As most of you probably know, I make my living as an Emergency Room physician. This fact defines me; not just as a physician, but also as a person. As much as I try to leave "the job" at the ED when I leave the hospital at the end of each shift, it remains a part of me. The ER doc in me comes out at unexpected times and unexpected places, often when folks around me least expect it, and without any conscious thought on my part. 

I'm not unique in this. Most ER docs I know who truly love this work and live their calling to Emergency Medicine are the same way. Which makes us pretty much a bunch of odd ducks. Doctors as a rule don't fit in all that well with most of society, in part because we are a bunch of science nerds (you have to be, to succeed in the educational process), and in part because we know things that the rest of society doesn't know. And I mean know, in the sense that we've lived through the ugly truth of those things in our clinical training and experience. 

But if all doctors in general are half a bubble off top dead center, ER docs are without a doubt a full bubble off, and then some. We don't even fit in with other docs. How do I know this? Because they tell us so. Last week one of our hospitalists--an internal medicine specialist, a really nice guy, a really smart guy I enjoy working with--came down to the ED to see a patient I had worked up and needed admission to his ICU. At that moment we were slammed. All 12 rooms were full: a child screaming in one room as the lab tech tried to stick her for blood tests, a batshit crazy psychotic screaming in another room because I'd been too busy to order another dose of Haldol to put him back into La-La Land, nurses rushing down the hall to the Trauma bay to attend to a cardiac arrest we'd clawed back from the brink of oblivion, ambulance crews streaming in and out of the bay doors. And me, in dirty scrubs with blood and God knows what else on 'em, hammering away at a barely functional keyboard in an attempt to input the complexity of a patient's case into the archaic EMR (electronic medical record) our hospital system bought back in the stone age and refuses to update because of the expense of doing so... in other words, it wasn't an environment that most people would consider anything close to normal. 

But it actually was normal. 

That's normal where I work, where I live and breathe. And it's normal for the men and women like me who have chosen this specialty--or fell into this specialty, as I did. We do other non-normal stuff, too. For instance, as you probably know I got involved with TEMS many years ago, and eventually ended up wearing armor and toting a rifle on my county's SWAT team. You don't see many pediatricians or dermatologists following that career path. ER docs, however, seem to gravitate to it like flies to... well, let's just leave that metaphor unfinished. But you know what I mean, if you know what I mean. 

Anyway, back to this encounter in my ED last week: my colleague looked around at the chaos of my Department and said, "You guys are really special, I could never do this". I took a moment to consider whether he mean "special" in the sense of belonging on the short bus with the window-lickers, but decided he meant it in a good way.

"Thanks," I said, and meant it. "You have to be something of a Cro-Magnon to work here, but once you get used to the saber toothed cats and giant cave bears, it feels like home."

He laughed, and patted my shoulder with what might have been affection, or appreciation, or maybe because he thought he had to calm me down the way you calm down a pissed-off junkyard dog, and he backed out of the department at record speed.

But that's how it is with us ER docs. Even if we come out of the department and attend meetings (we HATE meetings) the other docs smile and treat us the way you'd treat the aforementioned junkyard dog ("Nice doggie, good doggie, want a nice doggie treat, don't bite me, okay?"). At social events like dinners and Christmas parties (assuming we even get invited!) it's even worse.  I generally end up in the corner chatting with the security guards who feel just as ill at ease as I do. 

Which brings me to my friend Lamar, and the point of this blog. 

Lamar is an ER doc. And he's a damn good one. He's the medical director of our system's busiest hospital and ED. Like me, he's worked in the trenches long enough to be put in charge of a Department. Unlike me, he actually chose this specialty when he was still in med school, which by definition makes him even crazier than guys like me who fell into it after they started practice. 

Anyway, I was out fishing for speckled trout down the Laguna Madre with Lamar last week, and we got onto the topic of security in the ED. Which, if you've ever looked, is virtually nonexistent. Lamar confided that he is working on getting into a TEMS class that would put him on track to join a nearby Sheriff's Office, but his real goal isn't to practice tactical medicine (although he'd like that, you betcha!). His goal is to get his LE credential so he can carry a firearm when he's at work. 

He doesn't want to carry a firearm at work because he's afraid. He wants to carry a firearm at work because like most of us he's a guy who takes his personal security as his personal responsibility. But the law in Texas (and just about everywhere) prohibits carrying a firearm in a hospital unless you're a LEO. So he wants to become a LEO for that express purpose. 

Now, I know a few docs who are active/part-time and/or retired LEOs who carry concealed firearms on the job. And they'd be crazy not to. Because the insanity of Gun Free Zone thinking is nowhere more evident than in hospital Emergency Departments. Think about that. The local ED has a large stock of narcotics, benzodiazepines, and other juicy drugs. Its doors are wide open, so the sick and injured can gain access to critical medical care. There is almost always at least one doped-up felon in the department being treated for injuries sustained while resisting arrest, or a prisoner from the local Crossbars Hotel being seen for a routine medical complaint, which tends to attract their friends and family like flies to, well, you know.  (Why does that metaphor keep popping up? Could it be that we just had a Code Brown here in the department, and the aroma will hang in the air for the next 10 hours thanks to the inadequate HVAC system apparently required by law in all ED's?) And there is almost always nobody present with the means of resisting or countervailing an armed attacker who might want to steal our narcotics, or spring their buddy out of custody, etc, etc, etc. 

