Armed EMS – Reactive or Proactive?

It’s uncanny, and it’s happened at every single job I have ever worked at. “All employees must take the upcoming mandatory sexual harassment awareness course.”  It’s always reactive. It’s the knee-jerk response to a complaint being filed or to a lawsuit pending or lost.  It’s never the culture of intolerance to sexual harassment that is maintained throughout the agency’s lifespan.

It equates to learning to use a fire extinguisher after the building has burned down.  And that’s exactly what’s happening in EMS right now.  Across the country, we’re reacting.  We’re “up in arms” over the topic of whether or not we should be armed while staffing our agency.  The single-most resounding point I have heard is having to check our Constitutionally guaranteed Second Amendment rights at the door.  Our right to defend ourselves, forcefully, and if necessary, including the use of deadly force, is waived because we are health care providers.  But we’re also public safety too… right?  Generally expected to be put in harm’s way, alongside fire and law enforcement?  Are we no longer public when we punch a timeclock?  The laws apply to us just the same when we’re on the job as not, right?  Can we not get speeding tickets for speeding (not Code 3 since a specific law of exemption must exist) or be charged with kidnapping if we don’t obtain consent?  Can we not be charged with criminal negligence if we walk away from a dying patient that we have a duty to care for or if we worsen their condition?

Do you waive your rights to file assault or battery charges on a person who strikes you while you are in uniform?  Au contraire, many states have laws making the penalty worse in this instance.  If you are hurt in an accident and it’s the other guy’s fault, can you not go after them for personal damages, just as your agency will attempt to recover its losses?

There’s too much liability!

The “liability” argument is getting pretty old.  Personal and agency liability exists in everything we do of every moment of our shifts.  Read Rogue Medic’s blog if you don’t think so.  He has a penchant for showing us what we do and why we do it, despite the liability.  Isn’t that why insurance was created in the first place?  Isn’t that why agencies buy into those insurance policies so heavily?  Isn’t that why we may opt to carry personal liability insurance?

We won’t use it often enough to demonstrate proficiency!

The “infrequency of use and training” argument also pales in comparison considering some of the advanced procedures we are permitted to do at work, which can certainly kill someone if used improperly or injudiciously.  How many times have you done a surgical airway?  Pushed sodium bicarbonate or calcium chloride/gluconate?  How many babies do you deliver in the field annually?  How many times have you used the MAST/PASG and then how much benefit was realized?  How many times have you really needed to chemically sedate a patient?  How many times in your career have you done needle decompressions and then how many of the pneumothoraces are confirmed to have benefited from your procedure versus how many did you actually cause with the perceived need for needle decompression?  How many pediatrics have you intubated this year?  How many Dopamine drips do you hang annually?  How many blood transfusions?  How many times have you paced or done a synchronized cardioversion?  In thousands of EMS calls, I’ve done much of this (except delivered a baby, nor have I used calcium) and I have to say it totals less than 1% of my aggregate lifetime calls.  But I’ve spent literally hundreds of hours on these procedures and products, either in initial training or through mandatory continuing education.  Why don’t we take these dangerous procedures away?  Because at some point, they may actually save someone’s life.  If we don’t have them, and could have used them, then someone will assume liability for that too, and no one wants to pay that settlement or court award.  Each of these procedures or skills can cause harm or even death to our patients, and many agencies I have worked for in EMS have historically had a zero-tolerance policy for medical mistakes.  Some arbitrary statistic I read just yesterday said we still kill hundreds of patients every day in health care due to medical errors, so I looked into that more.  In 2009, there were 11,504 deaths by homicide using a firearm (36.7% of firearm related deaths versus 59.8% for suicide by firearm – per http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_03.pdf).  Conversely, just in Medicare beneficiaries, not including non-Medicare beneficiaries, fatal incidents during admissions peaked at 15,000 in a single month (Office of the Inspector General to DHHS – http://online.wsj.com/public/resources/documents/Makary0925.pdf ).  Holy cow!  And you’re worried about the possibility of me possessing a firearm?

