Some of my favorite bloggers like Rogue Medic, Ambulance Driver, Under the Lights, and Greg Friese have been discussing the topic:

"Should EMS Be Allowed to Carry Concealed Hand Guns on the Job?"

While as a rule, I try not to discuss politics, religion or guns in the interest of getting along, after thinking about it, I decided to share some of my thoughts on the topic.

First off, here are my gun credentials.  I don't have any.  I do not own a gun.  The last time I shot a gun was in YMCA camp when I was 12 and I earned a sharpshooter’s first class certificate with a 22 rifle.  I have never fired a handgun.

Perhaps I exhausted my gun desires during the cowboy phase of my early years.  There are many childhood photos of me with double  holstered cap guns drawn and firing.  I shot many an evil hombre with them, and once, unfortunately, I El-Kabonged a neighborhood friend with one of them during a play fight when I had not yet learned that there was a difference between cartoon violence and real violence.  I hit my friend in the head with my gun.  Hard.  His skin split open and out grew a lump just like in the toons, but unlike the toons, my momma got a phone call from my friend’s momma and I ended up getting grounded for a week, in addition to being spanked, back when spanking was not considered child abuse.

Today one of my best friends is a gun guy.  I would not call him a nut as I have great respect for his wisdom and judgment, particuarly on medical issues.  But I have been with him several times when he has visited with fellow gun aficionados.  These meetings tend to startle me.  Out of car trunks and boxes in closets and even desk drawers, these gun friendly folks always seem to produce all kinds of weaponry from German Lugars to assault rifles, which they pass around freely for admiration.  For someone who is not comfortable being around guns, it is quite an experience to behold, like suddenly feeling like you are the only human among an alien race or perhaps, maybe I am the only one from another planet, and I am just an outlier among red-blooded American males.  Sorry, I say, I’m good.  You can go on bogarting the 9 millimeter.  I don’t partake.  Curiously one day of my friend’s gun buddies called him up and asked my friend to come over to the buddy's house and take his guns away (just temporarily) as he was having some difficulties with his girlfriend at the time and did not want the guns there should he feel any sudden angry impulses toward her.  I am uncertain if this is an example of responsible gun ownership or a reason to fear gun ownership.

For several years, I had a rifle in my apartment within reach of my bed as well as a handgun in the nightstand.  When my college girlfriend and I moved to a not the best neighborhood apartment complex in Arlington, Virginia, which at the time was all we could afford, her father gave us the guns which had belonged to her recently deceased grandfather.  He said he felt safer knowing we had them for protection.  I don’t even know if they worked or would have fired if I had pulled the trigger on an intruder. I don’t even know if the guns were registered or in Virginia, if they needed to be.  I know I should have at least taken them to a range and fired them a time or two, as well as taken a gun safety class.  But I didn't. Fortunately, I never needed them. I shot no one and no one shot me.

I developed some rules about guns over the years.  Never date a woman who owns a gun (and unlike my girlfriend  at the time (a gentle soul) knows how to shoot it). Also, never date a woman who’s last boyfriend owns a gun.  I do read the papers and know the "one in the head two in the heart" slogan, (or is it "two in the heart, one in the head").  And I have been on more than a few gun violence calls in my years, including one where the shooter ignored the above rule and got a little more personnel.  “My Dick! My Dick!" His victim cried.  " He shot me in the Dick!”

I try to think back on all my years in EMS including many in a city with one of the highest murder rates in the nation (the violence seems to be largely directed at rival drug gangs and people who looked at them or their girlfriends the wrong way or innocent bystanders who were standing on the street corner doing nothing at 2:00 A.M. or innocent bystanders who were on their way to grammer school or even babes in their mother's arms) and try to imagine when if any time a concealed weapon would have benefited me or whether or not I would have ever been tempted to pull it or shoot someone.