America's ED's are the front line of our trauma system, and the retail store-front for our medical system. In a minor disaster, such as a multi-victim MVA, the ED is quite literally the gateway to preserving lives that hang in the balance, and in a major disaster, such as a refinery explosion or a school fire, the ED is the focal point of an entire community's response. Take out your community's ED, and your community's emergency response system shuts down. Not slows down; it shuts down cold. 

Yet America, in its dumbfuck politically-correct lawyer-bound risk-management gun-free-zone mentality, provides little or no security to these critical zones of care. Most ED's have minimal or no physical security... they can't even lock the doors to keep a bad guy out. Most ED's in America are in smallish community hospitals, laboring under tight budgets, and they can't afford to even have an unarmed security guard on hand 24/7. As for armed security? Don't make me laugh! Even if it was available free of charge, most hospital administrators and risk managers would throw up their hands in horror if you suggested putting armed guards in their ED's. I know of hospitals that have had gunfights break out in them, with armed gang members of one stripe blasting away at their rivals of the other stripe in the waiting room and parking lot while other injured gang members are being attended in the ED. And those hospitals STILL refuse to hire armed guards, or do anything to provide a safe and secure workplace for their docs and nurses and techs.

Because it would "send the wrong message to our community".  

I had an incident about 10 or 12 years ago in another state where I came face to face with the grim side of this reality. It was on a sunny Sunday morning in July, about 0900. A great day to go fishing, or have a picnic, or do anything outdoors. The department was quiet, and I was sipping my second cup of coffee and catching up on signing charts. My triage nurse, a great guy named Clay, came back to the nursing station to tell me, "We have a problem out in the waiting room. You'd better take a look." 

I went up front and peeked around the corner, and my heart sank. A tall 50-something man I knew well, a "frequent flier", a big man with serious mental health issues, was in front of the desk, shouting disjointed gibberish and gesticulating wildly. In one hand he had a small heavy-duty satchel, something like a bowling-ball bag, and it clearly had something heavy in it. Call me paranoid if you like, but I was 99% certain that bag contained a handgun. Speaking of paranoid, the guy happened to be a known paranoid schizophrenic, and he was off his meds, a not-uncommon problem with people who depend on the VA for their psychiatric care; I knew this because I'd seen him 2 nights before, at which time he'd taken a swing at me before he left AMA. 

The man caught sight of me peeking around the corner, and his actions escalated dramatically. He began to hammer on the (thankfully heavy) glass and he began to scream he was going to kill us all.  I told Clay to grab a syringe with 10 mg of Haldol and 5 mg of Valium in it (that's what we used at that time for such emergencies, but not what we use now... I use a waaaaaay better coctail now!) and in short order we entered the waiting room. I tried to distract the guy while Clay tried to circle around behind him to stick him in the butt with the sedative. No dice. This guy had his head on a swivel, and we did a long, slow, 3-way dance--circling counter-clockwise like Hurricane Katrina making her lazy way across the Gulf of Mexico-- all the way out to the main entry foyer and then back to the ED without Clay ever getting a chance to stick him.

Two things you need to know here: First, the front desk clerk had hit "the panic button" early, which is supposed to bring every squad car in the city screaming to our location. When there was no response, one of the nurses called and learned that they were on their way, but by some weird circumstance all 4 cars on duty were on the other side of the river, and BOTH bridges in town were closed, one for construction, and the other due to wrecked semi which was blocking all 4 lanes. The squads were on the way, but they had to drive 10 miles south to the next bridge. So we were on our own for the next 15-20 minutes. Second thing: this guy was known to us as a violent man, a paranoid schizophrenic, and Viet Nam vet.

(If you want to strike terror into the heart of any ER doc in America, whisper in his/her ear, "There's a paranoid Viet Nam vet off his meds in the lobby.")

Anyway, Clay and I danced this guy back to the ED doors, at which point he told us he had a shit-load of rifles in his truck, and he was going out to get one, and then he was going to come back and blow us all to hell. He turned and bolted out the door into the parking lot. I wish I could tell you how frightened I was at that moment. Then Clay kicked me back into gear.

"You know what the top story on CNN is gonna be tonight?" he said, in a voice more like a croak than his usual pleasant baritone. "'ER doc and nurse, fathers of seven children, gunned down by crazed Viet Nam vet.'"

Like I said, that kicked me back into gear. "No," I said. "That's not what the headlines will say. They'll say, 'ER doc and nurse defend their lives and ED from crazed Viet Nam vet, who was pronounced dead at the scene.'"

Clay turned to me, eyes wide. "Look," I said, "This guy is probably not lying. He probably has rifles in his truck. And if he comes back with one, he will kill everybody here. But it doesn't have to go that way." 

