After Orlando Shooting, First Responders Grapple With Psychological Toll

— -- When EMT Julio Salgado arrived at Orlando's Pulse nightclub in the early morning hours of June 12, he saw rows of wounded bodies as law enforcement officers dragged victims out of the building — later telling ABC News he's "never been on a scene like this before."

There were no medics or emergency personnel allowed inside the nightclub at that time, because the gunman was still firing. So Salgado and his EMT crew approached the injured victims outside with a backboard and stretcher, ducking down behind a shotgun-wielding officer.

"It was like a war scene," Salgado said. "It was load and go. Just get them out of there."

First responders train for mass casualty events like the Orlando shooting that left at least 49 people dead, making it the worst mass shooting in recent U.S. history and the deadliest attack in the country since 9/11. Despite their training, some struggle with the psychological impact that follows.

Police officers who responded to the shooting were immersed in utter chaos and darkness when they first entered Pulse. The only light came from a spinning disco ball that revealed a dance floor covered in blood, bodies and bullet casings, the officers told ABC Orlando affiliate WFTV.

Screams and gunshots echoed inside the nightclub as they looked for survivors and tried to stop the shooter. Patrons were running out of the building with open wounds, trying to escape. The officers told WFTV they went through the club “going one-by-one, pulling (victims) up and checking for pulses."

Once the Adrenaline Wears Off

Survivors, family members and friends are all at risk of emotional trauma following a mass shooting like the one at Pulse. For first responders, and the nurses, doctors, and surgeons who raced to the hospital to treat victims, that psychological impact can be especially intense, experts said.

“Once that adrenaline wears off and the muscle memory goes away, how do you deal with the effects of that?” Jason Marquez, President and CEO of First Response Training Groups in Orlando, which offers EMT and paramedic certification programs, told ABC News.

Marquez’s school for EMTs and paramedics sent more than 40 students and even more alumni to the scene of the Pulse shooting. Many of the students were dispatched specifically to tend to the families of victims in the immediate aftermath of the shooting — doing everything from bringing them pizza to offering prayers and someone to communicate with.

“We assigned one student to each family,” Marquez said. “If they want to sit there in silence, we’ll sit in silence. If they want us to pray to whatever God you want to pray to, we’ll do that.”

Recognizing that his students would need this type of support as well, he explained that his school held a gathering the day after the tragedy to provide a forum for people to talk and listen and process their experiences. He said communication is key to manage stress following such an event.

Dr. Daphne Simeon, an assistant professor of psychiatry at the Mount Sinai School of Medicine, stressed that “everyone has to process in their own way,” adding that no one should be forced to participate in structured group interventions.

“The major predictive factor is social support. It is incredibly effective,” said Simeon. “So, part of the acute interventions is discussing [one's] social network and enhancing it.”

The Long View

Dr. Louise Buhrmann, a psychiatrist in Orlando, is helping coordinate counseling efforts for the Pulse shooting with the Florida Psychiatric Society. She has been referring patients to the Zebra Coalition, a local LGBT-plus organization, where mental health volunteers are offering counseling.

So far the calls have come primarily from local residents who observed the shootings or have been following them on the news, but Buhrmann said she believes they will hear from more victims and first responders as time goes by.

“There will still be the people who were more involved [in the rescue]; they have been too busy to care for themselves,” she told ABC News. ”Problems can crop up at any time, people with previous trauma events can be reactivated."

Tony Colombrito, a professional counselor and American Red Cross disaster mental health volunteer, echoed this sentiment that reactions emerge over time. Colombrito was deployed to Sandy Hook Elementary School in Newtown, Connecticut, within hours of the December 2012 mass shooting there. He spent about a week providing support to first responders, victims’ families, and residents in the town.

He said some first responders wanted an ear to listen, while others needed a hug.

“Most didn’t want to talk about what they saw,” he told ABC News. “There’s the shock, but afterwards is when I think the real encounter with what happened starts to manifest.”

Dr. Matthew Levy, an emergency medicine physician at Johns Hopkins, said stigma may prevent first responders from seeking care. Levy was a first responder during the 2014 Columbia mall shooting, as well as serving as a paramedic on 9/11 and during Hurricane Katrina in 2005.

Levy said the most effective way of helping first responders is to train them to recognize distress in their peers.

“They are not alone. There may invariably be a moment when they feel like they are alone but they are not,” he told ABC News.

Resilience

David Kaplan, the chief professional officer at the American Counseling Association and a former first responder, said emergency personnel are trained to put their feelings aside in order to do their job and save lives. The problem, he said, is allowing themselves to feel after they have done their job so that they can process the experience and heal from it.

“I can tell you from my experience, the absolute most difficult thing was seeing a dead person,” Kaplan told ABC News. “The first overwhelming feeling I had was the need to go home and take a shower, that I just needed to go home and wash it all off me.”

Not all first responders will need counseling or will suffer from psychological disorders after responding to a mass casualty event like the Orlando shooting. Dr. Patricia Watson at the National Center for PTSD said most emergency personnel will recuperate mentally on their own over time.

“They might be exhausted and they might be shaken, but it doesn’t mean they need treatment or that they’re going to go on to have a disorder,” Watson said. “These are people who are trained to go toward danger.”

But it’s important for their peers to remain vigilant in offering support months down the road, while also providing options and giving them control over their recovery.

“It’s very, very important for them to feel in control of what happens next,” Watson said. “If they feel like it’s better for them to be on the job, then that should be respected.”

Salgado, the Orlando emergency medical technician, said he doesn’t know whether the two victims he transported to the hospital survived the shooting at Pulse because he never got their names. Wiping tears from his eyes, he told ABC News he’s had trouble sleeping since that night.

“Don’t get me wrong," Salgado said. "This is what we work for and train for."

Dr. Amy Glick is a psychiatry resident at Mount Sinai Hospital. She is currently a resident in the ABC News Medical Unit.