Aside of practice sessions, I’ve drawn my firearm once, prepared to fend off a rather large dog who decided to chase down my kids, but I never needed to fire it, as the dog came closer and closer to me standing between it and my kids, then for some unexplained reason, it just turned away and left.  I could have drawn on the job, but as like before in my civilian life, it was over a dog attacking a person, then turning on me, or a suffering deer in the roadway.  Improvisation, thankfully, saved me from a mauling, but the dog was put down by animal control anyway.  Are you worried that someone who has grown up around firearms and martial arts training, and has experience in the Marine Corps, corrections, and almost two decades of public safety isn’t qualified to handle a firearm?  Are you worried that I might accidentally kill someone?  Aren’t you worried I’ll do that and more with the tools prescribed to me to use autonomously in the line of duty?

I’ve never given calcium IV.  I also don’t expect I ever will.  You’ll never see me draw it up until the time I need to use it to potentially save a life.  I won’t walk around parading my lethal dose of IV calcium solution for all the world to see as if I could inject you with it in the blink of an eye and kill you.  But show me a patient with a Calcium Channel Blocker Overdose, then I won’t hesitate to use it.  If I wanted to kill, I certainly wouldn’t need to carry a firearm.  As a Paramedic, I have extensive knowledge of anatomy and physiology, which complements my previous experiences and training.  A thumbtack would do fine.  I can kill someone with a pencil too, or a defibrillator, or a 3-ton ambulance, and in fact, I’m statistically more likely to do it with the latter than any of the former, with a pathetic amount of initial training and no continuing training whatsoever.

Let’s say we are allowed to arm. How do we go about it?

I live in a frontier state… more cowboy than even Texas.  In my state, with either legal open-carry or CCW-permitted concealed-carry, we can bring our firearms anywhere we want, except schools (even universities have a provision to allow one to carry on campus), and select government buildings.  That’s it.  Everything else is fair game.  In Texas, you can’t even lawfully carry into a hospital, unless you are a peace officer too.  That’s a huge disadvantage to EMS carrying, eh?  Their laws would have to change to make it practical.

I think open-carry is a bad idea, unless you are also a dual EMT & law enforcement officer, and it’s part of your job.  It creates a point of fixation (whether as a distraction or morbid curiosity or threat perception) and opens us to more possibility of being disarmed.  It can create an unintentional barrier to patient care.  Better to have it in the bag of tricks and pull it out when there’s a need, rather than walking around with it for the world to see, like the calcium, right?  If I ever do get to carry on the job, I can assure you that you will never see it unless I need to draw it to save my life or yours.

What were we talking about?

We’re talking about armed EMS in light of an agency who publically announced they were entertaining the idea of allowing their EMT’s to be armed on the job.  They are not entertaining the idea of arming their EMT’s.  If you didn’t read that too carefully, you might not notice that it’s a distinct difference.  (http://www.daytondailynews.com/news/news/some-fearful-emts-want-guns-for-protection/nR933/)  Why?  Because they’ve had incidents where they feel it would have been prudent for their EMT’s to be armed.  In expected responses, “Call the police” is the war cry of the victims who decry the EMT’s right to self-preservation.  The police cannot be there with us on every call.  I’m now back to working in areas where your law enforcement backup could conceivably be up two hours away.

Can you imagine having our own law enforcement bodyguards on nursing home transfers?  If you answered yes, then I submit that your employer should require you to visit your local lab to render kidney-excreted waste by-products into a 6-ounce PVC plastic, translucent receptacle.  No, the police prioritize calls just like EMS does and they don’t give 2 cents about interfacility calls.  They’re not going unless they are requested or they feel there is sufficient risk to warrant police protection or intervention.