"What?" Clay asked, but I saw the glimmer of hope in his eyes. 

"I shot a cowboy match yesterday," I told him. "It ran late, so I didn't have time to bring my guns into the house. I've got two rifles in the trunk of my car. I'm going to get one of them. If he starts to come back at us with a rifle in his hands, I'm going to defend myself. And if you want to, I'll bring a rifle for you, too."

Clay's face began to color. "You're damn right I want to," he said firmly. 

"They'll fire us," I said simply. "The hospital will fire us, and we may even lose our licenses."

"I don't care," he responded. "At least my children won't grow up without their father."

And that was that. I ran through the department and out the back door to the doctors' parking lot, popped my trunk, and grabbed my two cased rifles. They weren't black rifles, they weren't even hunting rifles. They were Winchester Model 1892 lever rifles, one chambered in 45 Colt, the other in 357 Magnum. Both were legally "unloaded"; they had 10 rounds in the tube magazines, with an empty chamber. The ammo I use in Cowboy matches is full-power black powder loads, which means a flat-nose lead bullet loaded over a full charge of black powder, which was the authentic load used by "real" cowboys back in the 1800's. Plenty of power to kill an attacker in 1892, and plenty still in 2002. 

I ran back to the doors and handed the cased 357 to Clay. We pulled our rifles out and jacked rounds into the chambers. My heart was hammering, and my mouth was dry. We didn't say anything. We just stood on either side of the door, watching the man in the parking lot, who was less than 30 yards away, fumbling with a large ring of keys. He seemed to be having trouble opening the tailgate-topper of his truck. We could hear him shouting wildly even through the double glass doors. 

And then the cavalry rode up. Two squads with lights and sirens screamed into the parking lot, and in short order the officers had our boy in cuffs and in the backseat of one of the cars. Clay and I wasted no time in sliding the Winchesters back into their cases, and I slipped out back to put them in my trunk just as the supervising sergeant--who I knew well, of course--rolled up. His look told me he was damn near as scared and relieved as I was. He looked over the parking lot and confirmed that the situation was in hand, then strolled over to me and spoke softly.

"Hey, Doc, those things you were putting in your trunk, are they what I think they are?"  

I looked at him and nodded at Clay. "We figured we had no choice. I'm sure glad your boys arrived when they did."

The sarge blew out his cheeks and shook his head. "Me, too, Doc. Me too. The other woulda been a lotta paperwork. A lotta paperwork."

And then he put his hand on my shoulder, but not like my hospitalist colleague did last week. He put his hand on my shoulder and squeezed in a way that said more than words could say, in a language that warriors all know. And that was that. Nobody got shot, nobody got killed, and we all went home at the end of the shift. Well, except the Viet Nam vet, who went to the psychiatric hospital. Which was probably the closest thing to home he knows, so I guess we really all did go home after all.

As it turned out, the deranged man had a truckload of rifles and shotguns, mostly AR's, and all of them locked and loaded. There is no doubt he came prepared for the war he had never managed to leave behind in southeast Asia. 

The situation could have gone a lot differently. Clay's imagined CNN headline might well have happened, if the cops hadn't arrived on time, and if I hadn't serendipitously forgotten to take the rifles out of my car when I got home from the previous day's Cowboy match. But because of the idiots in charge of our hospital, idiots who think that guns are bad and visible security sends "the wrong message" to the community, we came within a whisker of being cheerfully sacrificed on the altar of Almighty Political Correctness and Risk Management.

Lest you think this was a one-off situation, let me disabuse you of that notion. ED staff are assaulted and injured in America with depressing regularity, and we are threatened many, many times every day. All because of the risk managers' mindset that we "must not offend the community".  

This idiotic do-not-offend mentality is insane. We put armed guards in our capitols, in our banks, in our securities houses. Armed guards patrol gated communities, industrial complexes, shopping malls. We sanction the use of armed guards to protect these things, because we recognize they are precious, and they are vulnerable to predators. Yet we do not provide armed security to our most vulnerable: our children in their schools, and our sick and infirm in our hospitals. The shooting by the ISIS-wannabe-nutjob in Ft. Lauderdale the past weekend would never have happened if armed security personnel were posted in adequate numbers in our airports. 

Are our children, our hospitals, our clinics and places of healing not at least as precious as our stocks and bonds and piles of gold bullion? If not, then what IS precious in America?

When is America going to wake up? It's time to take the sheepdogs off the leash and let them do what they do best. America could be the safest country in the world in short order if we would simply use the tools that are at hand: trained men and women who are warriors at heart and background, but who serve as helpers, teachers, healers in their current life. But the risk managers don't think we can be trusted with that. They don't think we are worthy of protecting. Not yet, anyway.  

In the meantime, guys like Lamar will quietly take their own route to securing themselves and their staff and patients. There are a lot of docs like Lamar. I thank God for them. They may not fit in with the other docs in the hospitals and clinics of America, but I think that's a good thing. Because they are quite literally the last line of defense against true chaos. 

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