these participants also discussed being in chronic pain and having a constant need for pain )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(medications. Several participants also mentioned self-medicating after 9/11, including the use of herbal preparations. Persons in )] TJ ET BT 26.250 696.048 Td /F1 9.8 Tf [(the interviews often mentioned heavy alcohol consumption for a short time after 9/11. Participants who reported current self-)] TJ ET BT 26.250 684.143 Td /F1 9.8 Tf [(medicating all had current probable PTSD. One participant discussed problems sleeping because of nightmares and when )] TJ ET BT 26.250 672.238 Td /F1 9.8 Tf [(asked how they managed this, they replied, )] TJ ET BT 216.472 672.238 Td /F5 9.8 Tf [(I take some NyQuil and a glass of wine.)] TJ ET BT 26.250 652.833 Td /F4 9.8 Tf [(Current health status, functional physical status impairments and disability)] TJ ET BT 26.250 633.429 Td /F1 9.8 Tf [(Long term disability in those who had suffered orthopedic injuries was not uncommon. In some cases, participants stated that )] TJ ET BT 26.250 621.524 Td /F1 9.8 Tf [(they were partially or fully disabled as a result of their injuries. Some participants stated that they are now disfigured, as noted )] TJ ET BT 26.250 609.619 Td /F1 9.8 Tf [(one participant who had sustained serious burns, and who did not like to go out in public because, as he said, )] TJ ET BT 501.007 609.619 Td /F5 9.8 Tf [(Kids say, )] TJ ET BT 26.250 597.714 Td /F5 9.8 Tf [(mommy look at that mans hands.)] TJ ET BT 26.250 578.310 Td /F1 9.8 Tf [(Some participants described mobility impairments that required the use of wheelchairs, walkers, or canes. Others had chronic )] TJ ET BT 26.250 566.405 Td /F1 9.8 Tf [(injury-related health problems \(such as loss of range of motion in injured limbs or chronic pain\). One participant who reported )] TJ ET BT 26.250 554.500 Td /F1 9.8 Tf [(broken bones in his fingers, reported now having arthritis in those fingers, saying)] TJ ET BT 373.613 554.500 Td /F5 9.8 Tf [( [Its] so bad that I cant even barely tie my )] TJ ET BT 26.250 542.595 Td /F5 9.8 Tf [(shoes or anything like that.)] TJ ET BT 145.473 542.595 Td /F1 9.8 Tf [( One participant who had suffered severe burns spoke of loss of dexterity in hands and loss of )] TJ ET BT 26.250 530.691 Td /F1 9.8 Tf [(sensitivity in finger tips. Physical symptoms and diseases described less frequently included hearing loss, dermatological )] TJ ET BT 26.250 518.786 Td /F1 9.8 Tf [(conditions, autoimmune diseases, and cancer. When discussing his current health and hearing loss, one participant said, )] TJ ET BT 26.250 506.881 Td /F5 9.8 Tf [([The doctor] said your hearing loss is remarkably advanced for a man your age.)] TJ ET BT 26.250 487.476 Td /F1 9.8 Tf [(Several participants stated that their injuries resulted in a diminution in their ability to physically perform their normal activities of )] TJ ET BT 26.250 475.572 Td /F1 9.8 Tf [(daily living, such as bathing, dressing, cooking, cleaning, etc. As noted one participant, )] TJ ET BT 402.356 475.572 Td /F5 9.8 Tf [(Ive got to accept the fact that I cant do )] TJ ET BT 26.250 463.667 Td /F5 9.8 Tf [(nothing like I used to.)] TJ ET BT 121.634 463.667 Td /F1 9.8 Tf [( Many seriously injured participants who had previously been very physically active \(playing sports, going )] TJ ET BT 26.250 451.762 Td /F1 9.8 Tf [(to the gym, participating in outdoor activities\) now reported that they could no longer do these things, as one person noted, )] TJ ET BT 26.250 439.857 Td /F5 9.8 Tf [(Life has certainly changed.)] TJ ET BT 26.250 420.453 Td /F1 9.8 Tf [(In addition to the long-term effect of physical injuries, almost all of the participants reported a variety of respiratory symptoms )] TJ ET BT 26.250 408.548 Td /F1 9.8 Tf [(and conditions, including asthma, reactive airway disease, sleep apnea, bronchitis, chronic pneumonia, and lung problems. )] TJ ET BT 26.250 396.643 Td /F1 9.8 Tf [(These respiratory problems also negatively impacted their current functional status. One participant said)] TJ ET BT 474.389 396.643 Td /F5 9.8 Tf [( I cant do any [type of] )] TJ ET BT 26.250 384.738 Td /F5 9.8 Tf [(work for any length of time without literally sitting down and trying to catch my breath.)] TJ ET BT 395.814 384.738 Td /F1 9.8 Tf [( Similarly, another participant stated )] TJ ET BT 26.250 372.834 Td /F5 9.8 Tf [(Even now, when I start to do anything strenuous, bingo, forget it, it takes me a while to recover from it)] TJ ET BT 469.534 372.834 Td /F1 9.8 Tf [( Many participants also )] TJ ET BT 26.250 360.929 Td /F1 9.8 Tf [(reported sinus and throat problems such as allergies, throat irritation, and acid reflux/gastroesophageal reflux diseases \(GERD\). )] TJ ET BT 26.250 349.024 Td /F1 9.8 Tf [(After one participant had an endoscopy, he said he was told that )] TJ ET BT 306.455 349.024 Td /F5 9.8 Tf [(it looked like I had swallowed some red hot coals.)] TJ ET BT 26.250 329.619 Td /F1 9.8 Tf [(In addition to physical ailments, many of the participants described a range of ongoing mental health symptoms related to the )] TJ ET BT 26.250 317.715 Td /F1 9.8 Tf [(event, including anxiety, depression, panic attacks, and sleep disturbances. Several had been diagnosed with PTSD, anxiety )] TJ ET BT 26.250 305.810 Td /F1 9.8 Tf [(disorder and/or depression by a clinician. Serious mental health problems were noted, as recalled by one person who said, )] TJ ET BT 26.250 293.905 Td /F5 9.8 Tf [([after 911], I would look at people and I would see their skeleton.)] TJ ET BT 310.774 293.905 Td /F1 9.8 Tf [( When asked how often this happened, the response was,)] TJ ET BT 26.250 282.000 Td /F5 9.8 Tf [(All the time.)] TJ ET BT 83.678 282.000 Td /F1 9.8 Tf [( For most participants reporting mental health symptoms, these generally became evident shortly after the WTC )] TJ ET BT 26.250 270.096 Td /F1 9.8 Tf [(event, although others reported that symptoms did not manifest until weeks or months later. Several participants reported that )] TJ ET BT 26.250 258.191 Td /F1 9.8 Tf [(their mental health symptoms have persisted for years. Anxiety symptoms included reluctance to fly, fear of being in crowds or )] TJ ET BT 26.250 246.286 Td /F1 9.8 Tf [(public spaces, other phobias, and nervousness. Some participants reported that they were generally now more emotional than )] TJ ET BT 26.250 234.381 Td /F1 9.8 Tf [(they were before 9/11. One participant stated, )] TJ ET BT 226.778 234.381 Td /F5 9.8 Tf [(Im very emotional now. Yeah. I am, [I] mean anything, it has me crying.)] TJ ET BT 542.152 234.381 Td /F1 9.8 Tf [( While )] TJ ET BT 26.250 222.477 Td /F1 9.8 Tf [(another said, )] TJ ET BT 85.325 222.477 Td /F5 9.8 Tf [(Some days Im fine and then theres other days where I get totally upset.)] TJ ET BT 403.975 222.477 Td /F1 9.8 Tf [( Participants also mentioned having )] TJ ET BT 26.250 210.572 Td /F1 9.8 Tf [(sleep problems, restlessness, nightmares, and insomnia. One participant described )] TJ ET BT 388.228 210.572 Td /F5 9.8 Tf [(My wife was telling me that half a dozen )] TJ ET BT 26.250 198.667 Td /F5 9.8 Tf [(times Id be crying in my sleep, yelling in my sleep. She said Im worried about you. Youre not right, youre not yourself. And I )] TJ ET BT 26.250 186.762 Td /F5 9.8 Tf [(knew I wasnt myself. I didnt want my kids going out, I didnt want them going anywhere.)] TJ ET BT 410.995 186.762 Td /F1 9.8 Tf [( Some, but not all, of the participants )] TJ ET BT 26.250 174.858 Td /F1 9.8 Tf [(with these types of symptoms eventually received mental health services such as counseling therapy and prescription )] TJ ET BT 26.250 162.953 Td /F1 9.8 Tf [(medications. Several participants reported that they had moved away from New York City to avoid any reminders of the event, )] TJ ET BT 26.250 151.048 Td /F1 9.8 Tf [(but that even after the relocation, their symptoms persisted.)] TJ ET BT 26.250 131.643 Td /F4 9.8 Tf [(Lifestyle impact)] TJ ET BT 26.250 112.239 Td /F1 9.8 Tf [(Almost all participants reported major changes in their lifestyle after 9/11. Some lifestyle changes were related to the loss of )] TJ ET BT 26.250 100.334 Td /F1 9.8 Tf [(their jobs, and in other cases, changes resulted because of their injuries and subsequent disabilities, as illustrated by this quote,)] TJ ET BT 26.250 88.429 Td /F5 9.8 Tf [(I left [or rather] I would say, that I was forced to take early \(disability\) retirement as a result of it. My wife works now and I just )] TJ ET BT 26.250 76.524 Td /F5 9.8 Tf [(take care of the kids.)] TJ ET BT 26.250 57.120 Td /F1 9.8 Tf [(Several participants reported that they now had little or no enjoyment in life and that they no longer had any interest in )] TJ ET BT 26.250 45.215 Td /F1 9.8 Tf [(participating in activities they had previously \(prior to 9/11\) found enjoyable. Examples of these activities included socializing )] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(7)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 199 0 obj << /Type /Page /Parent 3 0 R /Annots [ 201 0 R 203 0 R 205 0 R 207 0 R 209 0 R 211 0 R 213 0 R 215 0 R 217 0 R 219 0 R 221 0 R 223 0 R ] /Contents 200 0 R >> endobj 200 0 obj << /Length 29377 >> stream 0.271 0.267 0.267 rg q 15.000 29.491 577.500 747.509 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(with friends and family, working out, playing sports, outdoor activities with family, working around the house and garden, and )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(playing with their children. One participant said, )] TJ ET BT 233.252 755.571 Td /F5 9.8 Tf [(Im always one to say that I would never talk about any injuries because 2753 )] TJ ET BT 26.250 743.667 Td /F5 9.8 Tf [(people wouldve traded places with me that day. So I dont really talk about [my] injuries. But it really did change my life. )] TJ ET BT 26.250 731.762 Td /F5 9.8 Tf [(Especially having a two month old at the time. You [normally] want to be with them all the time and do things. So Ive been a lot )] TJ ET BT 26.250 719.857 Td /F5 9.8 Tf [(less active with my younger kid than I was with my now 20-year-old.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(Others spoke of missing social or cultural activities because they avoided going into Manhattan or taking the subway or flying on )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(airplanes. A participant commented: )] TJ ET BT 184.483 688.548 Td /F5 9.8 Tf [(If I have to go to the city for a function, Im a wreck.)] TJ ET BT 411.005 688.548 Td /F1 9.8 Tf [( When another participant was probed )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(further about their ability to take the subway they said, )] TJ ET BT 261.995 676.643 Td /F5 9.8 Tf [(I can, but its not something that I want to do and its not something Ill )] TJ ET BT 26.250 664.738 Td /F5 9.8 Tf [(stay up all night before- if I know Im going to go to the museum or take the train)] TJ ET BT 26.250 645.333 Td /F1 9.8 Tf [(Other participants described more extreme social isolation and a near total lack of contact with people and society \(e.g., not )] TJ ET BT 26.250 633.429 Td /F1 9.8 Tf [(wanting to leave their home, avoiding going out with friends\). One participant commented: )] TJ ET BT 415.889 633.429 Td /F5 9.8 Tf [(I didnt want to go out, I didnt want )] TJ ET BT 26.250 621.524 Td /F5 9.8 Tf [(to see anybody.)] TJ ET BT 98.332 621.524 Td /F1 9.8 Tf [( When asked about leisure activities and going out with friends, another participant simply said,)] TJ ET BT 507.471 621.524 Td /F5 9.8 Tf [( No, that [all] )] TJ ET BT 26.250 609.619 Td /F5 9.8 Tf [(stopped.)] TJ ET BT 26.250 590.214 Td /F4 9.8 Tf [(Availability of social support)] TJ ET BT 26.250 570.810 Td /F1 9.8 Tf [(Some study participants discussed different sources of support that helped them, not only recover from the effects of their )] TJ ET BT 26.250 558.905 Td /F1 9.8 Tf [(injuries, but to deal with the totality of the events of 9/11. The most commonly cited source of support was family. One )] TJ ET BT 26.250 547.000 Td /F1 9.8 Tf [(participant said,)] TJ ET BT 94.529 547.000 Td /F5 9.8 Tf [( I have to say that I think the fact that I have a very good home life has the biggest impact. I mean my wife is )] TJ ET BT 26.250 535.095 Td /F5 9.8 Tf [(shes constantly caring for me. Outside of our children Im her biggest priority. And so I would have to equate her support as )] TJ ET BT 26.250 523.191 Td /F5 9.8 Tf [(being my biggest coping mechanism.)] TJ ET BT 189.894 523.191 Td /F1 9.8 Tf [( When discussing the importance of the support he received from his wife and daughter, )] TJ ET BT 26.250 511.286 Td /F1 9.8 Tf [(another participant said, )] TJ ET BT 133.012 511.286 Td /F5 9.8 Tf [( because if it werent for them I dont know what wouldve happened to me.)] TJ ET BT 471.162 511.286 Td /F1 9.8 Tf [( Additional sources of )] TJ ET BT 26.250 499.381 Td /F1 9.8 Tf [(social support mentioned by participants were religion, therapy, friends, and volunteer activities.)] TJ ET BT 26.250 479.976 Td /F1 9.8 Tf [(Some participants however reported a dearth of social support. They felt that the only people who truly understood them were )] TJ ET BT 26.250 468.072 Td /F1 9.8 Tf [(other 9/11 survivors. One participant described it as, )] TJ ET BT 254.390 468.072 Td /F5 9.8 Tf [(You talk to the people you were with that know what youve been through. )] TJ ET BT 26.250 456.167 Td /F5 9.8 Tf [(Its very difficult to talk to other people about it.)] TJ ET BT 230.015 456.167 Td /F1 9.8 Tf [( This lack of ability to discuss feelings and emotions related to 9/11, coupled with )] TJ ET BT 26.250 444.262 Td /F1 9.8 Tf [(wanting to be isolated from everyone led to estrangement in families.)] TJ ET BT 26.250 424.857 Td /F4 9.8 Tf [(Economic impact)] TJ ET BT 26.250 405.453 Td /F1 9.8 Tf [(Participants reported a variety of economic consequences, and most were negative. Some economic impacts were directly due )] TJ ET BT 26.250 393.548 Td /F1 9.8 Tf [(to an injury sustained on 9/11, including the inability to work and the increased costs associated with medical care. Many of the )] TJ ET BT 26.250 381.643 Td /F1 9.8 Tf [(participants with more severe injuries, as well as those with subsequent health issues, had to retire with disability benefits or )] TJ ET BT 26.250 369.738 Td /F1 9.8 Tf [(take early retirement. One participant on permanent disability said, )] TJ ET BT 315.620 369.738 Td /F5 9.8 Tf [(Economically Im in a hard spot. I had to take a home equity )] TJ ET BT 26.250 357.834 Td /F5 9.8 Tf [(loan on my house to make ends meet.)] TJ ET BT 26.250 338.429 