Scenario time:

So you go to a residence and walk in to a scene with drug paraphernalia and weapons lying around in a back room near your patient.  You first response is probably canned, “withdraw and wait for police.”  Really, you didn’t get a clue about the danger until you were well inside the scene with no safe egress (yes, it really does happen).  Yeah, police are already on the way for a courtesy since you are in a downtrodden neighborhood with a history of non-compliance with the law, but you weren’t expecting anything like this on a routine medical call (you know, the type of low priority medical call that a certain emergency medical dispatching system says didn’t warrant a fire company to join you and your partner), so they’re in no hurry to get there for the sake of appearances.  You call for police to upgrade their response and send more units as you now find you are in a precarious situation, but they are still a couple minutes away, time extended by having to go from you to your dispatcher, to their dispatcher to their field units, and your life could be seconds from ending.  Your agency is too cheap unable to provide, finance, or even subsidize your own purchase of ballistics protection despite a history of annual shootings where your ambulances have been hit multiple times.  Don’t forget that once the police arrive, they still have to get to where you are, as you now realize that simply having them on scene does not protect you.  Still, that hasn’t occurred yet.  A lot of verbal judo at least convinces the occupants of the home to allow you to move your patient to the ambulance where you “have better equipment and lighting”, but they still won’t leave the patient’s side and impose their will to join you in the ambulance with raised, agitated voices, overwhelming numbers, and armed, sheer brute force potential.  Thank the maker, the police arrive and escort your cadre of intimidators to the curb and issue them all matching, shiny, silver bracelets while thanking them for assisting you.  Then your patient suddenly awakens and wants nothing to do with you and your Narcan remedy for what ails them, so they get up and leave you with some choice words echoing in your ears.  You make a note to dispatch to log that EMS should never go to that residence again without police escort.  You leave hastily without even thanking the police officers for saving your shebs, just grateful that you aren’t needing your own ambulance or hearse.  You also realize that this wasn’t a hypothetical situation or a daydream, but you actually lived through it.

Reactive or Proactive?

The situation above, while not even uncommon, did not necessarily warrant an EMT drawing a weapon, even though it certainly had the potential.  You don’t carry one for what you know you will meet.  You carry one for what you don’t know you’ll meet.  There’s a line of questioning and it goes: “Why are you carrying a gun? Are you expecting trouble?”  The reply is typically: “Well, I carry just in case there’s trouble I’m not expecting.  If I were expecting trouble, I’d bring my shotgun, a rifle, and a bunch of cops too.” As Colonel Nathan Jessup, played by Jack Nicholson in “A Few Good Men”, says, “Walk softly and carry an armored tank division…”

Does it have to take an EMT to be killed to get people to realize they should be allowed to protect themselves with like force or force +1?  Too late.  It’s already happened.  Several times.  Ask Kansas City EMS.  Are you going to learn to use that fire extinguisher in the midst of or after the fire, or are you going to learn to use it before you need it?  Then are you going to going to use a fire extinguisher on a fully-involved structure fire?  Are you going to stand inside the burning building while you wait for the fire department to come rescue you?  Are you going to be ready to give an IV Calcium solution to a person with a Calcium Channel Blocker overdose, or are you going to realize what you have in front of you and pull out your little pocket guide and learn it on the spot, and while you’re at it, learn about the complications of using IV Calcium solution?  With all the public shootings in the recent years, is it any wonder that applications for concealed weapons permits are on the rise?  People, in general, are becoming more proactive.  They don’t want to be a victim who survives and has to then contemplate the morality of self-defense.  I can see the news headlines now… “EMS crew held at gunpoint by thug saved from death by armed private citizen!”  I don’t want to be on a unit, have someone finish their attempt to kill my patient or steal my narcs, then decide I am a witness they don’t want available for prosecution.  Why should I be the one to realize the consequences for someone else’s desire to rob me of my right to unimpeded metabolism?

Our problem: I think one of our big problems is EMS is not becoming active at all, and when someone suggests we become proactive or reactive, they’re often labeled as some kind of heretic.  I can think of a few “EMS Greats” who were labeled the same in their day, and are now hailed as pioneers and people who are interested in doing whatever they could to make EMS better and safer.  At least we’re now openly discussing something that has been a problem since before the days of Johnny & Roy.

What should we do then?

