Over the 12 months preceding September 11, the Army’s DiLorenzo Tricare Health Clinic (DTHC) at the Pentagon works to develop its mass casualty (MASCAL) plan. This work will significantly and fortuitously help the clinic when it has to implement the plan in response to the Pentagon attack on 9/11. Major Lorie Brown, the chief nurse at the DTHC, is the chairperson for the DiLorenzo Action Response Team (DART). As she will later recall, over this 12-month period, the DART team works “on developing that [MASCAL] plan, really creating a whole new plan. We sat down and met on numerous occasions with the Air Force clinic [also based in the Pentagon], civilian EMS [Emergency Medical Services], Pentagon and [Department of Defense] hierarchy, DPS [the Defense Protective Service], and with the other civilian medical agencies.” They work through various issues, such as “what would happen in the event of a MASCAL, what each of our roles would be.” The DART team, Brown says, participates “in several large tabletop exercises with these external bodies, to include FEMA [the Federal Emergency Management Agency] and the others I just mentioned. We even did our own internal exercise where we made up the scenario of a plane crashing into the building.” [Marble and Milhiser, 9/2004, pp. 7] This “internal exercise” is likely a reference to an exercise held by the DTHC in May 2001 (see May 2001). [US Department of Health and Human Services, 7/2002, pp. B17 
] Another exercise Brown participates in over this period is the Pentagon Mass Casualty Exercise in October 2000 (see October 24-26, 2000), which also includes a scenario of a plane hitting the Pentagon. [MDW News Service, 11/3/2000] Brown will later credit this work developing the MASCAL plan as being of great benefit when the Pentagon is hit on 9/11, and the plan is initiated (see Soon after 9:37 a.m. September 11, 2001). She will say: “[O]ur planning truly made such a huge difference on that day. Our commander had the foresight to focus on MASCAL prep and gave us the time and budget to really revamp our old MASCAL plan. I can’t say enough about how critical this was to our success.” [Marble and Milhiser, 9/2004, pp. 7]
May 2001: Medics Train for Airplane Hitting Pentagon
The Army’s DiLorenzo Tricare Health Clinic (DTHC) and the Air Force Flight Medicine Clinic, both housed within the Pentagon, hold a tabletop exercise along with Arlington County Emergency Medical Services. The scenario practiced for is of an airplane crashing into the Pentagon’s west side—the same side as is impacted in the attack on 9/11. [US Department of Health and Human Services, 7/2002, pp. B17 ; Goldberg et al., 2007, pp. 23 and 107] Reportedly, the purpose of the exercise is “to fine-tune their emergency preparedness.” [US Medicine, 10/2001] According to US Medicine newspaper, the plane in the scenario is a hijacked Boeing 757. [US Medicine, 1/2002] (Flight 77, that targets the Pentagon on 9/11, is a 757. [New York Times, 9/13/2001] ) But a federally funded report on the response to the Pentagon attack says it is a commuter airplane. [US Department of Health and Human Services, 7/2002, pp. B17 ] The Defense Department’s own book about the Pentagon attack says the plane in this exercise is a twin-engine aircraft (757s, like Flight 77, are twin-engine aircraft), but that it crashes into the Pentagon by accident in the scenario. [New York Times, 9/13/2001; Goldberg et al., 2007, pp. 107] The idea of a plane hitting the Pentagon was suggested by Colonel John Baxter, the commander of the Air Force Flight Medicine Clinic, who has often been reminded that the Pentagon is on the flight path of nearby Reagan National Airport. The scenario was approved by Air Force Surgeon General Paul Carlton Jr. [Goldberg et al., 2007, pp. 107 and 109] Baxter and Col. James Geiling, the commander of the DTHC, later say this exercise prepares them well to respond to the Pentagon attack on 9/11. For example, the Air Force Flight Medicine Clinic retools its trauma packs as a result. [US Medicine, 10/2001] And, due to the exercise, staffers of both clinics will wear special blue vests on 9/11 labeled “physician,” “nurse,” or “EMT,” to allow for easy identification. [Uniformed Services University, 1/2002 ] Paul Carlton will say, “We learned a lot from that exercise and applied those lessons to September 11.” [Murphy, 2002, pp. 222] And Major Lorie Brown, the chief nurse of the DTHC, who leads the exercise, will later recall, “The training made a huge difference” on 9/11. [Nursing Spectrum, 9/24/2001] The two Pentagon clinics routinely hold mass casualty tabletop exercises. The scenario changes for each drill. [Goldberg et al., 2007, pp. 107]
