The nightmares still sometimes rouse Brian Cristofono from sleep.

Even now, nearly two years after the last calls for help came in, ghosts from his days as a firefighter and paramedic are tough to shake. Babies he couldn't save. Parents he struggled to comfort. Crash victims beyond reviving.

"They leave scars," said Cristofono, 42. "The job can really just be a dark look at life."

Traumas from his job — the one he dreamed of getting as a kid — led to a severe post-traumatic stress disorder (PTSD) diagnosis, costing him his marriage and causing him to retire from the St. Paul Fire Department in 2017. During his 13 years on the job with various departments, he said three colleagues killed themselves. Twice, Cristofono put a gun to his own head.

As troubling trends related to PTSD and suicide among firefighters come to light, officials in Minnesota and beyond are intensifying their push to raise awareness and lobby for more resources to help firefighters deal better with stress and trauma.

Research has long focused on the link between PTSD and suicide, but recent studies are calling attention to the increased risks that firefighters face.

Researchers estimate that anywhere from 7 to 37 percent of firefighters have PTSD. A study from Florida State University found that nearly half of firefighters have had suicidal thoughts and that about 1 in 5 have made plans to take their own lives.

But fire officials say they face a tough battle even as they sound the alarm for broader networks of support. They point to a work culture that overwhelmingly views treatment as a sign of weakness, and a broad lack of funding for education and services.

"People are losing their lives in these battles, and nobody is there to help them," said Eden Prairie Fire Chief George Esbensen, president of the Minnesota Firefighter Initiative (MnFIRE), a new nonprofit working to address mental health, cancer and cardiovascular disease in the fire service.

As momentum builds for change, Cristofono has become a leading voice for what he describes as a "silent epidemic."

Over the past year, he's spoken to lawmakers, leaders in the firefighting community and local fire departments across the metro.

Slowly, Cristofono said he's seen perceptions about behavioral health begin to change.

"Departments are calling me," he said. "They want to do something."

Firefighters are busier than ever, even as the number of fires in Minnesota has dipped in recent years.

Calls coming in to fire departments across the country have tripled since 1980, with nearly two-thirds seeking medical aid, according to the National Fire Protection Association.

But fire officials cite a lack of resources and funding as key challenges facing local departments. "Minnesota has a horrific track record on supporting its fire departments," Esbensen said.

Nationally, Minnesota ranks 45th in state and local government spending on fire protection, according to the Minnesota Center for Fiscal Excellence.

Fire service advocates have taken their plea to the State Capitol, where the ongoing fight includes a bill to make it easier for firefighters diagnosed with PTSD on the job to get workers' compensation.

MnFIRE also recently trained 40 firefighters as peer support counselors to oversee a new help line, 888-784-6634. Since January, they've fielded nearly 20 calls related to emotional trauma.

Some callers had a suicide plan ready and phoned the help line as a last call, Esbensen said. "I think the slow, little drops are starting to mount up," he said.

Longtime paramedic and former Woodbury firefighter Chris Caulkins studies suicide among emergency responders. He said 10 of his colleagues have taken their own lives.

"We get a front-row seat to all the atrocities and horrors of life," said Caulkins, emergency medical services program director at Century College in White Bear Lake.

It's why Cristofono's work in sharing his story is so crucial, Caulkins said: "He is a champion for the cause of bringing awareness to psychological trauma."

From Brooklyn Park to Maple Grove and Plymouth, Cristofono has recounted his struggles and talked of what pushed him into retirement. On a chilly March evening, he stood inside a West Metro Fire-Rescue District station in New Hope and relived the calls he just couldn't shake.

He told of a mother grabbing him by the chest, begging him for news of a baby he already knew was dead. He talked about a nurse doing chest compressions on an infant's lifeless body as a grieving family awaited a priest.

He described nightmares involving his own children and the dark feeling that he cannot save them.

But Cristofono didn't want to leave his listeners in gloom. So he ended by stressing how far he's come, how he's going to school to become a registered nurse, how his kids and fiancée mean everything to him.

Therapy, he said, has helped. The nightmares find him less often.

Cristofono wants his peers to recognize the warning signs for PTSD, so he gives his talks alongside Margaret Gavian, a Minneapolis-based psychologist who specializes in trauma and works with MnFIRE. Gavian finishes the sessions by telling listeners about symptoms and ways to get help.

She puts her contact information on the projection screen, encouraging them to reach out if they're struggling.

In New Hope, a few firefighters asked questions, but the room was mostly quiet by the end.

Gavian collected her things to leave. But before she could get out the fire station door, a man caught her attention. He had sat silently through the session, but there in the entryway he quietly asked for her card.

Hannah Covington • 612-673-4751