Td /F1 9.8 Tf [(Other economic impacts were related more generally to the events of 9/11. Several participants reported that they had lost their )] TJ ET BT 26.250 326.524 Td /F1 9.8 Tf [(job due to company downsizing or going out of business after 9/11. One participant mentioned the financial impact of having to )] TJ ET BT 26.250 314.619 Td /F1 9.8 Tf [(move out of the area, )] TJ ET BT 121.098 314.619 Td /F5 9.8 Tf [(I mean the whole event was a severe economic impact because I was basically in a rent-controlled )] TJ ET BT 26.250 302.715 Td /F5 9.8 Tf [(apartment in Battery Park and I had to move. So when I had to move, my rent tripled.)] TJ ET BT 26.250 266.112 Td /F4 12.0 Tf [(Discussion)] TJ ET BT 26.250 246.158 Td /F1 9.8 Tf [(As has been previously reported,)] TJ ET 0.267 0.267 0.267 rg BT 168.775 247.665 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 178.413 246.158 Td /F1 9.8 Tf [( many participants reported delay in seeking health care services after the event. )] TJ ET BT 26.250 234.253 Td /F1 9.8 Tf [(Oftentimes, the delay was quite extended, even when the participant had experienced relatively serious injuries. This was )] TJ ET BT 26.250 222.348 Td /F1 9.8 Tf [(especially common among first responders who tended to dismiss their own injuries so that they could return to duty as soon as )] TJ ET BT 26.250 210.444 Td /F1 9.8 Tf [(possible. They also did not want to make a big deal of the injury, as so many fellow responders had been killed. A similar )] TJ ET BT 26.250 198.539 Td /F1 9.8 Tf [(sentiment was also voiced by non-responders; they felt guilty that they had survived and did not want to acknowledge injuries in )] TJ ET BT 26.250 186.634 Td /F1 9.8 Tf [(the face of so many fatalities. To address this issue, recommendations regarding care for all acutely exposed survivors \(with or )] TJ ET BT 26.250 174.729 Td /F1 9.8 Tf [(without obvious injuries\) should include medical evaluation and treatment, as needed, at the earliest possible time following )] TJ ET BT 26.250 162.825 Td /F1 9.8 Tf [(mass casualty events. The medical evaluation should also include assessment for acute stress response, with follow-up )] TJ ET BT 26.250 150.920 Td /F1 9.8 Tf [(scheduled so that physical health status could be monitored and to identify psychological problems that may manifest at a later )] TJ ET BT 26.250 139.015 Td /F1 9.8 Tf [(time \(weeks or months after the event\). This follow-up visit would also allow for referral for any specialized medical or )] TJ ET BT 26.250 127.110 Td /F1 9.8 Tf [(psychological treatment. Programs like Project Liberty, started in the weeks after 9/11, should be implemented to provide free )] TJ ET BT 26.250 115.206 Td /F1 9.8 Tf [(public educational and crisis counseling services. This large-scale public health intervention aimed at ameliorating the traumatic )] TJ ET BT 26.250 103.301 Td /F1 9.8 Tf [(stress experienced by tens of thousands of New Yorkers in the disaster area.)] TJ ET 0.267 0.267 0.267 rg BT 358.442 104.808 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 363.261 103.301 Td /F1 9.8 Tf [( Individuals varied widely in the severity of )] TJ ET BT 26.250 91.396 Td /F1 9.8 Tf [(experienced trauma and associated traumatic reactions and individuals with the most severe reactions were referred to longer-)] TJ ET BT 26.250 79.491 Td /F1 9.8 Tf [(term mental health treatment services.)] TJ ET 0.267 0.267 0.267 rg BT 192.059 80.999 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 196.877 79.491 Td /F1 9.8 Tf [( Primary care providers now furnish over half of mental health treatment in this country )] TJ ET BT 26.250 67.587 Td /F1 9.8 Tf [(and about 25% of all primary care recipients have diagnosable mental disorders.)] TJ ET 0.267 0.267 0.267 rg BT 373.067 69.094 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 382.705 67.587 Td /F1 9.8 Tf [( In disaster exposed populations the need for )] TJ ET BT 26.250 55.682 Td /F1 9.8 Tf [(psychological care may rapidly overwhelm the available mental health services, and primary care providers could be a source of )] TJ ET BT 26.250 43.777 Td /F1 9.8 Tf [(mental health treatment after a disaster. In addition, this approach would also allow for an integrated mental health services with )] TJ ET Q q 15.000 29.491 577.500 747.509 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(with friends and family, working out, playing sports, outdoor activities with family, working around the house and garden, and )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(playing with their children. One participant said, )] TJ ET BT 233.252 755.571 Td /F5 9.8 Tf [(Im always one to say that I would never talk about any injuries because 2753 )] TJ ET BT 26.250 743.667 Td /F5 9.8 Tf [(people wouldve traded places with me that day. So I dont really talk about [my] injuries. But it really did change my life. )] TJ ET BT 26.250 731.762 Td /F5 9.8 Tf [(Especially having a two month old at the time. You [normally] want to be with them all the time and do things. So Ive been a lot )] TJ ET BT 26.250 719.857 Td /F5 9.8 Tf [(less active with my younger kid than I was with my now 20-year-old.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(Others spoke of missing social or cultural activities because they avoided going into Manhattan or taking the subway or flying on )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(airplanes. A participant commented: )] TJ ET BT 184.483 688.548 Td /F5 9.8 Tf [(If I have to go to the city for a function, Im a wreck.)] TJ ET BT 411.005 688.548 Td /F1 9.8 Tf [( When another participant was probed )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(further about their ability to take the subway they said, )] TJ ET BT 261.995 676.643 Td /F5 9.8 Tf [(I can, but its not something that I want to do and its not something Ill )] TJ ET BT 26.250 664.738 Td /F5 9.8 Tf [(stay up all night before- if I know Im going to go to the museum or take the train)] TJ ET BT 26.250 645.333 Td /F1 9.8 Tf [(Other participants described more extreme social isolation and a near total lack of contact with people and society \(e.g., not )] TJ ET BT 26.250 633.429 Td /F1 9.8 Tf [(wanting to leave their home, avoiding going out with friends\). One participant commented: )] TJ ET BT 415.889 633.429 Td /F5 9.8 Tf [(I didnt want to go out, I didnt want )] TJ ET BT 26.250 621.524 Td /F5 9.8 Tf [(to see anybody.)] TJ ET BT 98.332 621.524 Td /F1 9.8 Tf [( When asked about leisure activities and going out with friends, another participant simply said,)] TJ ET BT 507.471 621.524 Td /F5 9.8 Tf [( No, that [all] )] TJ ET BT 26.250 609.619 Td /F5 9.8 Tf [(stopped.)] TJ ET BT 26.250 590.214 Td /F4 9.8 Tf [(Availability of social support)] TJ ET BT 26.250 570.810 Td /F1 9.8 Tf [(Some study participants discussed different sources of support that helped them, not only recover from the effects of their )] TJ ET BT 26.250 558.905 Td /F1 9.8 Tf [(injuries, but to deal with the totality of the events of 9/11. The most commonly cited source of support was family. One )] TJ ET BT 26.250 547.000 Td /F1 9.8 Tf [(participant said,)] TJ ET BT 94.529 547.000 Td /F5 9.8 Tf [( I have to say that I think the fact that I have a very good home life has the biggest impact. I mean my wife is )] TJ ET BT 26.250 535.095 Td /F5 9.8 Tf [(shes constantly caring for me. Outside of our children Im her biggest priority. And so I would have to equate her support as )] TJ ET BT 26.250 523.191 Td /F5 9.8 Tf [(being my biggest coping mechanism.)] TJ ET BT 189.894 523.191 Td /F1 9.8 Tf [( When discussing the importance of the support he received from his wife and daughter, )] TJ ET BT 26.250 511.286 Td /F1 9.8 Tf [(another participant said, )] TJ ET BT 133.012 511.286 Td /F5 9.8 Tf [( because if it werent for them I dont know what wouldve happened to me.)] TJ ET BT 471.162 511.286 Td /F1 9.8 Tf [( Additional sources of )] TJ ET BT 26.250 499.381 Td /F1 9.8 Tf [(social support mentioned by participants were religion, therapy, friends, and volunteer activities.)] TJ ET BT 26.250 479.976 Td /F1 9.8 Tf [(Some participants however reported a dearth of social support. They felt that the only people who truly understood them were )] TJ ET BT 26.250 468.072 Td /F1 9.8 Tf [(other 9/11 survivors. One participant described it as, )] TJ ET BT 254.390 468.072 Td /F5 9.8 Tf [(You talk to the people you were with that know what youve been through. )] TJ ET BT 26.250 456.167 Td /F5 9.8 Tf [(Its very difficult to talk to other people about it.)] TJ ET BT 230.015 456.167 Td /F1 9.8 Tf [( This lack of ability to discuss feelings and emotions related to 9/11, coupled with )] TJ ET BT 26.250 444.262 Td /F1 9.8 Tf [(wanting to be isolated from everyone led to estrangement in families.)] TJ ET BT 26.250 424.857 Td /F4 9.8 Tf [(Economic impact)] TJ ET BT 26.250 405.453 Td /F1 9.8 Tf [(Participants reported a variety of economic consequences, and most were negative. Some economic impacts were directly due )] TJ ET BT 26.250 393.548 Td /F1 9.8 Tf [(to an injury sustained on 9/11, including the inability to work and the increased costs associated with medical care. Many of the )] TJ ET BT 26.250 381.643 Td /F1 9.8 Tf [(participants with more severe injuries, as well as those with subsequent health issues, had to retire with disability benefits or )] TJ ET BT 26.250 369.738 Td /F1 9.8 Tf [(take early retirement. One participant on permanent disability said, )] TJ ET BT 315.620 369.738 Td /F5 9.8 Tf [(Economically Im in a hard spot. I had to take a home equity )] TJ ET BT 26.250 357.834 Td /F5 9.8 Tf [(loan on my house to make ends meet.)] TJ ET BT 26.250 338.429 Td /F1 9.8 Tf [(Other economic impacts were related more generally to the events of 9/11. Several participants reported that they had lost their )] TJ ET BT 26.250 326.524 Td /F1 9.8 Tf [(job due to company downsizing or going out of business after 9/11. One participant mentioned the financial impact of having to )] TJ ET BT 26.250 314.619 Td /F1 9.8 Tf [(move out of the area, )] TJ ET BT 121.098 314.619 Td /F5 9.8 Tf [(I mean the whole event was a severe economic impact because I was basically in a rent-controlled )] TJ ET BT 26.250 302.715 Td /F5 9.8 Tf [(apartment in Battery Park and I had to move. So when I had to move, my rent tripled.)] TJ ET BT 26.250 266.112 Td /F4 12.0 Tf [(Discussion)] TJ ET BT 26.250 246.158 Td /F1 9.8 Tf [(As has been previously reported,)] TJ ET 0.267 0.267 0.267 rg BT 168.775 247.665 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 178.413 246.158 Td /F1 9.8 Tf [( many participants reported delay in seeking health care services after the event. )] TJ ET BT 26.250 234.253 Td /F1 9.8 Tf [(Oftentimes, the delay was quite extended, even when the participant had experienced relatively serious injuries. This was )] TJ ET BT 26.250 222.348 Td /F1 9.8 Tf [(especially common among first responders who tended to dismiss their own injuries so that they could return to duty as soon as )] TJ ET BT 26.250 210.444 Td /F1 9.8 Tf [(possible. They also did not want to make a big deal of the injury, as so many fellow responders had been killed. A similar )] TJ ET BT 26.250 198.539 Td /F1 9.8 Tf [(sentiment was also voiced by non-responders; they felt guilty that they had survived and did not want to acknowledge injuries in )] TJ ET BT 26.250 186.634 Td /F1 9.8 Tf [(the face of so many fatalities. To address this issue, recommendations regarding care for all acutely exposed survivors \(with or )] TJ ET BT 26.250 174.729 Td /F1 9.8 Tf [(without obvious injuries\) should include medical evaluation and treatment, as needed, at the earliest possible time following )] TJ ET BT 26.250 162.825 Td /F1 9.8 Tf [(mass casualty events. The medical evaluation should also include assessment for acute stress response, with follow-up )] TJ ET BT 26.250 150.920 Td /F1 9.8 Tf [(scheduled so that physical health status could be monitored and to identify psychological problems that may manifest at a later )] TJ ET BT 26.250 139.015 Td /F1 9.8 Tf [(time \(weeks or months after the event\). This follow-up visit would also allow for referral for any specialized medical or )] TJ ET BT 26.250 127.110 Td /F1 9.8 Tf [(psychological treatment. Programs like Project Liberty, started in the weeks after 9/11, should be implemented to provide free )] TJ ET BT 26.250 115.206 Td /F1 9.8 Tf [(public educational and crisis counseling services. This large-scale public health intervention aimed at ameliorating the traumatic )] TJ ET BT 26.250 103.301 Td /F1 9.8 Tf [(stress experienced by tens of thousands of New Yorkers in the disaster area.)] TJ ET 0.267 0.267 0.267 rg BT 358.442 104.808 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 363.261 103.301 Td /F1 9.8 Tf [( Individuals varied widely in the severity of )] TJ ET BT 26.250 91.396 Td /F1 9.8 Tf [(experienced trauma and associated traumatic reactions and individuals with the most severe reactions were referred to longer-)] TJ ET BT 26.250 79.491 Td /F1 9.8 Tf [(term mental health treatment services.)] TJ ET 0.267 0.267 0.267 rg BT 192.059 80.999 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 196.877 79.491 Td /F1 9.8 Tf [( Primary care providers now furnish over half of mental health treatment in this country )] TJ ET BT 26.250 67.587 Td /F1 9.8 Tf [(and about 25% of all primary care recipients have diagnosable mental disorders.)] TJ ET 0.267 0.267 0.267 rg BT 373.067 69.094 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 382.705 67.587 Td /F1 9.8 Tf [( In disaster exposed populations the need for )] TJ ET BT 26.250 55.682 Td /F1 9.8 Tf [(psychological care may rapidly overwhelm the available mental health services, and primary care providers could be a source of )] TJ ET BT 26.250 43.777 Td /F1 9.8 Tf [(mental health treatment after a disaster. In addition, this approach would also allow for an integrated mental health services with )] TJ ET Q q 15.000 29.491 577.500 747.509 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(with friends and family, working out, playing sports, outdoor activities with family, working around the house and garden, and )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(playing with their children. One participant said, )] TJ ET BT 233.252 755.571 Td /F5 9.8 Tf [(Im always one to say that I would never talk about any injuries because 2753 )] TJ ET BT 26.250 743.667 Td /F5 9.8 Tf [(people wouldve traded places with me that day. So I dont really talk about [my] injuries. But it really did change my life. )] TJ ET BT 26.250 731.762 Td /F5 9.8 Tf [(Especially having a two month old at the time. You [normally] want to be with them all the time and do things. So Ive been a lot )] TJ ET BT 26.250 719.857 Td /F5 9.8 Tf [(less active with my younger kid than I was with my now 20-year-old.