I did recently watch a rather chilling ESPN movie about a high school basketball star in Chicago (Ben Wilson who was the number #1 prospect in the nation) who was gunned down near his school one day back in 1984.  At the time, it was reported that he was a victim of a mugging.  In the movie however, they interview the shooter, who claimed he had taken his father’s handgun and gone out to try to get ten dollars back from a friend who had had it ripped off from another friend.  His story is when when he got there, the debt had already been settled, so he was just hanging out in front of a store with the gun still in his pants when the basketball player walked by and accidently bumped him.  When he shouted at the player to show some respect, the player turned and belittled him.  Words were exchanged.  It was then, the boy showed the gun in his pants.  But instead of having its intended effect of scaring off the taller boy, the ballplayer laughed at him and said, “What are you going to do shoot me?” And walked towards him.  The boy recalled his father saying that if you ever drew a gun, you would need to be prepared to use it, since he had just then suddenly drawn the gun, he was already at that point.  Boom!  Boom!  Boom! Two lives changed in an instant.

It is impossible for me to think of drawing a gun and then using it if the draw didn’t prevent the episode.  And in EMS it is hard for me imagine drawing on a rational person, of which we encounter so few.  Again, I am not gun-trained so I would have no business carrying a gun much less drawing it. But if I was qualified, I still have a hard time imagining it.

I have been lucky in that most of the violence against me has been from demented old ladies, hypoglycemics, and a few crazy people on PCP.  I am also lucky that I am both six foot eight, two hundred and twenty pounds and somewhat slow moving so that when I have been rushed and I have been, I have not appeared to be either aggressive or frightened.  I merely put my hands up, take a step back, and say, “Wow, Dude!”  I don’t project aggression.  I back off, I speak quietly and I never physically engage unless the patient is less than ten in which case, I can pick them up at arm’s length while they punch and kick, but are beyond the reach of my torso.  Maybe I have just been lucky.

Some of my fellow medics have gotten into wrestling matches, and I have jumped into the back of several ambulances in response to calls for help. Fortunately there have been enough of us, along with our trusty friends Ativan and Haldol to subdue the threats. But I wouldn't want to be wrestling if I had a gun on me, but then again, I don't even know where a concealed gun goes. In my boot? Up my sleeve? I am ignorant of these things.

I can't recall any EMS people being shot on the job around here.  I know one who was stabbed, but that was at very close range and by a psychiatric patient who grabbed the medic's own sissors and struck him in the leg.  I do know of ambulances being shot at and occasionally hit.  The last shooting I responded to involved a man who was sitting with another man in his car, doing a drug deal.  A man walked up to the car and shot the driver five times. The other guy got out of the car and walked away with the shooter. An ambulance crew driving down the street, heard the shots, ducked and then the next thing they knew they were getting T-boned by the shot man, who had put his car in gear and floored it.  The crew was okay and the man who had been shot five times, was lucky enough to survive himself. What if that crew had been packing? Would they have pulled their guns instead of ducking? Would one have attended to the patient while the other chased the bad men?

Many years ago in our city, a paramedic came upon a shooting as the gunmen sped away. The crowd pointed toward the car, and the paramedic seeing no one shot, (without getting out of his ambulance to check futher) immediately sped off after the get-a-way car, relaying information to the police over his radio. The police gave him a medal. His medical director almost yanked his medical control. It was quite a controversy that even played out in the newspapers. His fellow employees were not happy with him. I have always felt like we are without sides. We have free passes to wander through even the most dangerous areas. This made us targets. Not good.

I can recall a number of police officers being shot in the area.  Every one of them was ambushed, and several likely never knew what hit them.  Some officers have shot people who proved to be unarmed, which does not mean they did not pose immediate and deadly threats to the officers. And then there have been quite a few officers who pulled the trigger on themselves, sitting in their lonely cars, contemplating their lives gone adrift in an unpleasant world.

So given all of the above to show where I am coming from, it is no surprise that I would never carry a concealed handgun on the job.  I am clearly afraid of guns in most anyone's hands.  But how do I feel about others who are trained, rational and with quicker instincts and reflexes than my own carrying?  I do believe EMS has the right to protect itself and I believe in a safety first culture.  But let me ask this, Mr. Potential Gun Carrying EMT, how committed to safety are you?  How committed are your fellows in arms?

