On a Wednesday night in May 1984, firefighters and paramedics from the Fairfax County Fire and Rescue Department's Company No. 1 responded to a call that brought them face to face with the most primitive kind of terror.
A fire had broken out in an upstairs bedroom of an exclusive home in Great Falls. In the room, rescue workers found two dead children. Talia Kantarian, 6, was lying in a pool of blood, stabbed 32 times. Her sister, 5-year-old Jamie, was lying nearby, dead from severe blows to the head and burns.
The girls' mother, Nancy L. Kantarian, later pleaded guilty to killing her children and setting the house on fire. She was sentenced to an indefinite stay in a mental hospital.
For rescue workers at the scene, the Kantarian incident was not like others -- it would not go away when the job was done.
"They were very angry . . . . Even though the mother was sick, they were angry at her. These two kids were completely innocent," said Sgt. Craig Summers, who sat in on a debriefing session for fire and rescue workers several days later.
The Kantarian tragedy was a classic case of emergency workers confronted with what has come to be known as critical-incident stress.
"Critical-incident stress is any situation that causes [a rescue worker] to have an unusually strong emotional reaction," said Marla Zipin, coordinator of the fire department's employe assistance program, who added that confidentiality prohibited her from commenting directly on the effect of the Kantarian tragedy on rescue workers. "They [rescue workers] may feel depressed, or feel a sense of loss. They may have nausea or headaches. It could be almost any symptom."
Critical-incident stress is difficult to manage, Zipin said, because symptoms often arrive well after the event that precipitated them. "They can occur hours, days or weeks later, or even longer in some cases, especially if there has been denial of the problem."
"These are normal people having normal reactions to highly abnormal situations," said Dr. Jeffrey Mitchell, a psychologist with the University of Maryland who has been a pioneer in the study of critical-incident stress. Mitchell said the phenomenon first began to be studied seriously after the 1978 crash of a Pacific Southwest Airlines plane in San Diego.
The Kantarian case was the first time the department directly confronted the issue of critical-incident stress by providing emotional "debriefing" for rescue workers immediately after the tragedy.
The county will soon have a formal program in which debriefing teams of counselors will be on the scene at severe disasters, and further debriefing and more extensive counseling will be available afterward. Arlington and Alexandria have collaborated on a similar program since last year.
"Debriefing is designed to accelerate the healing process," Mitchell said. Mitchell will talk with Fairfax fire and rescue officials next month on techniques for implementing a critical-incident program.
Stress of all kinds, from routine job burnout to major emotional crises following a critical incident, is becoming a mounting problem, emergency workers say, especially in places such as Fairfax County, where affluent taxpayers expect nothing but the most modern and professional fire and rescue services.
The irony is that while the department's capabilities to save lives increases (because of sophisticated equipment and advanced training), the pressures under which rescue workers perform become greater.
In Fairfax, paramedics attend courses once a month to stay current with the latest developments in medical equipment and drugs, advances that effectively enable a hospital emergency room to be transported to the scene of a crisis. At the same time, Mitchell said, these improvements multiply a paramedic's burden many times over.
There are times, like the Kantarian case, when there simply are no miracles at hand. "We get all this new stuff, and it still doesn't work. It's very frustrating," said Summers.
"People expect you to be the hero, to arrive on the scene and be able to solve everything. But you can't always do that," added Lt. Harry Scott, who heads a paramedic unit at Company 9 in the Mount Vernon section of Fairfax County.
It was a quiet Saturday night earlier this month at Company 9. There were only two calls for Scott's paramedic team, both of them after dinner. Firefighters dined on hearty portions of homemade bread and stuffed peppers that they had prepared themselves. In between, Scott and two emergency medical services technicians under his command, George Harley and Eugene Zeman, talked about their job and the emotional pressures that come with it.
The first call came shortly before 8 p.m.