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(Others spoke of missing social or cultural activities because they avoided going into Manhattan or taking the subway or flying on )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(airplanes. A participant commented: )] TJ ET BT 184.483 688.548 Td /F5 9.8 Tf [(If I have to go to the city for a function, Im a wreck.)] TJ ET BT 411.005 688.548 Td /F1 9.8 Tf [( When another participant was probed )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(further about their ability to take the subway they said, )] TJ ET BT 261.995 676.643 Td /F5 9.8 Tf [(I can, but its not something that I want to do and its not something Ill )] TJ ET BT 26.250 664.738 Td /F5 9.8 Tf [(stay up all night before- if I know Im going to go to the museum or take the train)] TJ ET BT 26.250 645.333 Td /F1 9.8 Tf [(Other participants described more extreme social isolation and a near total lack of contact with people and society \(e.g., not )] TJ ET BT 26.250 633.429 Td /F1 9.8 Tf [(wanting to leave their home, avoiding going out with friends\). One participant commented: )] TJ ET BT 415.889 633.429 Td /F5 9.8 Tf [(I didnt want to go out, I didnt want )] TJ ET BT 26.250 621.524 Td /F5 9.8 Tf [(to see anybody.)] TJ ET BT 98.332 621.524 Td /F1 9.8 Tf [( When asked about leisure activities and going out with friends, another participant simply said,)] TJ ET BT 507.471 621.524 Td /F5 9.8 Tf [( No, that [all] )] TJ ET BT 26.250 609.619 Td /F5 9.8 Tf [(stopped.)] TJ ET BT 26.250 590.214 Td /F4 9.8 Tf [(Availability of social support)] TJ ET BT 26.250 570.810 Td /F1 9.8 Tf [(Some study participants discussed different sources of support that helped them, not only recover from the effects of their )] TJ ET BT 26.250 558.905 Td /F1 9.8 Tf [(injuries, but to deal with the totality of the events of 9/11. The most commonly cited source of support was family. One )] TJ ET BT 26.250 547.000 Td /F1 9.8 Tf [(participant said,)] TJ ET BT 94.529 547.000 Td /F5 9.8 Tf [( I have to say that I think the fact that I have a very good home life has the biggest impact. I mean my wife is )] TJ ET BT 26.250 535.095 Td /F5 9.8 Tf [(shes constantly caring for me. Outside of our children Im her biggest priority. And so I would have to equate her support as )] TJ ET BT 26.250 523.191 Td /F5 9.8 Tf [(being my biggest coping mechanism.)] TJ ET BT 189.894 523.191 Td /F1 9.8 Tf [( When discussing the importance of the support he received from his wife and daughter, )] TJ ET BT 26.250 511.286 Td /F1 9.8 Tf [(another participant said, )] TJ ET BT 133.012 511.286 Td /F5 9.8 Tf [( because if it werent for them I dont know what wouldve happened to me.)] TJ ET BT 471.162 511.286 Td /F1 9.8 Tf [( Additional sources of )] TJ ET BT 26.250 499.381 Td /F1 9.8 Tf [(social support mentioned by participants were religion, therapy, friends, and volunteer activities.)] TJ ET BT 26.250 479.976 Td /F1 9.8 Tf [(Some participants however reported a dearth of social support. They felt that the only people who truly understood them were )] TJ ET BT 26.250 468.072 Td /F1 9.8 Tf [(other 9/11 survivors. One participant described it as, )] TJ ET BT 254.390 468.072 Td /F5 9.8 Tf [(You talk to the people you were with that know what youve been through. )] TJ ET BT 26.250 456.167 Td /F5 9.8 Tf [(Its very difficult to talk to other people about it.)] TJ ET BT 230.015 456.167 Td /F1 9.8 Tf [( This lack of ability to discuss feelings and emotions related to 9/11, coupled with )] TJ ET BT 26.250 444.262 Td /F1 9.8 Tf [(wanting to be isolated from everyone led to estrangement in families.)] TJ ET BT 26.250 424.857 Td /F4 9.8 Tf [(Economic impact)] TJ ET BT 26.250 405.453 Td /F1 9.8 Tf [(Participants reported a variety of economic consequences, and most were negative. Some economic impacts were directly due )] TJ ET BT 26.250 393.548 Td /F1 9.8 Tf [(to an injury sustained on 9/11, including the inability to work and the increased costs associated with medical care. Many of the )] TJ ET BT 26.250 381.643 Td /F1 9.8 Tf [(participants with more severe injuries, as well as those with subsequent health issues, had to retire with disability benefits or )] TJ ET BT 26.250 369.738 Td /F1 9.8 Tf [(take early retirement. One participant on permanent disability said, )] TJ ET BT 315.620 369.738 Td /F5 9.8 Tf [(Economically Im in a hard spot. I had to take a home equity )] TJ ET BT 26.250 357.834 Td /F5 9.8 Tf [(loan on my house to make ends meet.)] TJ ET BT 26.250 338.429 Td /F1 9.8 Tf [(Other economic impacts were related more generally to the events of 9/11. Several participants reported that they had lost their )] TJ ET BT 26.250 326.524 Td /F1 9.8 Tf [(job due to company downsizing or going out of business after 9/11. One participant mentioned the financial impact of having to )] TJ ET BT 26.250 314.619 Td /F1 9.8 Tf [(move out of the area, )] TJ ET BT 121.098 314.619 Td /F5 9.8 Tf [(I mean the whole event was a severe economic impact because I was basically in a rent-controlled )] TJ ET BT 26.250 302.715 Td /F5 9.8 Tf [(apartment in Battery Park and I had to move. So when I had to move, my rent tripled.)] TJ ET BT 26.250 266.112 Td /F4 12.0 Tf [(Discussion)] TJ ET BT 26.250 246.158 Td /F1 9.8 Tf [(As has been previously reported,)] TJ ET 0.267 0.267 0.267 rg BT 168.775 247.665 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 178.413 246.158 Td /F1 9.8 Tf [( many participants reported delay in seeking health care services after the event. )] TJ ET BT 26.250 234.253 Td /F1 9.8 Tf [(Oftentimes, the delay was quite extended, even when the participant had experienced relatively serious injuries. This was )] TJ ET BT 26.250 222.348 Td /F1 9.8 Tf [(especially common among first responders who tended to dismiss their own injuries so that they could return to duty as soon as )] TJ ET BT 26.250 210.444 Td /F1 9.8 Tf [(possible. They also did not want to make a big deal of the injury, as so many fellow responders had been killed. A similar )] TJ ET BT 26.250 198.539 Td /F1 9.8 Tf [(sentiment was also voiced by non-responders; they felt guilty that they had survived and did not want to acknowledge injuries in )] TJ ET BT 26.250 186.634 Td /F1 9.8 Tf [(the face of so many fatalities. To address this issue, recommendations regarding care for all acutely exposed survivors \(with or )] TJ ET BT 26.250 174.729 Td /F1 9.8 Tf [(without obvious injuries\) should include medical evaluation and treatment, as needed, at the earliest possible time following )] TJ ET BT 26.250 162.825 Td /F1 9.8 Tf [(mass casualty events. The medical evaluation should also include assessment for acute stress response, with follow-up )] TJ ET BT 26.250 150.920 Td /F1 9.8 Tf [(scheduled so that physical health status could be monitored and to identify psychological problems that may manifest at a later )] TJ ET BT 26.250 139.015 Td /F1 9.8 Tf [(time \(weeks or months after the event\). This follow-up visit would also allow for referral for any specialized medical or )] TJ ET BT 26.250 127.110 Td /F1 9.8 Tf [(psychological treatment. Programs like Project Liberty, started in the weeks after 9/11, should be implemented to provide free )] TJ ET BT 26.250 115.206 Td /F1 9.8 Tf [(public educational and crisis counseling services. This large-scale public health intervention aimed at ameliorating the traumatic )] TJ ET BT 26.250 103.301 Td /F1 9.8 Tf [(stress experienced by tens of thousands of New Yorkers in the disaster area.)] TJ ET 0.267 0.267 0.267 rg BT 358.442 104.808 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 363.261 103.301 Td /F1 9.8 Tf [( Individuals varied widely in the severity of )] TJ ET BT 26.250 91.396 Td /F1 9.8 Tf [(experienced trauma and associated traumatic reactions and individuals with the most severe reactions were referred to longer-)] TJ ET BT 26.250 79.491 Td /F1 9.8 Tf [(term mental health treatment services.)] TJ ET 0.267 0.267 0.267 rg BT 192.059 80.999 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 196.877 79.491 Td /F1 9.8 Tf [( Primary care providers now furnish over half of mental health treatment in this country )] TJ ET BT 26.250 67.587 Td /F1 9.8 Tf [(and about 25% of all primary care recipients have diagnosable mental disorders.)] TJ ET 0.267 0.267 0.267 rg BT 373.067 69.094 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 382.705 67.587 Td /F1 9.8 Tf [( In disaster exposed populations the need for )] TJ ET BT 26.250 55.682 Td /F1 9.8 Tf [(psychological care may rapidly overwhelm the available mental health services, and primary care providers could be a source of )] TJ ET BT 26.250 43.777 Td /F1 9.8 Tf [(mental health treatment after a disaster. In addition, this approach would also allow for an integrated mental health services with )] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(8)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 201 0 obj << /Type /Annot /Subtype /Link /A 202 0 R /Border [0 0 0] /H /I /Rect [ 168.7755 246.8634 178.4128 255.6818 ] >> endobj 202 0 obj << /Type /Action >> endobj 203 0 obj << /Type /Annot /Subtype /Link /A 204 0 R /Border [0 0 0] /H /I /Rect [ 358.4423 104.0064 363.2609 112.8247 ] >> endobj 204 0 obj << /Type /Action >> endobj 205 0 obj << /Type /Annot /Subtype /Link /A 206 0 R /Border [0 0 0] /H /I /Rect [ 192.0585 80.1969 196.8772 89.0152 ] >> endobj 206 0 obj << /Type /Action >> endobj 207 0 obj << /Type /Annot /Subtype /Link /A 208 0 R /Border [0 0 0] /H /I /Rect [ 373.0673 68.2922 382.7046 77.1105 ] >> endobj 208 0 obj << /Type /Action >> endobj 209 0 obj << /Type /Annot /Subtype /Link /A 210 0 R /Border [0 0 0] /H /I /Rect [ 168.7755 246.8634 178.4128 255.6818 ] >> endobj 210 0 obj << /Type /Action >> endobj 211 0 obj << /Type /Annot /Subtype /Link /A 212 0 R /Border [0 0 0] /H /I /Rect [ 358.4423 104.0064 363.2609 112.8247 ] >> endobj 212 0 obj << /Type /Action >> endobj 213 0 obj << /Type /Annot /Subtype /Link /A 214 0 R /Border [0 0 0] /H /I /Rect [ 192.0585 80.1969 196.8772 89.0152 ] >> endobj 214 0 obj << /Type /Action >> endobj 215 0 obj << /Type /Annot /Subtype /Link /A 216 0 R /Border [0 0 0] /H /I /Rect [ 373.0673 68.2922 382.7046 77.1105 ] >> endobj 216 0 obj << /Type /Action >> endobj 217 0 obj << /Type /Annot /Subtype /Link /A 218 0 R /Border [0 0 0] /H /I /Rect [ 168.7755 246.8634 178.4128 255.6818 ] >> endobj 218 0 obj << /Type /Action >> endobj 219 0 obj << /Type /Annot /Subtype /Link /A 220 0 R /Border [0 0 0] /H /I /Rect [ 358.4423 104.0064 363.2609 112.8247 ] >> endobj 220 0 obj << /Type /Action >> endobj 221 0 obj << /Type /Annot /Subtype /Link /A 222 0 R /Border [0 0 0] /H /I /Rect [ 192.0585 80.1969 196.8772 89.0152 ] >> endobj 222 0 obj << /Type /Action >> endobj 223 0 obj << /Type /Annot /Subtype /Link /A 224 0 R /Border [0 0 0] /H /I /Rect [ 373.0673 68.2922 382.7046 77.1105 ] >> endobj 224 0 obj << /Type /Action >> endobj 225 0 obj << /Type /Page /Parent 3 0 R /Annots [ 227 0 R 229 0 R 231 0 R 233 0 R 235 0 R 237 0 R 239 0 R 241 0 R 243 0 R 245 0 R 247 0 R 249 0 R 251 0 R 253 0 R 255 0 R 257 0 R 259 0 R 261 0 R 263 0 R 265 0 R 267 0 R 269 0 R 271 0 R 273 0 R 275 0 R 277 0 R 279 0 R 281 0 R 283 0 R 285 0 R 287 0 R 289 0 R 291 0 R 293 0 R 295 0 R 297 0 R 299 0 R 301 0 R 303 0 R 305 0 R 307 0 R 309 0 R 311 0 R 313 0 R 315 0 R 317 0 R 319 0 R 321 0 R 323 0 R 325 0 R 327 0 R 329 0 R 331 0 R 333 0 R 335 0 R 337 0 R 339 0 R 341 0 R 343 0 R 345 0 R 347 0 R 349 0 R 351 0 R 353 0 R 355 0 R 357 0 R ] /Contents 226 0 R >> endobj 226 0 obj << /Length 36262 >> stream 0.271 0.267 0.267 rg q 15.000 26.525 577.500 750.475 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(physical healthcare in the same location, an approach that has been shown to be highly effective.)] TJ ET 0.267 0.267 0.267 rg BT 445.724 768.983 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 26.250 748.071 Td /F1 9.8 Tf [(As shown in previous studies on 9/11 survivors enrolled in the World Trade Center Health Registry, long-term physical and )] TJ ET BT 26.250 736.167 Td /F1 9.8 Tf [(mental health problems were common.)] TJ ET 0.267 0.267 0.267 rg BT 194.223 737.674 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 199.042 740.055 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 201.451 737.674 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 206.270 740.055 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 208.679 737.674 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 213.498 740.055 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 215.907 737.674 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 225.544 740.055 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 227.954 737.674 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 237.591 736.167 Td /F1 9.8 Tf [( The risk factors for long-term disability found in this study have also been )] TJ ET BT 26.250 724.262 Td /F1 9.8 Tf [(reported in other research on 9/11 survivors, namely severity of injury, intensity of peri-event traumatic exposure, and lack of )] TJ ET BT 26.250 712.357 Td /F1 9.8 Tf [(timely and effective mental health care.)] TJ ET 0.267 0.267 0.267 rg BT 195.325 713.864 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 204.962 716.245 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 207.371 713.864 Td /F4 8.7 Tf [(19)] TJ ET 0.271 0.267 0.267 rg BT 217.009 716.245 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 219.418 713.864 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 229.055 712.357 Td /F1 9.8 Tf [( A novel finding in our study was the extent of extreme social isolation in some )] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(participants. The upheaval this event caused in their lives led some survivors to become very socially withdrawn, which then in )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(turn led to further adverse effects on their overall quality of life. In many cases, social isolation in many participants resulted in )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(them being home bound, manifested especially in fearfulness of being out in public or in public spaces. Many participants no )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(longer engaged in activities and/or social events that had previously been enjoyable for them. Extreme fear about leaving the )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(home led to estrangement from their family members and friends. Several