Do you always wear gloves when touching a patient?

Do you always wear your seat belt? In the back as well as the front?

Do you work out in the gym, stretching and strengthening?

Do you eat a balanced diet?

Do you smoke?

Do you get enough sleep?

Have you had a flu shot?

Do you wear a safety helmet on duty throughout the entire shift?

Do you stop at every intersection when going lights and sirens and look both ways.

Do you wear body armor?

Do you wash your hands after every patient contact?

I do all of the above except wear the body armor and get the sleep part, and the wearing the seat belt in the back part, and the safety helmet, and sometimes the glove part and the always stopping completely at the intersection part, and remembering to wash my hands after every call, although I do wash my hands fairly regularly throughout the day, as well as use those ubiquitous foams.

 If you do all these things, then you are committed to safety, and as long as you have taken the proper gun safety classes and feel you are not a threat to your patients, the public or yourself carrying a gun, then I might stop and listen to you explain why carrying a gun on you while treating patients is a good idea.

Peace and respect to all my brothers and sisters.

 

 

Thanks for all your responses to my post on Guns and EMS. A couple clarifications and further thoughts.

In Connecticut, where I practice, it is specifically illegal for EMS to carry weapons. Also, there are never supposed to be any weapons in the back of the ambulance. When we transport an injured police officer, his weapon is taken from him by other officers and secured elsewhere.

Connecticut is not a liberal gun state. We don’t see a lot of guns here, although we hear a lot of gun fire in the city. 16.2 % of our citizens own guns, ranking 46th in the nation. Curiously our death rate per person from guns statewide is also 46th. Hartford, on the other hand, is rated the 7th most dangerous city in the United States, more dangerous than New Orleans and Baltimore, but less dangerous than Gary, Indiana, and Camden, New Jersey.

http://www.morganquitno.com/cit05pop.htm

The distinction is somewhat of a misnomer as while dangerous, Hartford is also small. We respond to drug-ridden neighborhoods, and yet just minutes away in other towwns, we respond to quite proper white picket fence neighborhoods with low crime rates.

A difference, I think, in guns and EMS between us here in Connecticut and other parts of the country is perhaps that on most of ous EMS gun calls (suicides excepted), or ordinary calls for that matter, there are not a lot of guns on scene. I imagine in other parts of the country it is perhaps impossible to walk into a room or respond to a car accident where there is not a private gun within someone’s grasp. Not very likely in our state.

While I said I do not own a gun and am quite scared of guns, I am not opposed to gun ownership. I believe in an active government, but I do not believe in an obtrusive government. I will gladly pay taxes for the common good, but I don’t want government either moralizing for me or telling me I can’t own a gun if I choose to. No bazooka, I can understand, but not a hunting rifle or a personal hand gun for protection.

As far as any of my partners having concealed guns on duty, I am still against it. While I have trusted all the partners I have had over the years to varying degrees from complete trust to never let them out of my sight and never let them touch the patient lack of trust, having them also carrying a gun adds a new complicated layer. I still don't see a reason for it in our work. And, as I said before, I have trouble with the "I need it for safety" argument when on a risk/reward benefit, there are so many other things we can do to improve our's and our partner’s safety that few people use. I have always found it odd that so many young heroes I work with will strap on a bullet proof vest, but wouldn’t be caught dead wearing a crash helmet on the job when they are far more likely to be injured or killed from head trauma in an ambulance crash, than they are to be shot. I worked with one partner who even refused to buckle her seat belt while she drove (she connected the seatbelt and put it behind the seat, but oddly insisted on locking the ambulance anytime she went three feet from it because it was the rule that we were to lock it when unattended. To each his or her own, I suppose, although I argued, not wearing her seatbelt made her a danger to me should we roll over and she become a missle headed at me, where I was less concerned with our laptops being stolen.