As seems to be the case with our upcoming presidential election, there’s little middle ground for this topic.  Here’s how I feel…

Maybe allowing concealed carry on the job isn’t the right thing to do.  I’m certain it isn’t for everyone.  It should NOT be mandated.  Personally, I’m for it, and I’m for some controls with it (like proficiency testing, laser targeting, a CCW/CWP, personal liability insurance, continuing education, and – something very hard to qualify – a generally responsible attitude).  I may be proven wrong over time, but with no facts and statistics for either side to go on with regards to EMS, I’m not sure who is ultimately right or wrong.  What I am sure about is what’s right for me.  I think you have a right to carry or not carry, but your rights end when you feel justified in imposing your beliefs and rights upon me.  They’re called rights for a reason, and we don’t vote on them.  I neither need, nor want, your permission to exercise my Constitutional rights.  If you don’t want to carry, that is your prerogative.  I think an employer should be allowed to trump your First Amendment rights, within reason, while working as you are accepting a wage in trade for representing the agency, but that should end when off-duty, and don’t forget the First Amendment was not intended to protect life, limb, and property.  What good is free speech when you aren’t alive to exercise it?  Martyrs don’t shelter, feed, and clothe your family.

Skip Kirkwood is one of those guys who speaks, and people listen.  He brought up an excellent point to me that made me look hard at what I think should happen.  Look up “respondeat superior”.  As it stands, the courts agree with employers of any profession prohibiting firearms on the job, to the point where it can cost you your job, but they’re losing the ability to tell us we can’t keep firearms secured in our vehicles, even on their property.  Knowledge of that term complicates my preconceived notions of what I think should happen.  Perhaps it means a generic waiver of liability be signed by every employee, regardless of their decision to carry a firearm or not.  Then anonymity and concealment become more universal.  I now am led to wonder if that applies to being employed by a government agency, since protection of citizens’ rights from the government is exactly why we have the Constitution.

I’ll make no predictions on the future of allowing EMS to be armed, since the human factor weighs too heavily, but I hope choice becomes the norm.  I also think we should spend at least a hundred hours on Assaultive Behavior Intervention and Crisis Counseling courses and internship, and neither of those involves a firearm, and that goes for all levels of EMS professionals.

Side note: Despite their “higher moral ground” and predisposition for mediation and diffusing violent situations peacefully throughout the galaxy, even the Jedi carry weapons.

Free for you:

The NRA has a program called Life Of Duty and there is a free one-year membership waiting for you.  I’ve taken advantage of it myself.  Someone else, who thinks you are worth investing in, has prepaid your membership.  Check it out and if you want to, take advantage of someone else’s generosity here:

http://nralifeofduty.tv/

Where else can you read about this hotbed topic?

• Everyday EMS Tips – http://everydayemstips.com/concealed-carry-for-ems-2-questions/
• Medic Madness – http://medicmadness.com/2012/09/arming-ems-the-debate-continues/
• EduMedic – http://edumedicblog.com/2012/09/ccw-on-duty-and-the-conversation-we-should-be-having/
• A Day In The Life Of An Ambulance Driver – http://ambulancedriverfiles.com/2012/09/20/guns-in-ems/ AND http://ambulancedriverfiles.com/2012/09/13/virginia-emts-granted-right-to-carry/
• EMS1 – http://www.ems1.com/ems-education/articles/1345171-Should-ambulance-crews-be-allowed-to-carry-weapons/
• Podmedic – http://www.mediccast.com/blog/2012/08/17/gun-toting-emts-and-paramedics/
• Added 10/01/2012: 510Medic: http://510medic.com/2012/09/19/should-ems-providers-be-carrying-guns-on-the-job/trackback/ 
• And Rogue Medic: http://roguemedic.com/2012/09/tubes-and-guns-and-training-oh-no/

Please weigh in.  Each of us bloggers are interested in hearing all sides.  We’re educated people.  We’re professionals.  A little warning… these people are very smart, so think carefully about what you say, and be prepared to defend your claims without taking offense.  Please educate and professionally present your perspective, don’t inflame.  Remember: Guns are wireless too!