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Lives Full of Emergencies

Paramedics are medical emergencies' first line of defense.

Heart attacks, water rescues, heat stroke, gunshot wounds, baby deliveries, burn victims and mass casualties are all in a day's work for Emergency Medical Services — EMS. May 15 to 21 is EMS Week.

Alexandria has one of the most highly skilled and best equipped EMS contingents in the state, according to Deputy Chief Vince Whitmore, EMS operations for the Alexandria Fire Department.

"We have a little different scenario here. Our EMS personnel do not have to be firefighters. We hire people who come to us with no experience as well as those with full credentials," Whitmore said.

"And we have found we have had about equal success with both groups. But, everybody goes through the same EMS training regardless of their entrance experience and credentials," he said.

Paramedics are trained in Advanced Life Support (ALS) techniques while firefighters are schooled in Basic Life Support. ALS includes such specialties as advanced airways management and administering drugs. "It requires a very unique skill to successfully insert a breathing tube," said James Vafier, M.D., the department's operational medical director.

EMS personnel operate under the aegis of a licensed physician as mandated by state law. For Alexandria's Fire Department that person has been Vafier since 1986.

He is only the second to hold that position since the program started in 1976. Prior to Vafier, Dr. John McDade was the operational medical director. "When I started in 1986 John was still here and he groomed me for this. I got the formal title in 1991," Vafier said.

"It just can't be any doctor. Someone serving as the OMD must be well versed in emergency medical services and hold Board Certification in that area," he said. Vafier is an emergency room physician at Inova Alexandria Hospital and volunteers his time to the Fire Department. He is not on the department's payroll.

One day each month he rides along with the paramedics on their duty calls. "I usually ride with the supervisor that day to observe operations. But, there are times when I go right to the scene and get in on the action," Vafier said.

ONE OF THOSE "ride along" days was Sept. 11, 2001. "I was actually at one of the fire station's watching television when the second plane hit the Twin Towers and then the Pentagon. We left immediately for the Pentagon and that's where I spent the next 14 hours as the command physician," he said.

He was joined there by a number of Alexandria firefighters and EMS personnel. Many rotated through long shifts for the next several days doing what they were trained for but hoped they would never have to use.

"I have been intimately involved with the department since I started. I am involved with hiring EMS personnel, their training and their reviews. We have 62 paramedics in this department. That affords me the opportunity to be very familiar with each individual's capabilities," Vafier said.

"The state requires all EMS personnel to go through 72 hours of training every two years to keep their skills current. Additionally we run our own evaluations and Dr. Vafier adds requirements. We take our personnel beyond the state requirements," Whitmore said.

"Every two years each paramedic must be recertified. And, every employee has a quarterly review by their immediate supervisor. This is supplemented by a quality improvement meeting every month," Vafier said.

Departmental procedures require that every paramedic team must file a report after every run. That report is then reviewed by others that are not part of that shift, according to Whitmore.

THERE IS ALSO a concurrent review of all patient codes, defining what the problem was, all patient complaints, all airway management incidents, and all transports out of the city. "It's a focused review. If we see problems occurring in patient care, we check to make sure the medics are doing all the checks properly," Vafier said.

"This is not a disciplinary process. It's a quality process," Whitmore said.

"Each review, good as well as critical, goes into a paramedic's file. We have a very tight process here in Alexandria. The purpose of quality assurance is to make sure the system is the best it can be," Vafier said.

Alexandria is one of the finest and most advanced EMS systems in the nation, according to Vafier. "We don't expect perfection on every call but we want every paramedic to strive for perfection on every call," he said.

ONE OF THE MOST critical calls is for cardiac arrest or heart attacks. Paramedics are specifically trained in a variety of procedures to deal with this and they have an array of equipment at their disposal, according to both men.

"But, there is still some controversy within the medical profession as to whether or not our paramedics should be performing these advanced procedures," Vafier said.

"We are actually seeing a decline in cardiac arrest because paramedics can perform these advanced procedure. Years ago we responded to cardiac arrest cases. Now we try to prevent them," Whitmore said.

In addressing a recent case where a patient was thought to be dead following a cardiac arrest but flickered back to life after paramedics left the scene, Vafier said, "We have very specific protocols how to assess a patient's condition, particularly if they appear to be dead."

He stated, "We have the equipment that can detect even a very faint pulse or heart beat. It should always be used in such cases. Taking a pulse is not the most accurate way to determine if the heart is still functioning."

When it comes to administering CPR, Vafier said, "The art of resuscitation is still a work in progress." Lately, that procedure has been questioned by various physicians as to whether or not the mouth-to-mouth element of the routine is causing more harm to the patient than helping them in that it interrupts the chest compression process.

"In Alexandria we adhere to the doctrine of general standard of care. The last major revisions dealing with advanced cardiac life support procedures was in 2000. The next ones are due in 2006," Vafier said.

Paramedics also operate as integral parts of the Fire Department's Marine Operations Team, where eight members are trained EMS personnel, and with Alexandria Police Department's Special Operations Team. Four paramedics are assigned to the latter.

All of this training and personnel are supported by specialized equipment ranging from a fully equipped, ready-to-roll mass casualty trailer and a hazardous materials unit. "We have recently received a grant to acquire a mass casualty truck," Whitmore said.