The day a gunman fired into a crowd of 22,000 people at the country music festival in Las Vegas, hospital nursing supervisor Antoinette Mullan was focused on one thing: saving lives.
She recalls dead bodies on gurneys across the triage floor, a trauma bay full of victims. But "in that moment, we're not aware of anything else but taking care of what's in front of us," Mullan said.
Proud as she was of the work her team did, she calls it "the most horrific evening of my life" -- the culmination of years of searing experiences she has tried to work through, mostly on her own.
"I can tell you that after 30 years, I still have emotional breakdowns and I never know when it's going to hit me," said Mullan.
Calamities seem to be multiplying in recent years, including mass shootings, fires, hurricanes and mudslides. Just last week, a gunman burst into the newsroom of the Capital Gazette in Annapolis, Md., killing five journalists and injuring two others.
Many of the men and women who respond to these tragedies have become heroes and victims at once. Some firefighters, emergency medical providers, law enforcement officers and others say the scale, sadness and sometimes sheer gruesomeness of their experiences haunt them, leading to tearfulness and depression, job burnout, substance abuse, relationship problems, even suicide.
Many, like Mullan, are stoic, forgoing counseling even when it is offered.
"I don't have this sense that I need to go and speak to someone," said Mullan. "Maybe I do, and I just don't know it."
In 2017, there were 346 mass shootings nationwide, including the Las Vegas massacre -- one of the deadliest in U.S. history -- according to Gun Violence Archive, a nonprofit organization that tracks the country's gun-related deaths.
The group, which defines mass shootings as ones in which four or more people are killed or injured, has identified 159 so far this year, through July 3.
The "first responders" who provide emergency aid have been hit hard not just by recent large-scale disasters but by the accumulation of stress and trauma over many years, research shows. Many studies have found elevated rates of post-traumatic stress disorder among nurses, firefighters and paramedics. A 2016 report by the International Association of Fire Fighters found that firefighters and paramedics are exhibiting levels of PTSD similar to that of combat veterans.
Experts have found a dearth of research on treatment, insufficient preparation by employers for traumatic events and significant stigma associated with seeking care for the emotional fallout of those events.
"When we have these national disasters or have a guy take a truck and run people over ... those are added stressors we aren't prepared for," said Jeff Dill, a former firefighter and licensed counselor.
Dill said the emotional toll of these large-scale horrific events is magnified because everyone is talking about them. They are inescapable and become emotional "trigger points."
"Anniversaries are the hardest," he said.
Some employers are working on developing greater peer support, he said, but it often comes after the fact rather than proactively. "We met a lot of resistance early on because of the [stoic] culture," said Dill, who travels the country teaching mental health awareness workshops for firefighters and other emergency personnel.
He said the culture is slowly shifting -- particularly because of the rise in mass public shootings across the country.
'I Was Scared'
In 2015, Gary Schuelke, a police watch commander, raced to the scene of a holiday party in San Bernardino, Calif., where he and his fellow officers faced a fusillade of gunfire from a pair of homegrown terrorists.
He'd seen a lot on the force over the years, but this call was different -- and not just because of the numerous casualties. His son, a young police officer, was there with him.
Schuelke and his son, Ryan, chased the assailants' car as the bullets whizzed by. It was the younger Schuelke's first time exchanging fire with suspects.
Afterward, when both were safe, "I asked him, You doing OK?" Gary Schuelke recounted. "If you're not, it's cool. You can talk to me about it. He said, 'I'm good, Dad. I'm very happy to be part of taking down the bad guys.'"
Ryan was "just like I was when I was in my 20s ... chasing bad guys and making arrests," the elder Schuelke said. He said he had decided early in his career to try to "compartmentalize" his work experiences so they wouldn't affect his personal life.
Still, certain calls have stuck with him. Like many first responders, he is particularly affected when kids are hurt or killed. He still recalls his first homicide, a 13-year-old girl shot in the hip.
"She bled out and took her last breath right there in front of me," Schuelke said. "That was the first time I was like, man, this job is real."
Generally, no one focused on officers' mental health back then, he said, but experience has taught him how important it is to do just that. After the 2014 terrorist attack, which left 14 would-be revelers dead, his department quickly set up a "debriefing" meeting for the officers involved.
"I made it a point in that meeting that I was going to talk about the fact that I was scared," said Schuelke. "Not try to be macho in there and act like nothing bothered me about it."
In 25 years as a firefighter, Randy Globerman was called upon time and again to cope with other people's traumas and disasters. He never really took account of how the experiences affected him.
"You spend all your career suppressing that stuff," he said.
Then came the Thomas Fire, considered the largest in California's history, which decimated hundreds of homes in Ventura and Santa Barbara counties. As his fellow firefighters were deployed to save what they could of their community, Globerman faced the real prospect of losing his own home.
For 36 hours, armed only with a bucket and water from his Jacuzzi, he fought to keep the flames back. He was frantic. "I was kind of a mess," said Globerman, 49. "I felt sick, I felt sad. I went through all sorts of crazy emotions."
In the end, he was successful -- his home survived -- and he went back to work, responding just months later to mudslides from the denuded, rain-soaked hills.
But Globerman struggled emotionally, and, as experts say is often the case among first responders, it affected his family life.
"My kids would do something silly that would otherwise make me laugh, but instead I would start crying," he said.
He experienced several episodes in which he felt as if he was having a heart attack. "It would come out of nowhere," Globerman said. "I felt like I was losing my mind."
He thinks now that his own near disaster unleashed "demons" he didn't even know he had from incidents throughout his career. And he felt he couldn't ask for help.
"A lot of the support you'd get from a normal incident wasn't there," he said. "Other than a few people, everybody worked on the fire for about a month straight."
He struggled through it on his own. Anxiety medication seemed to help. He said he's not proud of having used it, but "after five months, I can honestly say that the demons don't seem to bother me anymore."
Mullan, the Las Vegas nurse who did not seek counseling, said she is not sure she has "processed" the mass shooting almost a year later.
"Certain things trigger emotions that I didn't expect," Mullan said.
At a recent luncheon she attended, victims from the shooting shared their stories.
"It hit me like a ton of bricks," Mullan said. "And, yes, I did cry."