Before 9:37 a.m. September 11, 2001: Pentagon Clinic Has Crisis Equipment Ready Due to Inventory
The DiLorenzo Tricare Health Clinic inside the Pentagon has its equipment for dealing with mass casualty (MASCAL) incidents out of storage this morning, because staff members are doing an inventory. Major Lorie Brown, the chief nurse, will need to initiate the clinic’s MASCAL disaster plan after the Pentagon is hit at 9:37 a.m. (see Soon after 9:37 a.m. September 11, 2001). She later says, “So there were many pieces that just fell into place and worked so well on that day. It was just fortuitous. It was just amazing that way that things kind of happened the way they did.” [Nursing Spectrum, 9/24/2001; Marble and Milhiser, 9/2004, pp. 7]
Shortly After 9:37 a.m. September 11, 2001: Some Pentagon Medical Workers Initially Think Evacuation Is Part of a Drill
A number of medical workers at the US Army’s DiLorenzo Tricare Health Clinic (DTHC) initially believe the evacuation in response to the Pentagon attack is part of a training exercise. The DTHC is located in the basement on the east side of the Pentagon, more than 1,000 feet from where the building was hit, and therefore many of the people there did not feel or hear the impact when the attack occurred. [Nursing Spectrum, 9/24/2001; Goldberg et al., 2007, pp. 107-108; Creed and Newman, 2008, pp. 57-58] 
After being told to get out of the clinic, Captain Jennifer Glidewell leaves along with Sergeant Matthew Rosenberg. According to Glidewell, they are “thinking fire drill.” They head for the Pentagon’s center courtyard where they see an injured man running and screaming, with his face burnt and the skin hanging off. According to authors Patrick Creed and Rick Newman, Glidewell initially thinks this is “the best moulage job she had ever seen. Moulage was the makeup medical practitioners put on mock patients during exercises, to simulate injuries.” When she realizes the injuries are genuine, she grabs her radio and yells into it: “This is not a drill! This is real!” [Marble and Milhiser, 9/2004, pp. 19; Creed and Newman, 2008, pp. 57-58] Sergeant Mark Maxey Davis will recall, “I just thought [the evacuation] was a routine fire drill or something like that.” [Marble and Milhiser, 9/2004, pp. 69] Dr. Veena Railan describes: “I was not very sure what was happening, what was going on at that time. Maybe this is a drill because of what happened in New York.” [Marble and Milhiser, 9/2004, pp. 125] Staff Sergeant Keith Pernell recalls, “We just thought it was a regular fire drill.” [Marble and Milhiser, 9/2004, pp. 111] US Air Force Surgeon General Paul Carlton Jr. is accompanying a team of medics from the DTHC to the center courtyard. [Goldberg et al., 2007, pp. 109] He will recall that a young sergeant with him is “under the impression that this crash was yet another exercise.” Carlton tells him, “I think this one’s for real, my friend.” [Murphy, 2002, pp. 222] Captain Liza Lindenberg later describes, “Not until we went out the door did I see these plumes of smoke and thought, this is definitely not a drill.” [Marble and Milhiser, 9/2004, pp. 85] Major Bridget Larew remains at the clinic to help an injured victim. Soon, she will recall, “our medical teams were starting to come back in the building, realizing that this was not a drill and that they needed to be here with us to get supplies and stuff.” [Marble and Milhiser, 9/2004, pp. 83]
A factor that may have contributed to this confusion is that personnel from the DTHC have participated in at least two training exercises during the previous 12 months based around the scenario of a plane crashing into the Pentagon (see October 24-26, 2000 and May 2001). [MDW News Service, 11/3/2000; US Department of Health and Human Services, 7/2002, pp. B17 ; Goldberg et al., 2007, pp. 107] In response to the attack, the clinic’s workers will be involved with the emergency response, performing triage and treatment at the Pentagon. [US Department of Health and Human Services, 7/2002, pp. B1 ]
After 9:37 a.m. September 11, 2001: Emergency Responders Experience Communications Problems at Pentagon
