Even on Sept. 11, 2001, doctors knew.

They knew that on top of the immediate and devastating toll the terrorist attacks exacted that day, they would be seeing victims of another sort in the coming months and years.

They feared for the workers at the site. Some, they predicted, would have little time bombs ticking away after completing their gruesome work. They might have physical problems from breathing the noxious air. They might have emotional problems from the stress and grief and fear.

Now, more than a year later, those little time bombs are going off for some of the estimated 35,000 workers at the site.

Take George Smith

On Sept. 10, 2001, Smith was a healthy guy. Then the 56-year-old Middletown man spent nine months trucking rubble out of Ground Zero to Fresh Kills Landfill.

It was part of the job. He works for New York City's Department of Sanitation. And he'd do it again, if it came to that.

But he probably wouldn't be able to. For the past several months, Smith has been under a doctor's care. He works only light duty.

"My lungs aren't doing so good," he said. "I have a lot of pills and nebulizers and pump sprays to help me get by. The thing is, no one can tell me if I'll ever be able to breathe right again."

Or take 39-year-old Thomas Hickey of Glen Spey. He was a healthy guy, too, before Sept. 11, 2001.

Hickey is an ironworker with Local 40. He started at Ground Zero on Sept. 12 and worked straight through, seven days a week, until mid-November.

On Feb. 11, he took himself to the emergency room at Bon Secours Community Hospital in Port Jervis. He had severe bronchitis. And asthma. And a major sinus infection. And a headache that wouldn't quit. And a chronic cough.

"I'm all messed up," said Hickey. "I just had sinus surgery Oct. 1 to have badly infected tissue removed. Five hours on the table."

He's house-bound because his doctor says he can't work. He wakes up gasping for air in the night from the asthma.

Just as bad, he can't shake the nightmare images of the dead bodies. "I'm upset over stuff," he said. "All screwed up, really. I'm starting to see a psychiatrist about it."

Or take Victor Carusi, 34, of the Town of Newburgh. He's passed out twice since last Sept. 11 ­ both times from constricted airways that caused oxygen deprivation to his brain.

The NYPD detective spent a week at Ground Zero early on, then worked at Fresh Kills three times a week through April. He was doing a secondary search through the rubble, looking for victims' ID.

Sifting. Raking. Shoveling.

Carusi has suffered with severe post-nasal drip and a chronic cough ever since. He has asthma for the first time in his life. He has acid reflux. "So bad it awakens me in the middle of the night," said Carusi. "It feels like my stomach is coming out of my mouth."

And now he's getting earaches.

Problems without explanations

No one knows exactly how many others who worked at Ground Zero are also sick. And getting sicker.

What's more, no one knows exactly why they're sick ­ primarily with upper respiratory problems, including the famous World Trade Center Cough that just won't quit; and with emotional problems closely associated with post traumatic stress disorder.

These trends are emerging through the various screening programs, yet no one is able to adequately explain them.

For example, of the more than 1,000 people who have been screened thus far through the Mount Sinai Center for Occupational and Environmental Medicine, a "substantial portion" still have respiratory problems.

"But the air sampling done at the site doesn't fully explain the health problems we're seeing," said Dr. Robin Herbert, co-director of the Mount Sinai program. "We will never fully know what people were exposed to, but these are people who should be watched long-term."

Concrete dust

Early on, the tons of concrete pulverized to dust was the primary culprit behind the chronic coughing at the site.

"I was on the bucket brigade for awhile, and the biggest piece of concrete we saw was the size of a pebble," said Smith. "The rest was dust. And we were out there with nothing but handkerchiefs over our noses. So we coughed. And coughed."

But the concrete itself was not toxic, and people coughed and sneezed it out of their systems over time, said Dr. Raymond Basri, a Middletown internist who is treating dozens of New York City police, firefighters and non-uniform workers.

Of greater concern, though, is the toxins that were likely in the air. Yet in May, the Centers for Disease Control and Prevention said there were not enough toxic contaminants in the air to put workers at risk when judged against national safety standards.

Freon becomes phosgene

But one Orange County resident, who works for the Army's medical service, said the daily FEMA briefings he sat in on during the early weeks of the clean-up suggested otherwise.

"There were huge amounts of contaminants stored in those buildings," he said. Because the briefings were classified, he would not allow the Record to use his name. But among his concerns, he said, is phosgene.

Phosgene is a corrosive gas developed during World War I, which kills by burning and blistering the upper airways.

When freon used for air conditioning is vaporized, it becomes phosgene. About 90,000 pounds of freon was stored in tanks in the basement of the south tower. It is likely that a similar amount was stored in the north tower basement.

Early on, when the status of some of the large freon tanks was unknown, there were warnings that if workers started dropping over, it could mean a sudden phosgene release and the site should be cleared.

That didn't happen, but there is still some question about the damage that might have been caused by low levels of phosgene exposure. Some speculate that phosgene may be partially responsible for the World Trade Center Cough.

Asbestos, mercury, antifreeze

Asbestos is another concern. During construction, asbestos was used as fireproofing in the first 40 floors of the north tower and in the elevator shafts. Bulk samples of dust at the site showed asbestos concentrations as high as 20 percent in some places. Prolonged exposure can cause lung cancer.