became very anxious about their children and )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(spouses leaving the home- especially if they were going to be in crowded places, which also caused problems within the family. )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(Sleep disturbances and chronic pain led to self-medication, which also led many to withdraw from social contact.)] TJ ET BT 26.250 609.619 Td /F1 9.8 Tf [(It was not surprising to find that participants stressed the importance of emotional and social support from friends and family, as )] TJ ET BT 26.250 597.714 Td /F1 9.8 Tf [(high social support and social integration have been shown to decrease the odds of 9/11-related PTSD.)] TJ ET 0.267 0.267 0.267 rg BT 472.274 599.222 Td /F4 8.7 Tf [(21)] TJ ET 0.271 0.267 0.267 rg BT 481.911 601.603 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 484.320 599.222 Td /F4 8.7 Tf [(22)] TJ ET 0.271 0.267 0.267 rg BT 493.958 597.714 Td /F1 9.8 Tf [( An important )] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(finding is that some participants said they were only able to talk about their 9/11-experiences with others who had also been )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(there during the attacks. This may indicate a need for group therapy sessions or support groups after a disaster, for both the )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(individual and potentially their family. In cases where the participant did eventually enter mental health care treatment, treatment )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(was often reported to be efficacious, especially if they were able to form a strong therapeutic bond with their therapist. The need )] TJ ET BT 26.250 538.191 Td /F1 9.8 Tf [(for not only effective evidence-based individual mental health care for disaster survivors, but for their families as well, is an )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(important consideration raised by these study findings.)] TJ ET BT 26.250 506.881 Td /F1 9.8 Tf [(Early retirement or disability retirement was commonly reported, many participants were left without important benefits of work. )] TJ ET BT 26.250 494.976 Td /F1 9.8 Tf [(A recent study of WTCHR enrollees found that workers with chronic conditions were more likely to experience early retirement )] TJ ET BT 26.250 483.072 Td /F1 9.8 Tf [(and job loss, and the association was stronger in the presence of PTSD comorbidity.)] TJ ET 0.267 0.267 0.267 rg BT 390.413 484.579 Td /F4 8.7 Tf [(23)] TJ ET 0.271 0.267 0.267 rg BT 400.050 483.072 Td /F1 9.8 Tf [( A qualitative study of injured survivors of )] TJ ET BT 26.250 471.167 Td /F1 9.8 Tf [(The Station nightclub fire in Rhode Island also found that participants commented on themes of financial stress as well as )] TJ ET BT 26.250 459.262 Td /F1 9.8 Tf [(disruption to their daily lives, such as inability to work.)] TJ ET 0.267 0.267 0.267 rg BT 257.081 460.769 Td /F4 8.7 Tf [(24)] TJ ET 0.271 0.267 0.267 rg BT 266.719 459.262 Td /F1 9.8 Tf [( Beyond the issue of loss of income, which was very common in our )] TJ ET BT 26.250 447.357 Td /F1 9.8 Tf [(sample, loss of employment eliminated opportunities for workplace socialization and access to employee assistance programs, )] TJ ET BT 26.250 435.453 Td /F1 9.8 Tf [(leading further to social isolation. Moreover, because many firms went out of business, employees no longer even stayed in )] TJ ET BT 26.250 423.548 Td /F1 9.8 Tf [(touch with one another. This was true even for first responders who felt disconnected from their former friends, as they no )] TJ ET BT 26.250 411.643 Td /F1 9.8 Tf [(longer felt part of the team. In some cases though, retired first responders formed new bonds with other WTCD retirees.)] TJ ET BT 26.250 392.238 Td /F1 9.8 Tf [(We found that even among those who did not have current PTSD, there was a lack of recovery and diminished quality of life )] TJ ET BT 26.250 380.334 Td /F1 9.8 Tf [(reported. There are a number of possible reasons for this observation. One explanation might be a relatively new phenomenon )] TJ ET BT 26.250 368.429 Td /F1 9.8 Tf [(referred to as moral injury.)] TJ ET 0.267 0.267 0.267 rg BT 146.526 369.936 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 156.163 368.429 Td /F1 9.8 Tf [( There are similarities between reports of ongoing symptoms and sense of isolation in these )] TJ ET BT 26.250 356.524 Td /F1 9.8 Tf [(participants with those reported by returning war veterans. In our study, participants frequently witnessed suffering, horrific and )] TJ ET BT 26.250 344.619 Td /F1 9.8 Tf [(undignified death, and fear for their lives, and the symptoms commonly associated with moral injury \(guilt, remorse, and )] TJ ET BT 26.250 332.715 Td /F1 9.8 Tf [(demoralization\))] TJ ET 0.267 0.267 0.267 rg BT 92.891 334.222 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 102.529 332.715 Td /F1 9.8 Tf [( were also frequently reported by our study participants. Additional studies to assess this phenomenon in )] TJ ET BT 26.250 320.810 Td /F1 9.8 Tf [(disaster survivors, especially survivors of terrorist or mass-shooting atrocities are warranted. Another potential explanation could )] TJ ET BT 26.250 308.905 Td /F1 9.8 Tf [(be that participants have some form of survivors guilt. Survivors guilt is a mental condition that occurs when a person perceives )] TJ ET BT 26.250 297.000 Td /F1 9.8 Tf [(themselves to have done wrong by surviving a traumatic event when others did not.)] TJ ET 0.267 0.267 0.267 rg BT 386.084 298.508 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 395.721 297.000 Td /F1 9.8 Tf [( It may be found among survivors of )] TJ ET BT 26.250 285.096 Td /F1 9.8 Tf [(combat, natural disasters, and epidemics.)] TJ ET 0.267 0.267 0.267 rg BT 206.157 286.603 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 215.794 285.096 Td /F1 9.8 Tf [( In the Diagnostic and Statistical Manual of Mental Disorders V \(DSM-V\), it is )] TJ ET BT 26.250 273.191 Td /F1 9.8 Tf [(considered an associated descriptive feature of PTSD, described as a persistent negative trauma-related emotion.)] TJ ET 0.267 0.267 0.267 rg BT 518.303 274.698 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 527.941 273.191 Td /F1 9.8 Tf [( Survivor )] TJ ET BT 26.250 261.286 Td /F1 9.8 Tf [(guilt has also been implicated in the genesis of clinical depression. Although major clinical depression and PTSD are often )] TJ ET BT 26.250 249.381 Td /F1 9.8 Tf [(comorbid diagnoses, guilt may be present or absent in both.)] TJ ET 0.267 0.267 0.267 rg BT 284.752 250.889 Td /F4 8.7 Tf [(28)] TJ ET 0.271 0.267 0.267 rg BT 26.250 229.977 Td /F1 9.8 Tf [(On the other hand, just how participants who demonstrated resiliency were able to do so may be explained by recent work by )] TJ ET BT 26.250 218.072 Td /F1 9.8 Tf [(Richardson \(2015\) on the role of making sense in disaster recovery.)] TJ ET 0.267 0.267 0.267 rg BT 323.196 219.579 Td /F4 8.7 Tf [(29)] TJ ET 0.271 0.267 0.267 rg BT 332.833 218.072 Td /F1 9.8 Tf [( Programs, such as the docent program at the WTC )] TJ ET BT 26.250 206.167 Td /F1 9.8 Tf [(Tribute Center as described by Richardson, have been shown to help support recovery by allowing survivors to make better )] TJ ET BT 26.250 194.262 Td /F1 9.8 Tf [(sense of their trauma through sharing for posterity their own experiences on that day. This gave them both a sense of purpose )] TJ ET BT 26.250 182.358 Td /F1 9.8 Tf [(and a sense of pride that they could help others.)] TJ ET 0.267 0.267 0.267 rg BT 234.374 183.865 Td /F4 8.7 Tf [(30)] TJ ET 0.271 0.267 0.267 rg BT 26.250 162.953 Td /F1 9.8 Tf [(There is a growing interest in post-traumatic resilience and post-traumatic growth, which can result from devastating, )] TJ ET BT 26.250 151.048 Td /F1 9.8 Tf [(catastrophic events.)] TJ ET 0.267 0.267 0.267 rg BT 112.957 152.555 Td /F4 8.7 Tf [(31)] TJ ET 0.271 0.267 0.267 rg BT 122.594 151.048 Td /F1 9.8 Tf [( Though there may be a tendency to look to survivors of a traumatic event as victims of a tragedy, future )] TJ ET BT 26.250 139.143 Td /F1 9.8 Tf [(research into long-term outcomes should focus on factors contributing to survivor resiliency and positive outcomes in the face of )] TJ ET BT 26.250 127.239 Td /F1 9.8 Tf [(tragedy.)] TJ ET BT 26.250 107.834 Td /F4 9.8 Tf [(Limitations)] TJ ET BT 26.250 88.429 Td /F1 9.8 Tf [(This study focused solely on those injured on 9/11 and thus results reported here may not be representative of other non-inured )] TJ ET BT 26.250 76.524 Td /F1 9.8 Tf [(9/11 disaster survivors. With only 33 participants, this was a small sample, although we did reach thematic saturation. There )] TJ ET BT 26.250 64.620 Td /F1 9.8 Tf [(was also the risk of recall bias, however, we did have data from 2002-2003 on injuries reported at that time and we also framed )] TJ ET BT 26.250 52.715 Td /F1 9.8 Tf [(the questions on their current recovery and everyday functioning. Also, there is the possibility of self-report bias; participants )] TJ ET BT 26.250 40.810 Td /F1 9.8 Tf [(may have provided responses that they felt were socially acceptable. In spite of the potential limitations inherent in the design )] TJ ET Q q 15.000 26.525 577.500 750.475 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(physical healthcare in the same location, an approach that has been shown to be highly effective.)] TJ ET 0.267 0.267 0.267 rg BT 445.724 768.983 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 26.250 748.071 Td /F1 9.8 Tf [(As shown in previous studies on 9/11 survivors enrolled in the World Trade Center Health Registry, long-term physical and )] TJ ET BT 26.250 736.167 Td /F1 9.8 Tf [(mental health problems were common.)] TJ ET 0.267 0.267 0.267 rg BT 194.223 737.674 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 199.042 740.055 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 201.451 737.674 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 206.270 740.055 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 208.679 737.674 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 213.498 740.055 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 215.907 737.674 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 225.544 740.055 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 227.954 737.674 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 237.591 736.167 Td /F1 9.8 Tf [( The risk factors for long-term disability found in this study have also been )] TJ ET BT 26.250 724.262 Td /F1 9.8 Tf [(reported in other research on 9/11 survivors, namely severity of injury, intensity of peri-event traumatic exposure, and lack of )] TJ ET BT 26.250 712.357 Td /F1 9.8 Tf [(timely and effective mental health care.)] TJ ET 0.267 0.267 0.267 rg BT 195.325 713.864 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 204.962 716.245 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 207.371 713.864 Td /F4 8.7 Tf [(19)] TJ ET 0.271 0.267 0.267 rg BT 217.009 716.245 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 219.418 713.864 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 229.055 712.357 Td /F1 9.8 Tf [( A novel finding in our study was the extent of extreme social isolation in some )] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(participants. The upheaval this event caused in their lives led some survivors to become very socially withdrawn, which then in )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(turn led to further adverse effects on their overall quality of life. In many cases, social isolation in many participants resulted in )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(them being home bound, manifested especially in fearfulness of being out in public or in public spaces. Many participants no )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(longer engaged in activities and/or social events that had previously been enjoyable for them. Extreme fear about leaving the )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(home led to estrangement from their family members and friends. Several became very anxious about their children and )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(spouses leaving the home- especially if they were going to be in crowded places, which also caused problems within the family. )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(Sleep disturbances and chronic pain led to self-medication, which also led many to withdraw from social contact.)] TJ ET BT 26.250 609.619 Td /F1 9.8 Tf [(It was not surprising to find that participants stressed the importance of emotional and social support from friends and family, as )] TJ ET BT 26.250 597.714 Td /F1 9.8 Tf [(high social support and social integration have been shown to decrease the odds of 9/11-related PTSD.)] TJ ET 0.267 0.267 0.267 rg BT 472.274 599.222 Td /F4 8.7 Tf [(21)] TJ ET 0.271 0.267 0.267 rg BT 481.911 601.603 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 484.320 599.222 Td /F4 8.7 Tf [(22)] TJ ET 0.271 0.267 0.267 rg BT 493.958 597.714 Td /F1 9.8 Tf [( An important )] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(finding is that some participants said they were only able to talk about their 9/11-experiences with others who had also been )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(there during the attacks. This may indicate a need for group therapy sessions or support groups after a disaster, for both the )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(individual and potentially their family. In cases where the participant did eventually enter mental health care treatment, treatment )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(was often reported to be efficacious, especially if they were able to form a strong therapeutic bond with their therapist. The need )] TJ ET BT 26.250 538.191 Td /F1 9.8 Tf [(for not only effective evidence-based individual mental health care for disaster survivors, but for their families as well, is an )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(important consideration raised by these study findings.)] TJ ET BT 26.250 506.881 Td /F1 9.8 Tf [(Early retirement or disability retirement was commonly reported, many participants were left without important benefits of work. )] TJ ET BT 26.250 494.976 Td /F1 9.8 Tf [(A recent study of WTCHR enrollees found that workers with chronic conditions were more likely to experience early retirement )] TJ ET BT 26.250 483.072 Td /F1 9.8 Tf [(and job loss, and the association was stronger in the presence of PTSD comorbidity.)] TJ ET 0.267 0.267 