Finally, in answer to the suggestion that my not being drawn on in 20 years is somehow a reason that therefore a cop should not carry a gun if he is not drawn on for twenty years, I can only say, our jobs are different. Let’s say they were to make a movie about a police officer and one about a paramedic. The policeman movie begins with the police officer opening a door to see a bad man drawing a gun. You have the beginning of an interesting movie. What is going to happen? How will the police officer get the man disarmed? How will the conflict resolve? Now make the same movie with the paramedic. I will happily play the role of the paramedic. I open the door, I see the man draw his gun. I close the door. Movie over. As the credits roll, you see me running down the street as fast as can. Please dispose of any empty popcorn and soda containers on your way out of the theatre.

Peace out. 

It Depends

 An emergency doctor friend of mine has a great lecture called “It Depends…” He says that for many EMS patient care questions he is asked, the answer is “It depends…:” But there are other questions where it does not depend, he points out. For instance, when your patient suddenly goes into v-fib. There is no "It depends." You defibrillate. Your patient is in severe anaphylaxis. It does not depend, you give them epinephrine.

When I analyze a call now, I try to follow the decision making. Did it depend or did it not depend? and if it did depend, what did it depend on?

Here is a question that I recently considered. If you have a critical patient who you are worried may crash, when do you do the IV? At the patient’s side, on scene in the ambulance, or en route to the hospital? The key is that you need to have the IV when you need it. What is my thinking as I consider this question?

Well, it depends on whether or not I am going to be able to do anything for the patient and can the hospital do something that I can’t that will make a different in outcome. For instance, a gunshot to the torso. The patient needs a surgeon. My IV is not going to offer me much avenue to help. I would elect to do the IV en route once I have taken care of other priorities.

Now how about a pale, diaphoretic patient in ventricular tachycardia with a pulse? This of course raises the question of shocking or giving meds. Another it depends question. Let's say I choose to shock first and it is unsuccessful. Back to the IV question. For me there is no more it depends. It doesn't depend, I need the IV right then. I will go for the IV right at the bedside because I will be able to deliver amiodarone and if the patient codes, other ACLS drugs (for what they are worth). Bottom line, I won’t wait till the ambulance to get my IV.

Now let’s say the patient has sepsis and hypotension. Here my IV can be an avenue to give this patient needed fluid. While fluids may be life-saving the IV is less moment dependent than in the previous case, so depending on the surroundings in the home (lighting, space, etc), I may wait to the ambulance, and then depending on whether or not I think I can get the IV easily (or who is driving) I may elect to do the IV enroute or try first in the parked ambulance if the patient has poor vasculature and my partner is a rough driver.

Most every EMS call has many “it depends” moments. Here is one I am thinking about now. You are alone in back and your patient goes into sudden cardiac arrest. Ventricular fibrillation. You shock once with no success. What do you do? Do you have your partner continue to drive to the hospital while you try to manage the code or do you have him pull over and help you out in back?

What does your decision depend on? How far are you from the hospital? Can you effectively deliever quality compressions, manage the airway, and deliever quality care by yourself? How far away is help? Is it safe to pull over where you are? Does the screaming family member in the front seat affect your decision? I would lean strongly to pulling over at the first safe spot and getting assistance to work the code right there.

Tough calls. Tough questions.

And the answer? I think when deciding if it depends or does not depend, the answer must always be -- When it comes to what is best for the patient, it never depends.

Christian Smeck

 Christian Schmeck passed away a few days ago at 59. I saw his obituary posted in the EMS room at a local hospital. I suspect most of the newer EMTs who saw it didn’t know who he was.

I first met Chris over twenty years ago when I worked at the state health department. He was a service chief for a local volunteer ambulance and we had invited him to an EMS Summit to discuss ways the health department could improve the EMS system. He wore his white chief’s shirt with the gold badge on it, but he came across as an unassuming man who was happy to be invited, glad that someone wanted to listen to him. I remember sitting next to him at lunch and having a long talk with him about a call he did where he came upon a family found dead in their beds from carbon monoxide poisoning and I saw how deeply it affected him.