Mercury is another possible concern. Each tower had more than 1,000 thermostats, each containing an ounce of mercury, which vaporized. Mercury poisoning has been associated with a range of health problems, including neurological disorders, autism, chronic fatigue syndrome and infertility.

Pulverized glass, biocides, antifreeze and heavy metals like zinc and aluminum were also part of the chemical soup that workers were breathing, often without any respiratory protection.

Doctors, both local and in New York City, are feeling their way on what all this means.

The various agencies conducting screenings are testing for different things: FEMA has one program for the FDNY; Mount Sinai has a different program for non-FDNY workers; the Army has yet another screening program as do the NYPD aviators.

Doctors in private practice are following their own instincts and testing for what seems logical.

"I've looked at all the screening programs, and the one that seems most thorough is the police department aviators', so that's the one I'm following," said Basri.

Aluminum in blood

That program screens for heavy metals. And one unusual trend among Basri's patients is high aluminum levels in their blood.

"About 12 to 15 of the people I've tested have serum aluminum levels of three to five times normal," said Basri. "This is a small sampling, but it could be important."

Smith, a patient of Basri's, said his results showed levels in the range of 36 to 38. Normal is 3 to 9. "I don't know what it means, but it's high," he said.

Elevated aluminum can contaminate the body's filtration system ­ the kidneys and liver ­ causing neurological damage. While it's associated with dialysis patients, Basri said no one knows what the implications are for an otherwise healthy patient. Maybe something. Maybe nothing. Maybe we won't know for years.

"I don't want to raise additional fears, but I am asking local firefighters who were down there to come in and get tested for this," said Basri. "The FDNY has 10,000 blood samples, but they're not testing for serum aluminum. They should."

He's operating on the principle that the more information doctors gather, the better.

So are the doctors at Mount Sinai, although testing for heavy metals is not part of their program. On the other hand, a mental-health assessment is included.

Mental health problems

"We're just seeing the tip of the iceberg," said Herbert. "A substantial portion of those who've been screened so far have persistent mental health problems ­ post traumatic stress disorder, depression and anxiety."

She said Mount Sinai doctors are seeing a lot of patients whose marriages are falling apart. Some are entering into new relationships, formed under intense circumstances at the rescue site. The odds are against the survival of such relationships.

Mount Sinai will be opening a clinic in Yonkers next month to make it more convenient for Hudson Valley residents to get free screening.

And last week, the Mount Sinai project received a grant to go beyond mere screening. Doctors there can now treat both physical and mental disorders related to Ground Zero at no cost to the patient.

The program is open to all non-FDNY Ground Zero workers. And Herbert stresses that everyone who worked at Ground Zero ­ those without any symptoms or problems as well as those already under a doctor's care ­ should participate in the screening.

"We need to establish a baseline so that if problems show up in the future, we'll be better able to determine if they're Ground Zero related," she said.

Call 888-702-0630 for more information or to make an appointment.

Patient A -

Patient A is a 28-year-old male police officer who was a member of the National Guard and was activated on September 11th to provide a security perimeter around the World Trade Center site. He worked at the site for one month and was not initially provided with proper protective equipment or facilities to maintain proper personal hygiene. Subsequently, he developed breathing difficulty, unexplained rashes, and a staph infection in both ears. His ears are continually draining fluid and bleeding, causing disruption of his equilibrium and sleepless nights. The National Guard told him that any treatment would be at his own cost and seeing a military doctor was not an option. He also sought counseling for Post Traumatic Stress Disorder. The mental and physical illnesses that Patient A developed as a result of his work at Ground Zero have impacted his ability to perform his duty as a police officer, live a normal life, and pass the physical examination necessary for continuing service in the National Guard. When Patient A was seen at The Bear Stearns/Mount Sinai Health for Heroes Program, he was provided with medical prescriptions, sent for further testing, given the proper referrals to specialists, and scheduled to be seen again in one month for further evaluation.

Patient B -

Patient B is a 39-year-old female who provided emergency medical assistance at the World Trade Center site. On September 12, 2001, she was exposed to smoke and fumes at the site, which required her to be hospitalized for nausea and vomiting. After her service, she began to have difficulty breathing, tightness in her chest, a persistent cough, stomach pain, and frequent insomnia. She was diagnosed with asthma in 1999, but it has greatly worsened since 9/11 and she now has difficulty breathing when there is a sudden change in the weather or when exposed to paint, perfume, or smoke. She now has a very low tolerance for exercise. Patient B has, to date, required three follow-up appointments since her initial visit to track her progress and continue diagnosis of her illness. At the beginning of February, she had to check herself into the emergency room for body ache, fever, and trouble breathing. She is on medical leave from her position with the New York Fire Department and is unable to work. Our social worker continues to assist the patient with her request for Workers Compensation, which will allow her to have further tests that will aid in her diagnosis and treatment. Patient B will continue to be seen at The Bear Stearns/Mount Sinai Health for Heroes Program for as long as necessary and possible.