0.267 rg BT 390.413 484.579 Td /F4 8.7 Tf [(23)] TJ ET 0.271 0.267 0.267 rg BT 400.050 483.072 Td /F1 9.8 Tf [( A qualitative study of injured survivors of )] TJ ET BT 26.250 471.167 Td /F1 9.8 Tf [(The Station nightclub fire in Rhode Island also found that participants commented on themes of financial stress as well as )] TJ ET BT 26.250 459.262 Td /F1 9.8 Tf [(disruption to their daily lives, such as inability to work.)] TJ ET 0.267 0.267 0.267 rg BT 257.081 460.769 Td /F4 8.7 Tf [(24)] TJ ET 0.271 0.267 0.267 rg BT 266.719 459.262 Td /F1 9.8 Tf [( Beyond the issue of loss of income, which was very common in our )] TJ ET BT 26.250 447.357 Td /F1 9.8 Tf [(sample, loss of employment eliminated opportunities for workplace socialization and access to employee assistance programs, )] TJ ET BT 26.250 435.453 Td /F1 9.8 Tf [(leading further to social isolation. Moreover, because many firms went out of business, employees no longer even stayed in )] TJ ET BT 26.250 423.548 Td /F1 9.8 Tf [(touch with one another. This was true even for first responders who felt disconnected from their former friends, as they no )] TJ ET BT 26.250 411.643 Td /F1 9.8 Tf [(longer felt part of the team. In some cases though, retired first responders formed new bonds with other WTCD retirees.)] TJ ET BT 26.250 392.238 Td /F1 9.8 Tf [(We found that even among those who did not have current PTSD, there was a lack of recovery and diminished quality of life )] TJ ET BT 26.250 380.334 Td /F1 9.8 Tf [(reported. There are a number of possible reasons for this observation. One explanation might be a relatively new phenomenon )] TJ ET BT 26.250 368.429 Td /F1 9.8 Tf [(referred to as moral injury.)] TJ ET 0.267 0.267 0.267 rg BT 146.526 369.936 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 156.163 368.429 Td /F1 9.8 Tf [( There are similarities between reports of ongoing symptoms and sense of isolation in these )] TJ ET BT 26.250 356.524 Td /F1 9.8 Tf [(participants with those reported by returning war veterans. In our study, participants frequently witnessed suffering, horrific and )] TJ ET BT 26.250 344.619 Td /F1 9.8 Tf [(undignified death, and fear for their lives, and the symptoms commonly associated with moral injury \(guilt, remorse, and )] TJ ET BT 26.250 332.715 Td /F1 9.8 Tf [(demoralization\))] TJ ET 0.267 0.267 0.267 rg BT 92.891 334.222 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 102.529 332.715 Td /F1 9.8 Tf [( were also frequently reported by our study participants. Additional studies to assess this phenomenon in )] TJ ET BT 26.250 320.810 Td /F1 9.8 Tf [(disaster survivors, especially survivors of terrorist or mass-shooting atrocities are warranted. Another potential explanation could )] TJ ET BT 26.250 308.905 Td /F1 9.8 Tf [(be that participants have some form of survivors guilt. Survivors guilt is a mental condition that occurs when a person perceives )] TJ ET BT 26.250 297.000 Td /F1 9.8 Tf [(themselves to have done wrong by surviving a traumatic event when others did not.)] TJ ET 0.267 0.267 0.267 rg BT 386.084 298.508 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 395.721 297.000 Td /F1 9.8 Tf [( It may be found among survivors of )] TJ ET BT 26.250 285.096 Td /F1 9.8 Tf [(combat, natural disasters, and epidemics.)] TJ ET 0.267 0.267 0.267 rg BT 206.157 286.603 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 215.794 285.096 Td /F1 9.8 Tf [( In the Diagnostic and Statistical Manual of Mental Disorders V \(DSM-V\), it is )] TJ ET BT 26.250 273.191 Td /F1 9.8 Tf [(considered an associated descriptive feature of PTSD, described as a persistent negative trauma-related emotion.)] TJ ET 0.267 0.267 0.267 rg BT 518.303 274.698 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 527.941 273.191 Td /F1 9.8 Tf [( Survivor )] TJ ET BT 26.250 261.286 Td /F1 9.8 Tf [(guilt has also been implicated in the genesis of clinical depression. Although major clinical depression and PTSD are often )] TJ ET BT 26.250 249.381 Td /F1 9.8 Tf [(comorbid diagnoses, guilt may be present or absent in both.)] TJ ET 0.267 0.267 0.267 rg BT 284.752 250.889 Td /F4 8.7 Tf [(28)] TJ ET 0.271 0.267 0.267 rg BT 26.250 229.977 Td /F1 9.8 Tf [(On the other hand, just how participants who demonstrated resiliency were able to do so may be explained by recent work by )] TJ ET BT 26.250 218.072 Td /F1 9.8 Tf [(Richardson \(2015\) on the role of making sense in disaster recovery.)] TJ ET 0.267 0.267 0.267 rg BT 323.196 219.579 Td /F4 8.7 Tf [(29)] TJ ET 0.271 0.267 0.267 rg BT 332.833 218.072 Td /F1 9.8 Tf [( Programs, such as the docent program at the WTC )] TJ ET BT 26.250 206.167 Td /F1 9.8 Tf [(Tribute Center as described by Richardson, have been shown to help support recovery by allowing survivors to make better )] TJ ET BT 26.250 194.262 Td /F1 9.8 Tf [(sense of their trauma through sharing for posterity their own experiences on that day. This gave them both a sense of purpose )] TJ ET BT 26.250 182.358 Td /F1 9.8 Tf [(and a sense of pride that they could help others.)] TJ ET 0.267 0.267 0.267 rg BT 234.374 183.865 Td /F4 8.7 Tf [(30)] TJ ET 0.271 0.267 0.267 rg BT 26.250 162.953 Td /F1 9.8 Tf [(There is a growing interest in post-traumatic resilience and post-traumatic growth, which can result from devastating, )] TJ ET BT 26.250 151.048 Td /F1 9.8 Tf [(catastrophic events.)] TJ ET 0.267 0.267 0.267 rg BT 112.957 152.555 Td /F4 8.7 Tf [(31)] TJ ET 0.271 0.267 0.267 rg BT 122.594 151.048 Td /F1 9.8 Tf [( Though there may be a tendency to look to survivors of a traumatic event as victims of a tragedy, future )] TJ ET BT 26.250 139.143 Td /F1 9.8 Tf [(research into long-term outcomes should focus on factors contributing to survivor resiliency and positive outcomes in the face of )] TJ ET BT 26.250 127.239 Td /F1 9.8 Tf [(tragedy.)] TJ ET BT 26.250 107.834 Td /F4 9.8 Tf [(Limitations)] TJ ET BT 26.250 88.429 Td /F1 9.8 Tf [(This study focused solely on those injured on 9/11 and thus results reported here may not be representative of other non-inured )] TJ ET BT 26.250 76.524 Td /F1 9.8 Tf [(9/11 disaster survivors. With only 33 participants, this was a small sample, although we did reach thematic saturation. There )] TJ ET BT 26.250 64.620 Td /F1 9.8 Tf [(was also the risk of recall bias, however, we did have data from 2002-2003 on injuries reported at that time and we also framed )] TJ ET BT 26.250 52.715 Td /F1 9.8 Tf [(the questions on their current recovery and everyday functioning. Also, there is the possibility of self-report bias; participants )] TJ ET BT 26.250 40.810 Td /F1 9.8 Tf [(may have provided responses that they felt were socially acceptable. In spite of the potential limitations inherent in the design )] TJ ET Q q 15.000 26.525 577.500 750.475 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(physical healthcare in the same location, an approach that has been shown to be highly effective.)] TJ ET 0.267 0.267 0.267 rg BT 445.724 768.983 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 26.250 748.071 Td /F1 9.8 Tf [(As shown in previous studies on 9/11 survivors enrolled in the World Trade Center Health Registry, long-term physical and )] TJ ET BT 26.250 736.167 Td /F1 9.8 Tf [(mental health problems were common.)] TJ ET 0.267 0.267 0.267 rg BT 194.223 737.674 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 199.042 740.055 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 201.451 737.674 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 206.270 740.055 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 208.679 737.674 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 213.498 740.055 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 215.907 737.674 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 225.544 740.055 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 227.954 737.674 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 237.591 736.167 Td /F1 9.8 Tf [( The risk factors for long-term disability found in this study have also been )] TJ ET BT 26.250 724.262 Td /F1 9.8 Tf [(reported in other research on 9/11 survivors, namely severity of injury, intensity of peri-event traumatic exposure, and lack of )] TJ ET BT 26.250 712.357 Td /F1 9.8 Tf [(timely and effective mental health care.)] TJ ET 0.267 0.267 0.267 rg BT 195.325 713.864 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 204.962 716.245 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 207.371 713.864 Td /F4 8.7 Tf [(19)] TJ ET 0.271 0.267 0.267 rg BT 217.009 716.245 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 219.418 713.864 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 229.055 712.357 Td /F1 9.8 Tf [( A novel finding in our study was the extent of extreme social isolation in some )] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(participants. The upheaval this event caused in their lives led some survivors to become very socially withdrawn, which then in )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(turn led to further adverse effects on their overall quality of life. In many cases, social isolation in many participants resulted in )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(them being home bound, manifested especially in fearfulness of being out in public or in public spaces. Many participants no )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(longer engaged in activities and/or social events that had previously been enjoyable for them. Extreme fear about leaving the )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(home led to estrangement from their family members and friends. Several became very anxious about their children and )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(spouses leaving the home- especially if they were going to be in crowded places, which also caused problems within the family. )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(Sleep disturbances and chronic pain led to self-medication, which also led many to withdraw from social contact.)] TJ ET BT 26.250 609.619 Td /F1 9.8 Tf [(It was not surprising to find that participants stressed the importance of emotional and social support from friends and family, as )] TJ ET BT 26.250 597.714 Td /F1 9.8 Tf [(high social support and social integration have been shown to decrease the odds of 9/11-related PTSD.)] TJ ET 0.267 0.267 0.267 rg BT 472.274 599.222 Td /F4 8.7 Tf [(21)] TJ ET 0.271 0.267 0.267 rg BT 481.911 601.603 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 484.320 599.222 Td /F4 8.7 Tf [(22)] TJ ET 0.271 0.267 0.267 rg BT 493.958 597.714 Td /F1 9.8 Tf [( An important )] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(finding is that some participants said they were only able to talk about their 9/11-experiences with others who had also been )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(there during the attacks. This may indicate a need for group therapy sessions or support groups after a disaster, for both the )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(individual and potentially their family. In cases where the participant did eventually enter mental health care treatment, treatment )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(was often reported to be efficacious, especially if they were able to form a strong therapeutic bond with their therapist. The need )] TJ ET BT 26.250 538.191 Td /F1 9.8 Tf [(for not only effective evidence-based individual mental health care for disaster survivors, but for their families as well, is an )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(important consideration raised by these study findings.)] TJ ET BT 26.250 506.881 Td /F1 9.8 Tf [(Early retirement or disability retirement was commonly reported, many participants were left without important benefits of work. )] TJ ET BT 26.250 494.976 Td /F1 9.8 Tf [(A recent study of WTCHR enrollees found that workers with chronic conditions were more likely to experience early retirement )] TJ ET BT 26.250 483.072 Td /F1 9.8 Tf [(and job loss, and the association was stronger in the presence of PTSD comorbidity.)] TJ ET 0.267 0.267 0.267 rg BT 390.413 484.579 Td /F4 8.7 Tf [(23)] TJ ET 0.271 0.267 0.267 rg BT 400.050 483.072 Td /F1 9.8 Tf [( A qualitative study of injured survivors of )] TJ ET BT 26.250 471.167 Td /F1 9.8 Tf [(The Station nightclub fire in Rhode Island also found that participants commented on themes of financial stress as well as )] TJ ET BT 26.250 459.262 Td /F1 9.8 Tf [(disruption to their daily lives, such as inability to work.)] TJ ET 0.267 0.267 0.267 rg BT 257.081 460.769 Td /F4 8.7 Tf [(24)] TJ ET 0.271 0.267 0.267 rg BT 266.719 459.262 Td /F1 9.8 Tf [( Beyond the issue of loss of income, which was very common in our )] TJ ET BT 26.250 447.357 Td /F1 9.8 Tf [(sample, loss of employment eliminated opportunities for workplace socialization and access to employee assistance programs, )] TJ ET BT 26.250 435.453 Td /F1 9.8 Tf [(leading further to social isolation. Moreover, because many firms went out of business, employees no longer even stayed in )] TJ ET BT 26.250 423.548 Td /F1 9.8 Tf [(touch with one another. This was true even for first responders who felt disconnected from their former friends, as they no )] TJ ET BT 26.250 411.643 Td /F1 9.8 Tf [(longer felt part of the team. In some cases though, retired first responders formed new bonds with other WTCD retirees.)] TJ ET BT 26.250 392.238 Td /F1 9.8 Tf [(We found that even among those who did not have current PTSD, there was a lack of recovery and diminished quality of life )] TJ ET BT 26.250 380.334 Td /F1 9.8 Tf [(reported. There are a number of possible reasons for this observation. One explanation might be a relatively new phenomenon )] TJ ET BT 26.250 368.429 Td /F1 9.8 Tf [(referred to as moral injury.)] TJ ET 0.267 0.267 0.267 rg BT 146.526 369.936 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 156.163 368.429 Td /F1 9.8 Tf [( There are similarities between reports of ongoing symptoms and sense of isolation in these )] TJ ET BT 26.250 356.524 Td /F1 9.8 Tf [(participants with those reported by returning war veterans. In our study, participants frequently witnessed suffering, horrific and )] TJ ET BT 26.250 344.619 Td /F1 9.8 Tf [(undignified death, and fear for their lives, and the symptoms commonly associated with moral injury \(guilt, remorse, and )] TJ ET BT 26.250 332.715 Td /F1 9.8 Tf [(demoralization\))] TJ ET 0.267 0.267 0.267 rg BT 92.891 334.222 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 102.529 332.715 Td /F1 9.8 Tf [( were also frequently reported by our study