Emergency responders and others at the Pentagon experience serious problems with communications following the attack there. These difficulties last for several hours. [US Department of Health and Human Services, 7/2002, pp. 12-13 ; Goldberg et al., 2007, pp. 114] According to a federally funded report on the emergency response to the Pentagon attack, communications systems had been busy “even before American Airlines Flight 77 crashed into the Pentagon.” But when the crash occurs, “all area communications [seem] simultaneously overwhelmed.” [US Department of Health and Human Services, 7/2002, pp. A34 ] The Defense Department’s book about the Pentagon attack later describes, “Almost immediately radio traffic gridlocked, land lines were unavailable, and cellular telephone networks became so overloaded that for a time Pentagon officials and employees as well as some emergency responders could not call outside.” [Goldberg et al., 2007, pp. 114] This leads to significant problems: “Firefighters calling the [Arlington County Emergency Communications Center] couldn’t get through. Relatives of Pentagon workers found cellular and land lines jammed.” [US Department of Health and Human Services, 7/2002, pp. A34 ] The DiLorenzo Tricare Health Clinic at the Pentagon and the Rader Clinic at nearby Fort Myer are unable to establish reliable communications. Reportedly, “Hospitals and clinics could not be informed about the flow of casualties, and perhaps more damaging, communication between the fire and rescue and the emergency medical elements on-site was severely impaired.” [Goldberg et al., 2007, pp. 114] Officer Aubrey Davis of the Pentagon police heads to the crash site with Defense Secretary Donald Rumsfeld immediately after the Pentagon is hit. He receives frantic pleas over his radio, regarding Rumsfeld’s whereabouts. But, as Davis later recalls, “the system was overloaded, everyone on the frequency was talking, everything jumbled, so I couldn’t get through and they went on asking” (see (9:38 a.m.-10:00 a.m.) September 11, 2001). [Cockburn, 2007, pp. 1-2] Cellular and landline telephone communications remain “virtually unreliable or inaccessible during the first few hours of the response.” But later on, in the afternoon, Verizon technicians and Secret Service technical staff install portable cellular towers at the Pentagon, and this significantly increases cell phone access. [US Department of Health and Human Services, 7/2002, pp. C36 ] Communications problems are experienced not just around the Pentagon but also in the broader Washington area, with some senior government officials being affected (see (After 8:55 a.m.) September 11, 2001). [Verton, 2003, pp. 149]
Soon after 9:37 a.m. September 11, 2001: Pentagon Medical Staff Implement Mass Casualty Plan; Aided by Pre-9/11 Exercises
Soon after the Pentagon is hit, medical workers initiate their mass casualty plan (MASCAL) for dealing with disasters. Sergeant Matthew Rosenberg, a medic at the Pentagon’s DiLorenzo Tricare Health Clinic, arrives at the center courtyard. Seeing smoke rising from the side of the building and patients staggering out, he radios the clinic: “You need to initiate MASCAL right now! We have mass casualties! I need medical assets to the courtyard!” Major Lorie Brown, chief nurse of the DiLorenzo Clinic, says that as soon as she sees people running down the corridor to evacuate, “we initiated the MASCAL, started galvanizing all of our assets and put our plan in action.” [Washington Post, 9/16/2001; Marble and Milhiser, 9/2004, pp. 7, 39] The Pentagon has actually conducted at least three MASCAL training exercises in the previous 12 months, based around a plane crashing into the place (see October 24-26, 2000)(see May 2001)(see Early August 2001). Lieutenant Colonel John Felicio, the deputy commander for administration of the DiLorenzo Clinic, says, “The saving grace to our efforts was the two MASCAL exercises we previously had conducted.… Our scenario for both MASCALS was a plane flying into the Pentagon courtyard.” Furthermore, the nearby Walter Reed Army Medical Center (WRAMC), which sends ambulances in response to the attack, has recently recovered from a four-day power loss (see August 27-31, 2001). A military report will later state: “Many believe that [this] extended emergency… helped WRAMC in its response on September 11.” [Marble and Milhiser, 9/2004, pp. 18, 146]
