In Bakersfield, Calif., a dispatcher pleads with a nursing home worker to perform CPR on a dying patient or find someone who will. In Hillsborough County, Fla., fire and rescue workers rush to evacuate a house after a killer sinkhole swallows one of the bedrooms. In Kansas City, Mo., firefighters spend a hellish night fighting a deadly explosive fire in a popular restaurant.
Such stressful exposures come to the nation's emergency responders every day. And in many of the more than 33,000 departments, the most horrendous events bring a "debriefing" or an after-action review - a chance for crews to talk about what they saw and did, usually in the company of at least one mental health counselor.
But in the years since the Sept. 11 attacks and the aftermath sustained by firefighters and other emergency workers, fire service officials and mental health consultants have been looking for new approaches to give psychological support.
Last week, at an international conference in Baltimore, the National Fallen Firefighters Foundation introduced a new model for behavioral health care among emergency responders. It's based on the concept that no two firefighters will have the same reaction, even to the same event.
"One person's critical incident is another person's day at the office," said Dr. Richard Gist, principal assistant to the director of the Kansas City Fire Department and behavioral medicine specialist at the Kansas City University of Medicine and Biosciences. He helped write the new model.
"We realized that not all firefighters want or need to sit in a room immediately following a distressing situation and talk about their experiences," said Ronald Siarnicki, executive director of the foundation. "Instead, they want to know what resources are available to them and their families and how they can access those resources when necessary."
How to address professional counseling for those in stressful jobs has long been contentious among experts, with many discounting "critical incident stress debriefings" in recent years, instead turning to peer support or informal support networks as a first line of intervention.
The new model emphasizes that fire and EMS company officers - volunteer or professional - should regularly assess the reactions and behaviors of their crew members and notice if they change.
"One of the cornerstones is to know what going on in a person's life - that if their wife's pregnant and they respond to a call that involves a stillbirth, that's potentially more stressful for them," said Patricia Watson, a researcher with the National Center for Post Traumatic Stress Disorder who also worked on the new care model.
"We don't want interventions that are driven by events, we want an intervention that is driven by changes in people's reaction and functioning," she added. Watson and others stressed that they're not advising against professional counseling, just that it not be the first or only response.
One study by researchers at the Johns Hopkins Bloomberg School of Public Health found that protective service workers who are repeatedly exposed to traumatic events - and are new to the job - are most at risk for developing psychiatric disorders.
The research, based on national survey data and published last month in the journal Disaster Medicine and Public Health, suggests that those in the first years of their careers are most at risk for mood, anxiety and alcohol disorders and that interventions should be specially targeted to reach that group.
Emergency dispatchers who answer 911 calls can also suffer emotional distress and PTSD. A survey of 171 dispatchers by researchers from Northern Illinois University found that nearly a third experienced some level of traumatic distress during or after an event, and more than 3 percent had symptoms severe enough to qualify as PTSD.
They identified the worst, most stressful calls as those involving injury or death of a child, calls from suicidal individuals, shootings involving police officers and the unexpected death of an adult.
Gist said dispatchers also could face work-culture issues because some may be part of the fire service while others may work for law enforcement agencies. To deal with stress, Gist said, first responders "need to work with people who come out of the same organization, and interact the same way, to deal with trauma."