A few years later when I left the health department and started full-time as a paramedic, he was a training officer at the service where I was hired. He gave us all our orientation on our first day, and he was reassuring in providing guidance to the group of us new hires. Over the years I worked with him a few times. He was a good solid partner. Never a know-it-all, but not afraid to direct me if I started down a wrong track. And he was kind to patients – always. He never spoke a harsh word or showed a lack of patience.  He was an EMT you wanted taking care of one of your family members if they ever needed help.

Like many in EMS, he was often tired, working commercially during the day to support his family and then spending long hours as a volunteer at night, teaching classes and doing calls. As the years went by, he divorced, moved to a new town, joined another volunteer service, and suffered a slow decline in his health. Eventually, he gave up the road, and went into dispatch, and then just teaching. I saw him a few times in hospital rooms in the ED and did a double talk on seeing him on the other side of the stretcher.  I'd always stop and talk and wish him well.  He would tell me he was doing better, just waiting to be discharged or possibly just admitted for the night.

The last I saw him was in the aftermath of big storm we had last October. He was walking out of an emergency shelter. He wore a nasal cannula and carried a small O2 tank on his shoulder. I didn’t have time to talk, but we said hello.

For those EMTs who read his obituary, but who never knew the man, Christian Schmeck was one of us.

The Wheelchair

 The call is for an unresponsive in a wheelchair on a street corner in front of a social services agency.

A woman who works at the agency flags us down. She says she has a man in a wheelchair who is unresponsive. She does not know him. He is not a client there. She says a stranger wheeled him up in the chair, said he was on some heavy duty drugs, and then bolted.

The man in the wheelchair’s eyes are closed, his head is tilted all the way back and his mouth is wide open. He is about forty years old with long dirty hair to his shoulders. He is wearing an army jacket. He is breathing, but you have to watch him for several moments to see that he is his rate is so slow. His pupils are pinpoint. I give him a shake. He opens his eyes, mutters, and then he falls back asleep.

This appears to be a narcotic overdose. We lift him out of the wheelchair and place him on our stretcher, and then get him in the back of the ambulance. While I assess him further, my partner opens the ambulance's side door, and puts his wheelchair in.

When I started in EMS we always gave narcan to heroin overdoses. You had pinpoint pupils, you got narcan. Nowadays narcan is limited to suspected opiate overdoses who are hypoventilating -- low respiratory rate and/or high ETCO2.

I debate what to do about this guy. If I stimulate him enough I can keep his respiratory rate up, but he can’t talk to me. I don’t know his name or anything about him. And I have to keep stimulating him or else he'll drop back off to hardly breathing at all. I put him on the capnography and I get an ETCO2 of 57, which is high, and suggests he is not effectively ventilating. If I stimulate him, I can get him to breathe more and the number drops down. I leave him alone, and it goes back up. His respiratory rate is 4. The end tidal climbs back up into the 50s. I finally decide to just give him a tiny dose of Narcan -- 0.4 mg to wake him up just enough that I won’t have to keep shaking him every two minutes.

No sooner do I give the 0.4 mg, then he opens his eyes, looks right at me and curses. “Shit, you just gave me that narcan shit, motherfucker.” He tries to undo his straps. “Now I have to go out and start all the fuck over again.”

“Whoa, Whoa,” I say. “You were barely breathing. I had to give it to you.”

“No, if you left me alone, I would have been fine.”

“Left you alone? I didn’t go looking for you. You want to get high and not have anyone bother you, lock yourself in a room and put a do not disturb sign on your door. You OD in public, someone is bound to call us, and if you are not breathing effectively, I hate to break it to you, but you will get narcan.”

“Where am I?”

“You were out and barely breathing. So you are in the ambulance now, headed to the hospital.”

“Where’s my money? Did you take my money?”

He frantically reaches for his pockets and is relieved when he pulls out some crumpled bills including at least a twenty.

“And we have your wheelchair with us, so don’t worry about that.”

“Wheelchair?” he says.

