Nancy Thompson, 32, teared up instantly at the memory.
The first responder knew a train had collided with a school bus in Larimore, N.D. She knew there might be injuries.
She and her husband-also a first responder and a firefighter-were among the first emergency personnel at the scene. The train conductor, engineer and a few homeowners who lived near the crash site were the only others present.
It was one of her worst nightmares come true, she said.
"It was chaos," she said.
But despite her initial shock, she had a job to do, she said. Thompson, who was four months pregnant at the time, had to pronounce the bus driver, Max Danner, 62, and Cassidy Sandstrom, 17, dead. A dozen other children, ages 5 to 16, were also injured in the crash. An investigation attributed the cause to driver error.
"We knew the parents and the kids, and I knew the bus driver personally from the school," she said.
Once she returned home, she hugged the first person she saw-fellow first responder Nichole Jorgenson, Thompson said.
This accident was extreme. But the ongoing stress of the job-especially after treating familiar faces-wears on first responders and leads to burnout, some responders said. Coupled with recruiting struggles, this poses a significant threat to a state that sees fewer volunteers.
In 2011, 86 percent of emergency personnel were volunteers in North Dakota, according to a state rural emergency services report. Today, it's 76 percent, according to the state Department of Health.
Estimates of other states vary, with some officials saying 80 percent of emergency personnel volunteer nationwide. In Minnesota, about 60 percent of emergency personnel and paramedics volunteer for the state's ambulance services, according to a news report.
First responders often turn to each other or the North Dakota Critical Incident Stress Management program to work through stress, but the program often goes unused, said Kari Kuhn, an administrative support supervisor for CISM.
"First responders are used to doing what they need to do," she said. "They don't always consider themselves as needing help."
Crisis team assistance
Crisis team members provide first responders with first-level counseling, Kuhn said.
The CISM team is volunteer-based, located across the state and consists of mental health workers, clergy and other emergency workers who meet with first responders and provide follow-up later if necessary. Members get paid mileage and meals for travel.
"A lot of times it's a one-time thing, and also to find out if (first responders) are seeking professional help," she said.
On average, the team responds to calls about three times a month. This doesn't necessarily reflect the need, though-first responders can be reluctant to ask for help, and the western part of the state is particularly silent, but "they're also really busy," Kuhn said.
Several who responded to the call in Larimore-an effort that included five from Altru Ambulance Service, local firefighters and other emergency personnel-debriefed with each other at the scene. It's unclear how many used the CISM team.
Finding volunteers for the state CISM team is tough, especially as the service isn't used every day. That makes it hard for newly-trained personnel to feel comfortable in that role, Kuhn said. The ability to offer training sessions depends on state and federal funding, and even the state crisis program doesn't receive automatic funding, she said.
"People don't necessarily think of those first responders as ones that need help, because there is no proof of the help --- there is no way to measure effectiveness," she said. "But if they were all gone, what would people do? We need them out there. Not everybody wants to be in that job. It's a tough job."
Someone to talk to
Dozens of emergency personnel from the area responded to the accident in Larimore.
Jorgenson, 31, was among them. She had arrived on the scene just as the last ambulance pulled out, and she assisted the injured and made sure the crew was physically and mentally OK, she said. The response was among the best they'd had, she said.
Jorgenson and Thompson, who live in Larimore, are among 10 to 15 active first responders in the area. They're also among a few who can offer advanced life support assistance.
As they talked to the Herald in March, U.S. Sen. Heidi Heitkamp, D-N.D., along with Alejandro Mayorkas, deputy secretary for the Department of Homeland Security, stood a few feet away. Speaking before several first responders at the fire hall, Mayorkas and Heitkamp wanted to hear about the challenges they face and asked for ideas on how to better serve the national emergency community.
First responders in Larimore frequently get calls from elderly residents, mostly regarding heart attacks or respiratory difficulties, Jorgenson said. But they must be ready for anything and be able to shut down their emotions in an instant-an ability that's part self-discipline and part personality trait-and that narrows the candidate pool. High stress, low pay and being constantly on-call can also make the job less appealing, they said.
"There are so many volunteer services around the state, some are closing their doors because they don't have enough volunteers," Jorgenson said.
But in Larimore, every emergency call comes from a familiar face. Jorgenson and Thompson know nearly every resident by address and feel like they're caring for family, which also makes their job more meaningful, they said.
Members of Jorgenson's family also hold emergency personnel positions, so "it's in her blood," she said.
"There's definitely tough aspects of it, but good aspects make up for it," she said.
Knowing they ease the fear or pain someone at a time of need is one of the most fulfilling parts of the job, they said. But sometimes, a simple act can make the biggest difference for first responders and the people they help.
"The best thing is having somebody say, 'Thank you for helping me through this,'" said Jorgenson. "Sometimes, somebody just wants someone to talk to."