participants. Additional studies to assess this phenomenon in )] TJ ET BT 26.250 320.810 Td /F1 9.8 Tf [(disaster survivors, especially survivors of terrorist or mass-shooting atrocities are warranted. Another potential explanation could )] TJ ET BT 26.250 308.905 Td /F1 9.8 Tf [(be that participants have some form of survivors guilt. Survivors guilt is a mental condition that occurs when a person perceives )] TJ ET BT 26.250 297.000 Td /F1 9.8 Tf [(themselves to have done wrong by surviving a traumatic event when others did not.)] TJ ET 0.267 0.267 0.267 rg BT 386.084 298.508 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 395.721 297.000 Td /F1 9.8 Tf [( It may be found among survivors of )] TJ ET BT 26.250 285.096 Td /F1 9.8 Tf [(combat, natural disasters, and epidemics.)] TJ ET 0.267 0.267 0.267 rg BT 206.157 286.603 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 215.794 285.096 Td /F1 9.8 Tf [( In the Diagnostic and Statistical Manual of Mental Disorders V \(DSM-V\), it is )] TJ ET BT 26.250 273.191 Td /F1 9.8 Tf [(considered an associated descriptive feature of PTSD, described as a persistent negative trauma-related emotion.)] TJ ET 0.267 0.267 0.267 rg BT 518.303 274.698 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 527.941 273.191 Td /F1 9.8 Tf [( Survivor )] TJ ET BT 26.250 261.286 Td /F1 9.8 Tf [(guilt has also been implicated in the genesis of clinical depression. Although major clinical depression and PTSD are often )] TJ ET BT 26.250 249.381 Td /F1 9.8 Tf [(comorbid diagnoses, guilt may be present or absent in both.)] TJ ET 0.267 0.267 0.267 rg BT 284.752 250.889 Td /F4 8.7 Tf [(28)] TJ ET 0.271 0.267 0.267 rg BT 26.250 229.977 Td /F1 9.8 Tf [(On the other hand, just how participants who demonstrated resiliency were able to do so may be explained by recent work by )] TJ ET BT 26.250 218.072 Td /F1 9.8 Tf [(Richardson \(2015\) on the role of making sense in disaster recovery.)] TJ ET 0.267 0.267 0.267 rg BT 323.196 219.579 Td /F4 8.7 Tf [(29)] TJ ET 0.271 0.267 0.267 rg BT 332.833 218.072 Td /F1 9.8 Tf [( Programs, such as the docent program at the WTC )] TJ ET BT 26.250 206.167 Td /F1 9.8 Tf [(Tribute Center as described by Richardson, have been shown to help support recovery by allowing survivors to make better )] TJ ET BT 26.250 194.262 Td /F1 9.8 Tf [(sense of their trauma through sharing for posterity their own experiences on that day. This gave them both a sense of purpose )] TJ ET BT 26.250 182.358 Td /F1 9.8 Tf [(and a sense of pride that they could help others.)] TJ ET 0.267 0.267 0.267 rg BT 234.374 183.865 Td /F4 8.7 Tf [(30)] TJ ET 0.271 0.267 0.267 rg BT 26.250 162.953 Td /F1 9.8 Tf [(There is a growing interest in post-traumatic resilience and post-traumatic growth, which can result from devastating, )] TJ ET BT 26.250 151.048 Td /F1 9.8 Tf [(catastrophic events.)] TJ ET 0.267 0.267 0.267 rg BT 112.957 152.555 Td /F4 8.7 Tf [(31)] TJ ET 0.271 0.267 0.267 rg BT 122.594 151.048 Td /F1 9.8 Tf [( Though there may be a tendency to look to survivors of a traumatic event as victims of a tragedy, future )] TJ ET BT 26.250 139.143 Td /F1 9.8 Tf [(research into long-term outcomes should focus on factors contributing to survivor resiliency and positive outcomes in the face of )] TJ ET BT 26.250 127.239 Td /F1 9.8 Tf [(tragedy.)] TJ ET BT 26.250 107.834 Td /F4 9.8 Tf [(Limitations)] TJ ET BT 26.250 88.429 Td /F1 9.8 Tf [(This study focused solely on those injured on 9/11 and thus results reported here may not be representative of other non-inured )] TJ ET BT 26.250 76.524 Td /F1 9.8 Tf [(9/11 disaster survivors. With only 33 participants, this was a small sample, although we did reach thematic saturation. There )] TJ ET BT 26.250 64.620 Td /F1 9.8 Tf [(was also the risk of recall bias, however, we did have data from 2002-2003 on injuries reported at that time and we also framed )] TJ ET BT 26.250 52.715 Td /F1 9.8 Tf [(the questions on their current recovery and everyday functioning. Also, there is the possibility of self-report bias; participants )] TJ ET BT 26.250 40.810 Td /F1 9.8 Tf [(may have provided responses that they felt were socially acceptable. In spite of the potential limitations inherent in the design )] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(9)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 227 0 obj << /Type /Annot /Subtype /Link /A 228 0 R /Border [0 0 0] /H /I /Rect [ 445.7242 768.1817 455.3616 777.0000 ] >> endobj 228 0 obj << /Type /Action >> endobj 229 0 obj << /Type /Annot /Subtype /Link /A 230 0 R /Border [0 0 0] /H /I /Rect [ 194.2230 736.8722 199.0417 745.6905 ] >> endobj 230 0 obj << /Type /Action >> endobj 231 0 obj << /Type /Annot /Subtype /Link /A 232 0 R /Border [0 0 0] /H /I /Rect [ 201.4510 736.8722 206.2697 745.6905 ] >> endobj 232 0 obj << /Type /Action >> endobj 233 0 obj << /Type /Annot /Subtype /Link /A 234 0 R /Border [0 0 0] /H /I /Rect [ 208.6790 736.8722 213.4977 745.6905 ] >> endobj 234 0 obj << /Type /Action >> endobj 235 0 obj << /Type /Annot /Subtype /Link /A 236 0 R /Border [0 0 0] /H /I /Rect [ 215.9070 736.8722 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0] /H /I /Rect [ 234.3735 183.0632 244.0108 191.8815 ] >> endobj 356 0 obj << /Type /Action >> endobj 357 0 obj << /Type /Annot /Subtype /Link /A 358 0 R /Border [0 0 0] /H /I /Rect [ 112.9567 151.7537 122.5941 160.5720 ] >> endobj 358 0 obj << /Type /Action >> endobj 359 0 obj << /Type /Page /Parent 3 0 R /Contents 360 0 R >> endobj 360 0 obj << /Length 16415 >> stream 0.271 0.267 0.267 rg q 15.000 32.422 577.500 744.578 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(and sampling, this exploratory study was appropriate for this stage of inquiry and provided unanticipated avenues for further )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(research.)] TJ ET BT 26.250 718.969 Td /F4 12.0 Tf [(Conclusions)] TJ ET BT 26.250 699.015 Td /F1 9.8 Tf [(In this study we were able to identify serious long-term health and mental health effects related to the WTCD. Among those )] TJ ET BT 26.250 687.110 Td /F1 9.8 Tf [(injured, quality of life was seriously and negatively affected. Public health has a responsibility to aid survivors and community )] TJ ET BT 26.250 675.205 Td /F1 9.8 Tf [(members both immediately following a disaster event and, importantly, in the long-term. Because both natural and human-)] TJ ET BT 26.250 663.300 Td /F1 9.8 Tf [(caused disasters are increasing in frequency and severity, communities and government agencies should prepare now with )] TJ ET BT 26.250 651.396 Td /F1 9.8 Tf [(respect to the provision of short and long-term assessment and treatment for victims of these types of events. The full )] TJ ET BT 26.250 639.491 Td /F1 9.8 Tf [(functioning and participation of all members of the community is essential for community resiliency and recovery following )] TJ ET BT 26.250 627.586 Td /F1 9.8 Tf [(disasters.)] TJ ET BT 26.250 590.984 Td /F4 12.0 Tf [(Data Availability Statement)] TJ ET BT 26.250 571.029 Td /F1 9.8 Tf [(Due to ethical restrictions, the qualitative data in the study is only available upon request. For further information regarding data )] TJ ET BT 26.250 559.125 Td /F1 9.8 Tf [(availability please contact Lisa Gargano: lgargano1@health.nyc.gov.)] TJ ET BT 26.250 522.522 Td /F4 12.0 Tf [(Corresponding Author)] TJ ET BT 26.250 502.568 Td /F1 9.8 Tf [(Lisa Gargano: lgargano1@health.nyc.gov)] TJ ET BT 26.250 465.965 Td /F4 12.0 Tf [(Competing Interests)] TJ ET BT 26.250 446.011 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 409.409 Td /F4 12.0 Tf [(Acknowledgements)] TJ ET BT 26.250 389.454 Td /F1 9.8 Tf [(We would like to thank our study participants. We would also like to thank Angela Nguyen, Sharon Perlman, Charon Gwynn, )] TJ ET BT 26.250 377.550 Td /F1 9.8 Tf [(and James Hadler for their helpful comments.)] TJ ET BT 26.250 348.447 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 320.993 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 320.993 Td /F1 9.8 Tf [(Brackbill RM, Hadler JL, DiGrande L, et al. Asthma and posttraumatic stress symptoms 5 to 6 years following exposure to the )] TJ ET BT 26.250 309.088 Td /F1 9.8 Tf [(World Trade Center terrorist attack. JAMA. Aug 5 2009;302\(5\):502-516.)] TJ ET BT 26.250 289.683 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 289.683 Td /F1 9.8 Tf [(Fergusson DM, Horwood LJ, Boden JM, Mulder RT. Impact of a major disaster on the mental health of a well-studied cohort. )] TJ ET BT 26.250 277.779 Td /F1 9.8 Tf [(JAMA psychiatry. Sep 2014;71\(9\):1025-1031.)] TJ ET BT 26.250 258.374 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 258.374 Td /F1 9.8 Tf [(Neria Y, Olfson M, Gameroff MJ, et al. The mental health consequences of disaster-related loss: findings from primary care )] TJ ET BT 26.250 246.469 Td /F1 9.8 Tf [(one year after the 9/11 terrorist attacks. Psychiatry. Winter 2008;71\(4\):339-348.)] TJ ET BT 26.250 227.064 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 227.064 Td /F1 9.8 Tf [(North CS. Current research and recent breakthroughs on the mental health effects of disasters. Current Psychiatry Reports. )] TJ ET BT 26.250 215.160 Td /F1 9.8 Tf [(Oct 2014;16\(10\):481.)] TJ ET BT 26.250 195.755 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 195.755 Td /F1 9.8 Tf [(North CS, Barney CJ, Pollio DE. A focus group study of the impact of trauma exposure in the 9/11 terrorist attacks. Social )] TJ ET BT 26.250 183.850 Td /F1 9.8 Tf [(psychiatry and psychiatric epidemiology. Apr 2015;50\(4\):569-578.)] TJ ET BT 26.250 164.445 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 164.445 Td /F1 9.8 Tf [(Farfel M, DiGrande L, Brackbill R, et al. An overview of 9/11 experiences and respiratory and mental health conditions among )] TJ ET BT 26.250 152.541 Td /F1 9.8 Tf [(World Trade Center Health Registry enrollees. Journal of Urban Health : Bulletin of the New York Academy of Medicine. Nov )] TJ ET BT 26.250 140.636 Td /F1 9.8 Tf [(2008;85\(6\):880-909.)] TJ ET BT 26.250 121.231 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 121.231 Td /F1 9.8 Tf [(Brackbill RM, Thorpe LE, DiGrande L, et al. Surveillance for World Trade Center disaster health effects among survivors of )] TJ ET BT 26.250 109.326 Td /F1 9.8 Tf [(collapsed and damaged buildings. MMWR Surveill Summ. Apr 7 2006;55\(2\):1-18.)] TJ ET BT 26.250 89.922 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 89.922 Td /F1 9.8 Tf [(Jordan HT, Miller-Archie SA, Cone JE, Morabia A, Stellman SD. Heart disease among adults exposed to the September 11, )] TJ ET BT 26.250 78.017 Td /F1 9.8 Tf [(2001 World Trade Center disaster: results from the World Trade Center Health Registry. Preventive Medicine. Dec )] TJ ET BT 26.250 66.112 Td /F1 9.8 Tf [(2011;53\(6\):370-376.)] TJ ET BT 26.250 46.707 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 46.707 Td /F1 9.8 Tf [(Felton CJ. Project Liberty: a public health response to New Yorkers' mental health needs arising from the World Trade )] TJ ET Q q 15.000 32.422 577.500 744.578 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(and sampling, this exploratory study was appropriate for this stage of inquiry and provided unanticipated avenues for further )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(research.)] TJ ET BT 26.250 718.969 Td /F4 12.0 Tf [(Conclusions)] TJ ET BT 26.250 699.015 Td /F1 9.8 Tf [(In this study we were able to identify serious long-term health and mental health effects related to the WTCD. Among those )] TJ ET BT 26.250 687.110 Td /F1 9.8 Tf [(injured, quality of life was seriously and negatively affected. Public health has a responsibility to aid survivors and community )] TJ ET BT 26.250 675.205 Td /F1 9.8 Tf [(members both immediately following a disaster event and, importantly, in the long-term. Because both natural and human-)] TJ ET BT 26.250 663.300 Td /F1 9.8 Tf [(caused disasters are increasing in frequency and severity, communities and government agencies should prepare now with )] TJ ET BT 26.250 651.396 Td /F1 9.8 Tf [(respect to the provision of short and long-term assessment and treatment for victims of these types of events. The full )] TJ ET BT 26.250 639.491 Td /F1 9.8 Tf [(functioning and participation of all members of the community is essential for community resiliency and recovery following )] TJ ET BT 26.250 627.586 Td /F1 9.8 Tf [(disasters.)] TJ ET BT 26.250 590.984 Td /F4 12.0 Tf [(Data Availability Statement)] TJ ET BT 26.250 571.029 Td /F1 9.8 Tf [(Due to ethical restrictions, the qualitative data in the study is only available upon request. For further information regarding data )] TJ ET BT 26.250 559.125 Td /F1 9.8 Tf [(availability please contact Lisa Gargano: lgargano1@health.nyc.gov.)] TJ ET BT 26.250 522.522 Td /F4 12.0 Tf [(Corresponding Author)] TJ ET BT 26.250 502.568 Td /F1 9.8 Tf [(Lisa Gargano: lgargano1@health.nyc.gov)] TJ ET BT 26.250 465.965 Td /F4 12.0 Tf [(Competing Interests)] TJ ET BT 26.250 446.011 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 409.409 Td /F4 12.0 Tf [(Acknowledgements)] TJ ET BT 26.250 389.454 Td /F1 9.8 Tf [(We would like to thank our study participants. We would also like to thank Angela Nguyen, Sharon Perlman, Charon Gwynn, )] TJ ET BT 26.250 377.550 Td /F1 9.8 Tf [(and James Hadler for their helpful comments.)] TJ ET BT 26.250 348.447 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 320.993 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 320.993 Td /F1 9.8 Tf [(Brackbill RM, Hadler JL, DiGrande L, et al. Asthma and posttraumatic stress symptoms 5 to 6 years following exposure to the )] TJ ET BT 26.250 309.088 Td /F1 9.8 Tf [(World Trade Center terrorist attack. JAMA. Aug 5 2009;302\(5\):502-516.)] TJ ET BT 26.250 289.683 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 289.683 Td /F1 9.8 Tf [(Fergusson DM, Horwood LJ, Boden JM, Mulder RT. Impact of a major disaster on the mental health of a well-studied cohort. )] TJ ET BT 26.250 277.779 Td /F1 9.8 Tf [(JAMA psychiatry. Sep 2014;71\(9\):1025-1031.)] TJ ET BT 26.250 258.374 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 258.374 Td /F1 9.8 Tf [(Neria Y, Olfson M, Gameroff MJ, et al. The mental health consequences of disaster-related loss: findings from primary care )] TJ ET BT 26.250 246.469 Td /F1 9.8 Tf [(one year after the 9/11 terrorist attacks. Psychiatry. Winter 2008;71\(4\):339-348.)] TJ ET BT 26.250 227.064 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 227.064 Td /F1 9.8 Tf [(North CS. Current research and recent breakthroughs on the mental health effects of disasters. Current