With a firefighter driving, Scott and Harley raced in an ambulance to a hotel on the Richmond Highway. Minutes later, Scott and Harley were attending to Mary, a short, middle-aged woman with closely cropped light-brown hair.
Fully reclined on her bed, the slits that under ordinary circumstances would be Mary's eyes, start to widen, and a few barely coherent words escape from her mouth.
Reading the label on a container of pills, Scott calmly asks, "Mary, how many of these did you take?"
The answer comes slowly. "Ten. I think."
Harley then asked, as though they were old friends, "Mary, why did you take the pills?"
All she does is groan.
But by this time Mary is sitting up, and Scott and Harley have hooked an electrocardiogram to her chest to monitor her heartbeat, and they give her medicine that will soon make her vomit.
Mary is clearly comforted, even pleased, by Scott and Harley's attempts to coax her out of her stupor. One suspects that this is more attention than Mary gets from the rest of the world.
A police officer tells Scott that this is not the first time Mary has been in trouble. In fact, Mary had done the exact same thing two weeks earlier. "Mary gets upset with her boyfriend, and then she drinks too much and takes pills," he explains.
Mary is loaded into a Fairfax County Fire and Rescue Department ambulance, and, with Harley at her side, she is taken to Mount Vernon Hospital, where she will stay the night. She will be fine.
"A pretty routine case," Scott said later. "Something like that could keep us away from a serious accident where there are people who urgently need our help."
Serious accidents, in fact, are the incidents that cause rescue workers the greatest stress, Scott said. He recalled occasions when, arriving at automobile accidents, he was immediately confronted with a life-or-death decision.
"There might be two cars there and you know you only have time to pry loose the people in one. You have to look and say, 'These ones aren't going to make it and go help the others who still have a chance.'"
There are times, Scott said, when he is haunted because he is able to pull someone from death. "What if I save this guy and he uses up all his savings [on hospital bills], and then he dies anyway, or becomes a vegetable? Who am I to play God?"
Accidents become especially haunting when there are children involved -- one of the primary causes of critical-incident stress. Summers, in a separate interview, recalled a case where a child died in his arms from breathing difficulties caused by a severe case of influenza. "I just kept running the call over and over in my mind . . . . A week later I just broke down," he said.
Summers said admitting to an emotional crisis goes against the code of the rescue profession -- even the most gruesome incidents are not supposed to leave you emotionally upset. "It's the macho image. In reality that does more harm than good . . . . You keep stuffing these things in the closet and eventually the door will fly open."
If certain key incidents leave paramedics particularly affected, however, Scott conceded that one of the factors leading to the stress he feels is the desensitization that comes with the job.
"I've been at accidents where someone has died and everyone is crying. And I just look at the person and say: 'Yeah, he's dead.' . . . I feel like, 'God, why don't I feel sorry for that person? What right do I have to be happy?'"
Zeman agreed. "After a while, a heart attack becomes just another heart attack."
Then there are women like Anna, the second call that came in shortly before 10 p.m. Although a severe case of pneumonia leaves her barely able to breathe, she screams in terror between gasps at every step Scott and Harley take to help restore her breathing. She also demands that she be taken not to Mount Vernon Hospital, but to Alexandria Hospital, 15 minutes farther away. "A lot of times people don't seem to appreciate that you are trying to help. It's frustrating," Scott said.
When talking about their jobs, most rescue workers say that, in between the frustrations, they feel a real joy in helping people. "There are times when you know that you've saved someone's life -- and that's a great feeling. That justifies the whole thing right there," Scott said.
"Most [rescue workers] are very committed to what they do . . . . Most are risk takers and achievers who enjoy their work," Mitchell said.
For every horror story, most paramedics have a triumph to match. Summers recalled several years ago when he revived a 3-year-old who had passed out after being unable to breathe. "By the time we got her to the emergency room, she was kicking and screaming, and everyone's face was smiling. Every year on her birthday her parents send me a birthday card."