“Yeah, your wheelchair. Your buddy wheeled you over to the agency and they called 911. We put your wheelchair in the side. It’s right here, behind you. Safe and sound.”

“I don’t have a wheelchair.”

“Huh?”

“I don’t have a wheelchair.”

“You can walk?”

“Fuck, yeah.”

“Well, you were in a wheelchair.”

He looks puzzled, and then he says, “Wait a minute, does it say, "Property of Sam Thorpe' on it?”

“I don’t know. Maybe.”

“My roommate has a wheelchair.”

I slide over and look at the wheelchair. “Property of Sam Thorpe,” I say.

“That’s it. It’s my roommate’s wheelchair.”

“What’s wrong with your roommate?”

“He doesn’t have any legs.”

***

At the hospital, the patient continues to bitch that I gave him narcan. We put him on a bed in the hallway and tuck the wheelchair in next to the bed. No sooner have I started down the hall when a nurse takes the wheelchair and starts wheeling it away.

“Whooa, whoa,” I say. “That’s his roommate’s wheelchair?”

“Where’s his roommate?” she says.

I hold my hands out. “If only I had a crystal ball.”

How EMS is Like Baseball (But With Better Food)

 I think EMS is a lot like baseball. It can be fairly slow-paced (boring, if you prefer), but it has its moments of excitement. You have your days when you don't even remember the calls you did they were so routine. Like in baseball, you can stand around all game in the outfield waiting for them to hit you a ball, and maybe on a typical day, you get a couple easy flys you can catch, or maybe a couple singles come out your way that you retrieve, and return to the infield with a crisp throw. Every so often you get a chance to make a spectacular play, and even rarer, you get a chance to make a spectacular play with the game and the season on the line. Same with at the plate, you bat your average for the season, and every now and then you get a chance to win the game in the last of the ninth, but that chance is rare. It’s a long season, and, just like in EMS, the trick is to stay ready on every play, never knowing when you will be truly tested.

The above, translated, means, its been pretty slow and non-exiting lately at the ambulance ballpark. Some days it is more like a six year old girl’s softball game than the major leagues. (In girl’s youth softball everyone bats and there are a lot of walks). (Today I’ve transported three kids from a school bus accident who had no injuries, a two day old fall and I did a dialysis transfer). The highlight of my days has been finding good things to eat. While I love a Fenway Frank as well as the next guy, after awhile regular ballpark food can taste pretty bland. One good thing about the city I work in is the food is varied, multiethnic and generally awesome. Instead of writing about calls, I have been collecting notes on restaurants. I found an excellent plantain porridge at Mr. Snapper’s on Albany Avenue last week for $2.50, some great crispy roast duck from the A Dong Supermarket on Shield Street, and later had the best jerk pork I’ve had outside of Jamaica at the Jerk Pit Café out north on Main Street just past where Windsor Street hooks back up with Main. Today, I ate the Bem Brasil Buffett on South Whitney for lunch where you pay $4.99 a pound for food. I had chicken simmered with potatoes, short ribs, rice with vegetables, and a fried stuffed green pepper. It was great. As soon as I’d finished, I wanted to go back for me, but by then we had been moved to area 16. I’m hoping later to get posted to area 10 where on the way there I can get a pizza empanada at Aqui Me Quedo on Park Street.

Oh, yeah, and I’m listening to the Red Sox on the radio right now. Unfortunately, they are down 4-1 early in the game and unless they get their act together in the next couple games, they are in jeopardy of missing the playoffs.

Heroics may be needed.

***

Postscript: The Sox lost the first game of their double-header 6-5. They rallied to win the nightcap 18-9, and they remain two games in the wildcard lead. I did another transfer, a crash with leg deformity, and a shooting to the arm. The MVA and the GSW were stable enough to get pain management (Fentanyl) from me. I didn’t get to Aqui Me Quedo, but did get a most excellent Jamaican chicken patty (chicken in a light pastry) for $1.80 at the Golden Crust Bakery at the corner of Woodland and Albany.