Psychiatry Reports. )] TJ ET BT 26.250 215.160 Td /F1 9.8 Tf [(Oct 2014;16\(10\):481.)] TJ ET BT 26.250 195.755 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 195.755 Td /F1 9.8 Tf [(North CS, Barney CJ, Pollio DE. A focus group study of the impact of trauma exposure in the 9/11 terrorist attacks. Social )] TJ ET BT 26.250 183.850 Td /F1 9.8 Tf [(psychiatry and psychiatric epidemiology. Apr 2015;50\(4\):569-578.)] TJ ET BT 26.250 164.445 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 164.445 Td /F1 9.8 Tf [(Farfel M, DiGrande L, Brackbill R, et al. An overview of 9/11 experiences and respiratory and mental health conditions among )] TJ ET BT 26.250 152.541 Td /F1 9.8 Tf [(World Trade Center Health Registry enrollees. Journal of Urban Health : Bulletin of the New York Academy of Medicine. Nov )] TJ ET BT 26.250 140.636 Td /F1 9.8 Tf [(2008;85\(6\):880-909.)] TJ ET BT 26.250 121.231 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 121.231 Td /F1 9.8 Tf [(Brackbill RM, Thorpe LE, DiGrande L, et al. Surveillance for World Trade Center disaster health effects among survivors of )] TJ ET BT 26.250 109.326 Td /F1 9.8 Tf [(collapsed and damaged buildings. MMWR Surveill Summ. Apr 7 2006;55\(2\):1-18.)] TJ ET BT 26.250 89.922 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 89.922 Td /F1 9.8 Tf [(Jordan HT, Miller-Archie SA, Cone JE, Morabia A, Stellman SD. Heart disease among adults exposed to the September 11, )] TJ ET BT 26.250 78.017 Td /F1 9.8 Tf [(2001 World Trade Center disaster: results from the World Trade Center Health Registry. Preventive Medicine. Dec )] TJ ET BT 26.250 66.112 Td /F1 9.8 Tf [(2011;53\(6\):370-376.)] TJ ET BT 26.250 46.707 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 46.707 Td /F1 9.8 Tf [(Felton CJ. Project Liberty: a public health response to New Yorkers' mental health needs arising from the World Trade )] TJ ET Q q 15.000 32.422 577.500 744.578 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(and sampling, this exploratory study was appropriate for this stage of inquiry and provided unanticipated avenues for further )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(research.)] TJ ET BT 26.250 718.969 Td /F4 12.0 Tf [(Conclusions)] TJ ET BT 26.250 699.015 Td /F1 9.8 Tf [(In this study we were able to identify serious long-term health and mental health effects related to the WTCD. Among those )] TJ ET BT 26.250 687.110 Td /F1 9.8 Tf [(injured, quality of life was seriously and negatively affected. Public health has a responsibility to aid survivors and community )] TJ ET BT 26.250 675.205 Td /F1 9.8 Tf [(members both immediately following a disaster event and, importantly, in the long-term. Because both natural and human-)] TJ ET BT 26.250 663.300 Td /F1 9.8 Tf [(caused disasters are increasing in frequency and severity, communities and government agencies should prepare now with )] TJ ET BT 26.250 651.396 Td /F1 9.8 Tf [(respect to the provision of short and long-term assessment and treatment for victims of these types of events. The full )] TJ ET BT 26.250 639.491 Td /F1 9.8 Tf [(functioning and participation of all members of the community is essential for community resiliency and recovery following )] TJ ET BT 26.250 627.586 Td /F1 9.8 Tf [(disasters.)] TJ ET BT 26.250 590.984 Td /F4 12.0 Tf [(Data Availability Statement)] TJ ET BT 26.250 571.029 Td /F1 9.8 Tf [(Due to ethical restrictions, the qualitative data in the study is only available upon request. For further information regarding data )] TJ ET BT 26.250 559.125 Td /F1 9.8 Tf [(availability please contact Lisa Gargano: lgargano1@health.nyc.gov.)] TJ ET BT 26.250 522.522 Td /F4 12.0 Tf [(Corresponding Author)] TJ ET BT 26.250 502.568 Td /F1 9.8 Tf [(Lisa Gargano: lgargano1@health.nyc.gov)] TJ ET BT 26.250 465.965 Td /F4 12.0 Tf [(Competing Interests)] TJ ET BT 26.250 446.011 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 409.409 Td /F4 12.0 Tf [(Acknowledgements)] TJ ET BT 26.250 389.454 Td /F1 9.8 Tf [(We would like to thank our study participants. We would also like to thank Angela Nguyen, Sharon Perlman, Charon Gwynn, )] TJ ET BT 26.250 377.550 Td /F1 9.8 Tf [(and James Hadler for their helpful comments.)] TJ ET BT 26.250 348.447 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 320.993 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 320.993 Td /F1 9.8 Tf [(Brackbill RM, Hadler JL, DiGrande L, et al. Asthma and posttraumatic stress symptoms 5 to 6 years following exposure to the )] TJ ET BT 26.250 309.088 Td /F1 9.8 Tf [(World Trade Center terrorist attack. JAMA. Aug 5 2009;302\(5\):502-516.)] TJ ET BT 26.250 289.683 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 289.683 Td /F1 9.8 Tf [(Fergusson DM, Horwood LJ, Boden JM, Mulder RT. Impact of a major disaster on the mental health of a well-studied cohort. )] TJ ET BT 26.250 277.779 Td /F1 9.8 Tf [(JAMA psychiatry. Sep 2014;71\(9\):1025-1031.)] TJ ET BT 26.250 258.374 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 258.374 Td /F1 9.8 Tf [(Neria Y, Olfson M, Gameroff MJ, et al. The mental health consequences of disaster-related loss: findings from primary care )] TJ ET BT 26.250 246.469 Td /F1 9.8 Tf [(one year after the 9/11 terrorist attacks. Psychiatry. Winter 2008;71\(4\):339-348.)] TJ ET BT 26.250 227.064 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 227.064 Td /F1 9.8 Tf [(North CS. Current research and recent breakthroughs on the mental health effects of disasters. Current Psychiatry Reports. )] TJ ET BT 26.250 215.160 Td /F1 9.8 Tf [(Oct 2014;16\(10\):481.)] TJ ET BT 26.250 195.755 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 195.755 Td /F1 9.8 Tf [(North CS, Barney CJ, Pollio DE. A focus group study of the impact of trauma exposure in the 9/11 terrorist attacks. Social )] TJ ET BT 26.250 183.850 Td /F1 9.8 Tf [(psychiatry and psychiatric epidemiology. Apr 2015;50\(4\):569-578.)] TJ ET BT 26.250 164.445 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 164.445 Td /F1 9.8 Tf [(Farfel M, DiGrande L, Brackbill R, et al. An overview of 9/11 experiences and respiratory and mental health conditions among )] TJ ET BT 26.250 152.541 Td /F1 9.8 Tf [(World Trade Center Health Registry enrollees. Journal of Urban Health : Bulletin of the New York Academy of Medicine. Nov )] TJ ET BT 26.250 140.636 Td /F1 9.8 Tf [(2008;85\(6\):880-909.)] TJ ET BT 26.250 121.231 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 121.231 Td /F1 9.8 Tf [(Brackbill RM, Thorpe LE, DiGrande L, et al. Surveillance for World Trade Center disaster health effects among survivors of )] TJ ET BT 26.250 109.326 Td /F1 9.8 Tf [(collapsed and damaged buildings. MMWR Surveill Summ. Apr 7 2006;55\(2\):1-18.)] TJ ET BT 26.250 89.922 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 89.922 Td /F1 9.8 Tf [(Jordan HT, Miller-Archie SA, Cone JE, Morabia A, Stellman SD. Heart disease among adults exposed to the September 11, )] TJ ET BT 26.250 78.017 Td /F1 9.8 Tf [(2001 World Trade Center disaster: results from the World Trade Center Health Registry. Preventive Medicine. Dec )] TJ ET BT 26.250 66.112 Td /F1 9.8 Tf [(2011;53\(6\):370-376.)] TJ ET BT 26.250 46.707 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 46.707 Td /F1 9.8 Tf [(Felton CJ. Project Liberty: a public health response to New Yorkers' mental health needs arising from the World Trade )] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(10)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 361 0 obj << /Type /Page /Parent 3 0 R /Contents 362 0 R >> endobj 362 0 obj << /Length 22085 >> stream 0.271 0.267 0.267 rg q 15.000 37.477 577.500 739.523 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(Center terrorist attacks. Journal of Urban Health : Bulletin of the New York Academy of Medicine. Sep 2002;79\(3\):429-433.)] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 748.071 Td /F1 9.8 Tf [(Fusch PI, Ness LR. Are We There Yet? Data Saturation in Qualitative Research. The Qualitative Report. 2015;20\(9\):1408-)] TJ ET BT 26.250 736.167 Td /F1 9.8 Tf [(1416.)] TJ ET BT 26.250 716.762 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 716.762 Td /F1 9.8 Tf [(Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist \(PCL\). )] TJ ET BT 26.250 704.857 Td /F1 9.8 Tf [(Behaviour Research and Therapy. Aug 1996;34\(8\):669-673.)] TJ ET BT 26.250 685.452 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 685.452 Td /F1 9.8 Tf [(Braun V, Corbin V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3\(2\):77-101.)] TJ ET BT 26.250 666.048 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 666.048 Td /F1 9.8 Tf [(Burnard P. A method of analysing interview transcripts in qualitative research. Nurse Education Today. Dec 1991;11\(6\):461-)] TJ ET BT 26.250 654.143 Td /F1 9.8 Tf [(466.)] TJ ET BT 26.250 634.738 Td /F1 9.8 Tf [(14.)] TJ ET BT 43.553 634.738 Td /F1 9.8 Tf [(Rapid assessment of injuries among survivors of the terrorist attack on the World Trade Center--New York City, September )] TJ ET BT 26.250 622.833 Td /F1 9.8 Tf [(2001. MMWR. Morbidity and Mortality Weekly report. Jan 11 2002;51\(1\):1-5.)] TJ ET BT 26.250 603.429 Td /F1 9.8 Tf [(15.)] TJ ET BT 43.553 603.429 Td /F1 9.8 Tf [(Reiger D, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive )] TJ ET BT 26.250 591.524 Td /F1 9.8 Tf [(disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch )] TJ ET BT 26.250 579.619 Td /F1 9.8 Tf [(Gen Psychiatry. 1993;50\(2\):85-94.)] TJ ET BT 26.250 560.214 Td /F1 9.8 Tf [(16.)] TJ ET BT 43.553 560.214 Td /F1 9.8 Tf [(World Health Organization. Integrating Mental Health into Primary Care: A Global Perspective. . 2008; )] TJ ET BT 26.250 548.310 Td /F1 9.8 Tf [(https://www.who.int/mental_health/resources/mentalhealth_PHC_2008.pdf. Accessed September 20, 2016, 2016.)] TJ ET BT 26.250 528.905 Td /F1 9.8 Tf [(17.)] TJ ET BT 43.553 528.905 Td /F1 9.8 Tf [(Brackbill RM, Cone JE, Farfel MR, Stellman SD. Chronic physical health consequences of being injured during the terrorist )] TJ ET BT 26.250 517.000 Td /F1 9.8 Tf [(attacks on World Trade Center on September 11, 2001. American Journal of Epidemiology. May 1 2014;179\(9\):1076-1085.)] TJ ET BT 26.250 497.595 Td /F1 9.8 Tf [(18.)] TJ ET BT 43.553 497.595 Td /F1 9.8 Tf [(Welch AE, Caramanica K, Debchoudhury I, et al. A qualitative examination of health and health care utilization after the )] TJ ET BT 26.250 485.691 Td /F1 9.8 Tf [(September 11th terror attacks among World Trade Center Health Registry enrollees. BMC Public Health. 2012;12:721.)] TJ ET BT 26.250 466.286 Td /F1 9.8 Tf [(19.)] TJ ET BT 43.553 466.286 Td /F1 9.8 Tf [(Gross R, Neria Y, Tao XG, et al. Posttraumatic stress disorder and other psychological sequelae among world trade center )] TJ ET BT 26.250 454.381 Td /F1 9.8 Tf [(clean up and recovery workers. Annals of the New York Academy of Sciences. Jul 2006;1071:495-499.)] TJ ET BT 26.250 434.976 Td /F1 9.8 Tf [(20.)] TJ ET BT 43.553 434.976 Td /F1 9.8 Tf [(Nair HP, Ekenga CC, Cone JE, Brackbill RM, Farfel MR, Stellman SD. Co-occurring lower respiratory symptoms and )] TJ ET BT 26.250 423.072 Td /F1 9.8 Tf [(posttraumatic stress disorder 5 to 6 years after the World Trade Center terrorist attack. American journal of Public Health. Oct )] TJ ET BT 26.250 411.167 Td /F1 9.8 Tf [(2012;102\(10\):1964-1973)] TJ ET BT 26.250 391.762 Td /F1 9.8 Tf [(21.)] TJ ET BT 43.553 391.762 Td /F1 9.8 Tf [(Brackbill RM, Stellman SD, Perlman SE, Walker DJ, Farfel MR. Mental health of those directly exposed to the World Trade )] TJ ET BT 26.250 379.857 Td /F1 9.8 Tf [(Center disaster: unmet mental health care need, mental health treatment service use, and quality of life. Soc Sci Med. Mar )] TJ ET BT 26.250 367.953 Td /F1 9.8 Tf [(2013;81:110-114.)] TJ ET BT 26.250 348.548 Td /F1 9.8 Tf [(22.)] TJ ET BT 43.553 348.548 Td /F1 9.8 Tf [(Caramanica K, Brackbill RM, Stellman SD, Farfel MR. Posttraumatic Stress Disorder after Hurricane Sandy among Persons )] TJ ET BT 26.250 336.643 Td /F1 9.8 Tf [(Exposed to the 9/11 Disaster. International Journal of Emergency Mental Health. 2015;17\(1\):356-362.)] TJ ET BT 26.250 317.238 Td /F1 9.8 Tf [(23.)] TJ ET BT 43.553 317.238 Td /F1 9.8 Tf [(Yu S, Brackbill RM, Locke S, Stellman SD, Gargano LM. Impact of 9/11-related chronic conditions and PTSD comorbidity )] TJ ET BT 26.250 305.334 Td /F1 9.8 Tf [(on early retirement and job loss among World Trade Center disaster rescue and recovery workers. American Journal of )] TJ ET BT 26.250 293.429 Td /F1 9.8 Tf [(Industrial Medicine. 2016;59\(9\):731-741.)] TJ ET BT 26.250 274.024 Td /F1 9.8 Tf [(24.)] TJ ET BT 43.553 274.024 Td /F1 9.8 Tf [(Trinh NH, Nadler DL, Shie V, et al. Psychological sequelae of the station nightclub fire: Comparing survivors with and )] TJ ET BT 26.250 262.119 Td /F1 9.8 Tf [(without physical injuries using a mixed-methods analysis. PloS One. 2014;9\(12\):e115013.)] TJ ET BT 26.250 242.715 Td /F1 9.8 Tf [(25.)] TJ ET BT 43.553 242.715 Td /F1 9.8 Tf [(Maguen S, Litz B. Moral Injury in Veterans of War. PTSD Research Quarterly. 2013;23\(1\):1-6.)] TJ ET BT 26.250 223.310 Td /F1 9.8 Tf [(26.)] TJ ET BT 43.553 223.310 Td /F1 9.8 Tf [(Wilson JP, Raphael B, eds. Theoretical and Conceptual Foundations of Traumatic Stress Syndromes. New York, NY: )] TJ ET BT 26.250 211.405 Td /F1 9.8 Tf [(Plenum Press; 1993. The International Handbook of Traumatic Stress Syndromes.)] TJ ET BT 26.250 192.000 Td /F1 9.8 Tf [(27.)] TJ ET BT 43.553 192.000 Td /F1 9.8 Tf [(American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders \(Fifth ed.\). . Arlington, VA2013.)] TJ ET BT 26.250 172.596 Td /F1 9.8 Tf [(28.)] TJ ET BT 43.553 172.596 Td /F1 9.8 Tf [(Khouzam HR, Kissmeyer P. Antidepressant treatment, posttraumatic stress disorder, survivor guilt, and spiritual awakening. )] TJ ET BT 26.250 160.691 Td /F1 9.8 Tf [(Journal of Traumatic Stress. Oct 1997;10\(4\):691-696.)] TJ ET BT 26.250 141.286 Td /F1 9.8 Tf [(29.)] TJ ET BT 43.553 141.286 Td /F1 9.8 Tf [(Richardson KM. Meaning reconstruction in the face of terror: An examination of recovery and posttraumatic growth among )] TJ ET BT 26.250 129.381 Td /F1 9.8 Tf [(victims of the 9/11 World Trade Center attacks. J Emerg Manag. May-Jun 2015;13\(3\):239-246.)] TJ ET BT 26.250 109.977 Td /F1 9.8 Tf [(30.)] TJ ET BT 43.553 109.977 Td /F1 9.8 Tf [(Gershon RR, Rubin MS, Qureshi KA, Canton AN, Matzner FJ. Participatory action research methodology in disaster )] TJ ET BT 26.250 98.072 Td /F1 9.8 Tf [(research: results from the World Trade Center evacuation study. Disaster Medicine and Public Health Preparedness. Oct )] TJ ET BT 26.250 86.167 Td /F1 9.8 Tf [(2008;2\(3\):142-149.)] TJ ET Q q 15.000 37.477 577.500 739.523 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(Center terrorist attacks. Journal of Urban Health : Bulletin of the New York Academy of Medicine. Sep 2002;79\(3\):429-433.)] