"When everything happened, big trays of pizza were left out on the counter in the cafeteria," Dillon explained. "Over the next week while we processed the scene it began to rot and smell really bad, and it blended with the other unfortunate smells, like blood just down the hallway - the smell of evil. After that, anytime I'd smell pizza, it would take me back to that time."

During a 30-year career as a volunteer firefighter and emergency medical technician, paramedic and police officer, Dillon had seen "the worst of the worst - plane crashes, burned bodies, terrible car accidents," he said. "Sandy Hook was the straw that broke the camel's back."

Plagued by anger, disbelief, sadness and flashbacks, Dillon withdrew from everyone. He carried his gun all the time so that he would be prepared if there was another attack. His world started to unravel. He began drinking too much. He and his wife divorced. After being arrested for driving while intoxicated, Dillon realized he needed help. He was suffering from post-traumatic stress disorder (PTSD), a mental illness associated with anxiety, agitation, fear, nightmares and the feeling of another tragedy looming everywhere.

In the nation's firehouses, hospitals, call centers and police stations, many first responders are struggling with PTSD wrought by both the everyday deaths and tragedies encountered on the job and a national epidemic of mass shootings, from Connecticut's Sandy Hook and Florida's Marjory Stoneman Douglas High School to a Walmart in El Paso, Texas, a bar in Dayton, Ohio, and a garlic festival in Gilroy, California.

First responder Ken Dillon with his dog, Murph. Dillon says he credits his recovery from post-traumatic stress disorder to self-awareness, professional help from doctors, and support from his peers and his agency. Photo by Eva Deitch for The Washington Post

"We rush into burning fires or deal with the worst injuries - that's our job, it's what we're trained to do," Dillon said. "But we're also human, and sometimes our brains can't compute the horrible things we see."

According to a 2015 national survey of over 4,000 police officers, paramedics, emergency medical technicians and firefighters, emergency workers are 10 times more likely to attempt suicide on average than another person - roughly 6 percent of those surveyed had tried to take their lives. A more recent survey of Virginia first responders similarly showed a heavy psychological toll.

New survey shows heavy psychological toll for Virginia first responders

A growing number of states, including Colorado, Texas, Vermont, Louisiana, Minnesota and Connecticut, have recently passed legislation to provide workers' compensation for first responders suffering from PTSD.

While the bills offering benefits have been heralded as victories for responders, they have also been criticized for being too restrictive, denying benefits to some vulnerable medical service personnel. For example, a bill passed in Connecticut in May provides benefits to police, fire and parole officers, but it excludes coverage for EMTs, paramedics and dispatchers. Critics of the bill say it also failed to consider the cumulative effect of tragedies to which the first responders were exposed. As the bill stands, a mental health professional must conclude that PTSD is the direct result of a certain qualifying event. For example, viewing a deceased minor, experiencing the death of a person, or witnessing a traumatic injury that causes the loss of a body part or vital body function.

Psychologists define a traumatic event as a situation in which a person experiences or perceives a threat of death or injury for themselves or others, causing stress and feelings of fear, helplessness and hyper-vigilance.

"These are normal reactions to an abnormal circumstance," explained Laurence Miller, a psychiatrist in Boca Raton, Florida, who often treats first responders dealing with mental trauma. "These mass shootings, especially when children are involved, that's when you see [first responders] break down," Miller said. "We all identify with children being slain. You see these people go numb and withdraw, they develop a lack of motivation, they second-guess themselves. If they've used alcohol as a coping mechanism in the past, they might abuse it."

Jill Barron, a Yale University psychiatrist, has worked with first responders after both 9/11 and the Sandy Hook massacre. She said first responders work in a hero culture, where broken bones and scars are considered battle wounds, while mental injuries are a sign of weakness. "They're dealing with trauma after trauma after trauma while being told to suck it up, toughen up," she said. "The attitude is push it down and move on."

In a 2017 University of Phoenix survey of 2,000 first responders, nearly 40 percent said they would face negative repercussions at work for seeking mental health services.

Gerry Realin, a retired Florida police officer, said he has experienced such repercussions firsthand. Realin worked on the hazmat team that responded on June 12, 2016, to the Pulse nightclub in Orlando, where 49 people were fatally shot and 53 others were injured. After spending nearly five hours inside the club identifying, moving and body-bagging the bullet-riddled slain victims, Realin couldn't stop having nightmares and flashbacks. The sight of a white sheet, used at the scene to cover the corpses, still takes him back to the scene. "My wife doesn't buy white anymore," Realin said. "All our blankets are blue."

Realin retired on disability but is locked in a legal battle with the city of Orlando over health costs related to his treatment. (Orlando city public information officer Karyn Barber said the city "is committed to the health and well-being of our first responders" and that Realin "is receiving all benefits for which he is eligible.")

At the time of the Pulse shooting, Florida did not provide workers' compensation for such mental health injuries as PTSD without an accompanying physical injury, though it does now, spurred in part by the Marjory Stoneman Douglas High School shooting in February 2018, in which 17 students and staff were killed.

Troy Anderson, a former Connecticut state police sergeant who responded to the Sandy Hook shooting and subsequently led the effort to create Connecticut's State Troopers Offering Peer Support (STOPS) program providing officers with confidential peer counseling services, said new laws in Florida, Connecticut and elsewhere that provide benefits to first responders suffering from PTSD will help a lot of people.

However, he said he thinks there needs to be a cultural shift to provide emergency workers support long before they're exposed to traumas that can cause PTSD. "At the [police] academy, you spend forever learning how to make your bed and do a hundred pushups, but there needs to be training for how to take care of your mental health, because tragedy is going to happen," he said. "If you are educated ahead of time, you're going to say, I know what this is - it's post traumatic stress - and I know what to do, and I know it's okay to get help."

Dillon credits his recovery from PTSD to self-awareness, professional help from doctors, and support from his peers and his agency. "You can't delete PTSD, you're never completely cured, but you can learn to combat the symptoms and the triggers in a healthy way," he said. "The old me would have a beer. Now I talk it out with somebody, or go for a hike."

It's important for first responders to remember that it's normal to have a mental response to tragedies, he said. "We're all human. We all have emotions. And we can smash the stigma so people aren't afraid to talk about it."

This article was written by Rene Ebersole, a reporter for The Washington Post.

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First responders struggle with PTSD caused by the emergencies, deaths, tragedies they face every day - Brainerd Dispatch