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 748.071 Td /F1 9.8 Tf [(Fusch PI, Ness LR. Are We There Yet? Data Saturation in Qualitative Research. The Qualitative Report. 2015;20\(9\):1408-)] TJ ET BT 26.250 736.167 Td /F1 9.8 Tf [(1416.)] TJ ET BT 26.250 716.762 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 716.762 Td /F1 9.8 Tf [(Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist \(PCL\). )] TJ ET BT 26.250 704.857 Td /F1 9.8 Tf [(Behaviour Research and Therapy. Aug 1996;34\(8\):669-673.)] TJ ET BT 26.250 685.452 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 685.452 Td /F1 9.8 Tf [(Braun V, Corbin V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3\(2\):77-101.)] TJ ET BT 26.250 666.048 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 666.048 Td /F1 9.8 Tf [(Burnard P. A method of analysing interview transcripts in qualitative research. Nurse Education Today. Dec 1991;11\(6\):461-)] TJ ET BT 26.250 654.143 Td /F1 9.8 Tf [(466.)] TJ ET BT 26.250 634.738 Td /F1 9.8 Tf [(14.)] TJ ET BT 43.553 634.738 Td /F1 9.8 Tf [(Rapid assessment of injuries among survivors of the terrorist attack on the World Trade Center--New York City, September )] TJ ET BT 26.250 622.833 Td /F1 9.8 Tf [(2001. MMWR. Morbidity and Mortality Weekly report. Jan 11 2002;51\(1\):1-5.)] TJ ET BT 26.250 603.429 Td /F1 9.8 Tf [(15.)] TJ ET BT 43.553 603.429 Td /F1 9.8 Tf [(Reiger D, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive )] TJ ET BT 26.250 591.524 Td /F1 9.8 Tf [(disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch )] TJ ET BT 26.250 579.619 Td /F1 9.8 Tf [(Gen Psychiatry. 1993;50\(2\):85-94.)] TJ ET BT 26.250 560.214 Td /F1 9.8 Tf [(16.)] TJ ET BT 43.553 560.214 Td /F1 9.8 Tf [(World Health Organization. Integrating Mental Health into Primary Care: A Global Perspective. . 2008; )] TJ ET BT 26.250 548.310 Td /F1 9.8 Tf [(https://www.who.int/mental_health/resources/mentalhealth_PHC_2008.pdf. Accessed September 20, 2016, 2016.)] TJ ET BT 26.250 528.905 Td /F1 9.8 Tf [(17.)] TJ ET BT 43.553 528.905 Td /F1 9.8 Tf [(Brackbill RM, Cone JE, Farfel MR, Stellman SD. Chronic physical health consequences of being injured during the terrorist )] TJ ET BT 26.250 517.000 Td /F1 9.8 Tf [(attacks on World Trade Center on September 11, 2001. American Journal of Epidemiology. May 1 2014;179\(9\):1076-1085.)] TJ ET BT 26.250 497.595 Td /F1 9.8 Tf [(18.)] TJ ET BT 43.553 497.595 Td /F1 9.8 Tf [(Welch AE, Caramanica K, Debchoudhury I, et al. A qualitative examination of health and health care utilization after the )] TJ ET BT 26.250 485.691 Td /F1 9.8 Tf [(September 11th terror attacks among World Trade Center Health Registry enrollees. BMC Public Health. 2012;12:721.)] TJ ET BT 26.250 466.286 Td /F1 9.8 Tf [(19.)] TJ ET BT 43.553 466.286 Td /F1 9.8 Tf [(Gross R, Neria Y, Tao XG, et al. Posttraumatic stress disorder and other psychological sequelae among world trade center )] TJ ET BT 26.250 454.381 Td /F1 9.8 Tf [(clean up and recovery workers. Annals of the New York Academy of Sciences. Jul 2006;1071:495-499.)] TJ ET BT 26.250 434.976 Td /F1 9.8 Tf [(20.)] TJ ET BT 43.553 434.976 Td /F1 9.8 Tf [(Nair HP, Ekenga CC, Cone JE, Brackbill RM, Farfel MR, Stellman SD. Co-occurring lower respiratory symptoms and )] TJ ET BT 26.250 423.072 Td /F1 9.8 Tf [(posttraumatic stress disorder 5 to 6 years after the World Trade Center terrorist attack. American journal of Public Health. Oct )] TJ ET BT 26.250 411.167 Td /F1 9.8 Tf [(2012;102\(10\):1964-1973)] TJ ET BT 26.250 391.762 Td /F1 9.8 Tf [(21.)] TJ ET BT 43.553 391.762 Td /F1 9.8 Tf [(Brackbill RM, Stellman SD, Perlman SE, Walker DJ, Farfel MR. Mental health of those directly exposed to the World Trade )] TJ ET BT 26.250 379.857 Td /F1 9.8 Tf [(Center disaster: unmet mental health care need, mental health treatment service use, and quality of life. Soc Sci Med. Mar )] TJ ET BT 26.250 367.953 Td /F1 9.8 Tf [(2013;81:110-114.)] TJ ET BT 26.250 348.548 Td /F1 9.8 Tf [(22.)] TJ ET BT 43.553 348.548 Td /F1 9.8 Tf [(Caramanica K, Brackbill RM, Stellman SD, Farfel MR. Posttraumatic Stress Disorder after Hurricane Sandy among Persons )] TJ ET BT 26.250 336.643 Td /F1 9.8 Tf [(Exposed to the 9/11 Disaster. International Journal of Emergency Mental Health. 2015;17\(1\):356-362.)] TJ ET BT 26.250 317.238 Td /F1 9.8 Tf [(23.)] TJ ET BT 43.553 317.238 Td /F1 9.8 Tf [(Yu S, Brackbill RM, Locke S, Stellman SD, Gargano LM. Impact of 9/11-related chronic conditions and PTSD comorbidity )] TJ ET BT 26.250 305.334 Td /F1 9.8 Tf [(on early retirement and job loss among World Trade Center disaster rescue and recovery workers. American Journal of )] TJ ET BT 26.250 293.429 Td /F1 9.8 Tf [(Industrial Medicine. 2016;59\(9\):731-741.)] TJ ET BT 26.250 274.024 Td /F1 9.8 Tf [(24.)] TJ ET BT 43.553 274.024 Td /F1 9.8 Tf [(Trinh NH, Nadler DL, Shie V, et al. Psychological sequelae of the station nightclub fire: Comparing survivors with and )] TJ ET BT 26.250 262.119 Td /F1 9.8 Tf [(without physical injuries using a mixed-methods analysis. PloS One. 2014;9\(12\):e115013.)] TJ ET BT 26.250 242.715 Td /F1 9.8 Tf [(25.)] TJ ET BT 43.553 242.715 Td /F1 9.8 Tf [(Maguen S, Litz B. Moral Injury in Veterans of War. PTSD Research Quarterly. 2013;23\(1\):1-6.)] TJ ET BT 26.250 223.310 Td /F1 9.8 Tf [(26.)] TJ ET BT 43.553 223.310 Td /F1 9.8 Tf [(Wilson JP, Raphael B, eds. Theoretical and Conceptual Foundations of Traumatic Stress Syndromes. New York, NY: )] TJ ET BT 26.250 211.405 Td /F1 9.8 Tf [(Plenum Press; 1993. The International Handbook of Traumatic Stress Syndromes.)] TJ ET BT 26.250 192.000 Td /F1 9.8 Tf [(27.)] TJ ET BT 43.553 192.000 Td /F1 9.8 Tf [(American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders \(Fifth ed.\). . Arlington, VA2013.)] TJ ET BT 26.250 172.596 Td /F1 9.8 Tf [(28.)] TJ ET BT 43.553 172.596 Td /F1 9.8 Tf [(Khouzam HR, Kissmeyer P. Antidepressant treatment, posttraumatic stress disorder, survivor guilt, and spiritual awakening. )] TJ ET BT 26.250 160.691 Td /F1 9.8 Tf [(Journal of Traumatic Stress. Oct 1997;10\(4\):691-696.)] TJ ET BT 26.250 141.286 Td /F1 9.8 Tf [(29.)] TJ ET BT 43.553 141.286 Td /F1 9.8 Tf [(Richardson KM. Meaning reconstruction in the face of terror: An examination of recovery and posttraumatic growth among )] TJ ET BT 26.250 129.381 Td /F1 9.8 Tf [(victims of the 9/11 World Trade Center attacks. J Emerg Manag. May-Jun 2015;13\(3\):239-246.)] TJ ET BT 26.250 109.977 Td /F1 9.8 Tf [(30.)] TJ ET BT 43.553 109.977 Td /F1 9.8 Tf [(Gershon RR, Rubin MS, Qureshi KA, Canton AN, Matzner FJ. Participatory action research methodology in disaster )] TJ ET BT 26.250 98.072 Td /F1 9.8 Tf [(research: results from the World Trade Center evacuation study. Disaster Medicine and Public Health Preparedness. Oct )] TJ ET BT 26.250 86.167 Td /F1 9.8 Tf [(2008;2\(3\):142-149.)] TJ ET Q q 15.000 37.477 577.500 739.523 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(Center terrorist attacks. Journal of Urban Health : Bulletin of the New York Academy of Medicine. Sep 2002;79\(3\):429-433.)] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 748.071 Td /F1 9.8 Tf [(Fusch PI, Ness LR. Are We There Yet? Data Saturation in Qualitative Research. The Qualitative Report. 2015;20\(9\):1408-)] TJ ET BT 26.250 736.167 Td /F1 9.8 Tf [(1416.)] TJ ET BT 26.250 716.762 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 716.762 Td /F1 9.8 Tf [(Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist \(PCL\). )] TJ ET BT 26.250 704.857 Td /F1 9.8 Tf [(Behaviour Research and Therapy. Aug 1996;34\(8\):669-673.)] TJ ET BT 26.250 685.452 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 685.452 Td /F1 9.8 Tf [(Braun V, Corbin V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3\(2\):77-101.)] TJ ET BT 26.250 666.048 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 666.048 Td /F1 9.8 Tf [(Burnard P. A method of analysing interview transcripts in qualitative research. Nurse Education Today. Dec 1991;11\(6\):461-)] TJ ET BT 26.250 654.143 Td /F1 9.8 Tf [(466.)] TJ ET BT 26.250 634.738 Td /F1 9.8 Tf [(14.)] TJ ET BT 43.553 634.738 Td /F1 9.8 Tf [(Rapid assessment of injuries among survivors of the terrorist attack on the World Trade Center--New York City, September )] TJ ET BT 26.250 622.833 Td /F1 9.8 Tf [(2001. MMWR. Morbidity and Mortality Weekly report. Jan 11 2002;51\(1\):1-5.)] TJ ET BT 26.250 603.429 Td /F1 9.8 Tf [(15.)] TJ ET BT 43.553 603.429 Td /F1 9.8 Tf [(Reiger D, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive )] TJ ET BT 26.250 591.524 Td /F1 9.8 Tf [(disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch )] TJ ET BT 26.250 579.619 Td /F1 9.8 Tf [(Gen Psychiatry. 1993;50\(2\):85-94.)] TJ ET BT 26.250 560.214 Td /F1 9.8 Tf [(16.)] TJ ET BT 43.553 560.214 Td /F1 9.8 Tf [(World Health Organization. Integrating Mental Health into Primary Care: A Global Perspective. . 2008; )] TJ ET BT 26.250 548.310 Td /F1 9.8 Tf [(https://www.who.int/mental_health/resources/mentalhealth_PHC_2008.pdf. Accessed September 20, 2016, 2016.)] TJ ET BT 26.250 528.905 Td /F1 9.8 Tf [(17.)] TJ ET BT 43.553 528.905 Td /F1 9.8 Tf [(Brackbill RM, Cone JE, Farfel MR, Stellman SD. Chronic physical health consequences of being injured during the terrorist )] TJ ET BT 26.250 517.000 Td /F1 9.8 Tf [(attacks on World Trade Center on September 11, 2001. American Journal of Epidemiology. May 1 2014;179\(9\):1076-1085.)] TJ ET BT 26.250 497.595 Td /F1 9.8 Tf [(18.)] TJ ET BT 43.553 497.595 Td /F1 9.8 Tf [(Welch AE, Caramanica K, Debchoudhury I, et al. A qualitative examination of health and health care utilization after the )] TJ ET BT 26.250 485.691 Td /F1 9.8 Tf [(September 11th terror attacks among World Trade Center Health Registry enrollees. BMC Public Health. 2012;12:721.)] TJ ET BT 26.250 466.286 Td /F1 9.8 Tf [(19.)] TJ ET BT 43.553 466.286 Td /F1 9.8 Tf [(Gross R, Neria Y, Tao XG, et al. Posttraumatic stress disorder and other psychological sequelae among world trade center )] TJ ET BT 26.250 454.381 Td /F1 9.8 Tf [(clean up and recovery workers. Annals of the New York Academy of Sciences. Jul 2006;1071:495-499.)] TJ ET BT 26.250 434.976 Td /F1 9.8 Tf [(20.)] TJ ET BT 43.553 434.976 Td /F1 9.8 Tf [(Nair HP, Ekenga CC, Cone JE, Brackbill RM, Farfel MR, Stellman SD. Co-occurring lower respiratory symptoms and )] TJ ET BT 26.250 423.072 Td /F1 9.8 Tf [(posttraumatic stress disorder 5 to 6 years after the World Trade Center terrorist attack. American journal of Public Health. Oct )] TJ ET BT 26.250 411.167 Td /F1 9.8 Tf [(2012;102\(10\):1964-1973)] TJ ET BT 26.250 391.762 Td /F1 9.8 Tf [(21.)] TJ ET BT 43.553 391.762 Td /F1 9.8 Tf [(Brackbill RM, Stellman SD, Perlman SE, Walker DJ, Farfel MR. Mental health of those directly exposed to the World Trade )] TJ ET BT 26.250 379.857 Td /F1 9.8 Tf [(Center disaster: unmet mental health care need, mental health treatment service use, and quality of life. Soc Sci Med. Mar )] TJ ET BT 26.250 367.953 Td /F1 9.8 Tf [(2013;81:110-114.)] TJ ET BT 26.250 348.548 Td /F1 9.8 Tf [(22.)] TJ ET BT 43.553 348.548 Td /F1 9.8 Tf [(Caramanica K, Brackbill RM, Stellman SD, Farfel MR. Posttraumatic Stress Disorder after Hurricane Sandy among Persons )] TJ ET BT 26.250 336.643 Td /F1 9.8 Tf [(Exposed to the 9/11 Disaster. International Journal of Emergency Mental Health. 2015;17\(1\):356-362.)] TJ ET BT 26.250 317.238 Td /F1 9.8 Tf [(23.)] TJ ET BT 43.553 317.238 Td /F1 9.8 Tf [(Yu S, Brackbill RM, Locke S, Stellman SD, Gargano LM. Impact of 9/11-related chronic conditions and PTSD comorbidity )] TJ ET BT 26.250 305.334 Td /F1 9.8 Tf [(on early retirement and job loss among World Trade Center disaster rescue and recovery workers. American Journal of )] TJ ET BT 26.250 293.429 Td /F1 9.8 Tf [(Industrial Medicine. 2016;59\(9\):731-741.)] TJ ET BT 26.250 274.024 Td /F1 9.8 Tf [(24.)] TJ ET BT 43.553 274.024 Td /F1 9.8 Tf [(Trinh NH, Nadler DL, Shie V, et al. Psychological sequelae of the station nightclub fire: Comparing survivors with and )] TJ ET BT 26.250 262.119 Td /F1 9.8 Tf [(without physical injuries using a mixed-methods analysis. PloS One. 2014;9\(12\):e115013.)] TJ ET BT 26.250 242.715 Td /F1 9.8 Tf [(25.)] TJ ET BT 43.553 242.715 Td /F1 9.8 Tf [(Maguen S, Litz B. Moral Injury in Veterans of War. PTSD Research Quarterly. 2013;23\(1\):1-6.)] TJ ET BT 26.250 223.310 Td /F1 9.8 Tf [(26.)] TJ ET BT 43.553 223.310 Td /F1 9.8 Tf [(Wilson JP, Raphael B, eds. Theoretical and Conceptual Foundations of Traumatic Stress Syndromes. New York, NY: )] TJ ET BT 26.250 211.405 Td /F1 9.8 Tf [(Plenum Press; 1993. The International Handbook of Traumatic Stress Syndromes.)] TJ ET BT 26.250 192.000 Td /F1 9.8 Tf [(27.)] TJ ET BT 43.553 192.000 Td /F1 9.8 Tf [(American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders \(Fifth ed.\). . Arlington, VA2013.)] TJ ET BT 26.250 172.596 Td /F1 9.8 Tf [(28.)] TJ ET BT 43.553 172.596 Td /F1 9.8 Tf [(Khouzam HR, Kissmeyer P. Antidepressant treatment, posttraumatic stress disorder, survivor guilt, and spiritual awakening. )] TJ ET BT 26.250 160.691 Td /F1 9.8 Tf [(Journal of Traumatic Stress. Oct 1997;10\(4\):691-696.)] TJ ET BT 26.250 141.286 Td /F1 9.8 Tf [(29.)] TJ ET BT 43.553 141.286 Td /F1 9.8 Tf [(Richardson KM. Meaning reconstruction in the face of terror: An examination of recovery and posttraumatic growth among )] TJ ET BT 26.250 129.381 Td /F1 9.8 Tf [(victims of the 9/11 World Trade Center attacks. J Emerg Manag. May-Jun 2015;13\(3\):239-246.)] TJ ET BT 26.250 109.977 Td /F1 9.8 Tf [(30.)] TJ ET BT 43.553 109.977 Td /F1 9.8 Tf [(Gershon RR, Rubin MS, Qureshi KA, Canton AN, Matzner FJ. Participatory action research methodology in disaster )] TJ ET BT 26.250 98.072 Td /F1 9.8 Tf [(research: results from the World Trade Center evacuation study. Disaster Medicine and Public Health Preparedness. Oct )] TJ ET BT 26.250 86.167 Td /F1 9.8 Tf [(2008;2\(3\):142-149.)] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(11)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 363 0 obj << /Type /Page /Parent 3 0 R /Contents 364 0 R >> endobj 364 0 obj << /Length 1226 >> stream 0.271 0.267 0.267 rg q 15.000 730.691 577.500 46.309 re W n 0.271 0.267 0.267 rg BT 26.250 759.976 Td /F1 9.8 Tf [(31.)] TJ ET BT 43.553 759.976 Td /F1 9.8 Tf [(Karanci NA, Acarturk. 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