Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Two Ridiculous Comments on Tubes and Guns and Training, Oh No

This is long, but some unusually bad arguments were made in the comments. I need to make examples of them.

Both The Unwired Medic and Garrett responded to Tubes and Guns and Training, Oh No. First, let’s look at what Garrett wrote –

> Where do I suggest that is the case?

Where your graphic talks about being 20 feet away from the patient. That suggests that the patient is the only person we have to worry about.

If you add more people with weapons, it only gets worse for you. I did not limit the possible attackers to the patient. Look again.

 

 

That does not mean that the attacker is not someone else within 20 feet. Outside of 20 feet, I did not even mention the patient.

>Attempting to draw a concealed weapon will distract from what should be done in a violent situation.

What I find interesting about this phrase is that you’ve placed all of the conditionals (attempting, should) on your side of the estimates. If something can go wrong, it must go wrong. It implies both a lack of skill and a lack of ability to take reasonable action. Running from a knife is fun. It also isn’t always practical. It’s even worse if somebody starts shooting at you.

No.

Your concealed carry argument assumes that everything will go just right for the person carrying concealed.

We can’t get medics to practice with equipment that is much more likely to make a difference between life and death, so if I imply that you do not get much practice drawing from concealed while being shot at, or stabbed, am I implying too much?

Please share video of your skill at drawing from concealed, while being shot at or stabbed. We can use that as a basis for training, so that we do not endanger patients, family, bystanders, and partners by having unskilled concealed carry drawing and firing of handgunson scene.

Other weapons (chair drug bag/drug box, monitor, oxygen cylinder, . . . ) are more practical and do not need to be concealed. You prefer to attempt to draw a properly concealed handgun, while avoiding shooting the people who are not attacking you, such as your partner and the patient and the neighbors.

> The rate of murder of EMS personnel in the communities you do not go into is still zero.

Not according to this news article.
http://www.firehouse.com/news/10495630/new-york-emt-shot-and-killed-by-patient

I had not read about that. I have asked for information about any on-duty homicides in previous discussions about this and nobody has ever produced anything except for the lovers’ quarrel at the station.

Or this research article which suggests about 2/year:

http://www.emsedsem.org/Prior Articles/EMS_Fatalities from JEMS.pdf

I had not seen that, either.

That is a link to a JEMS description of a paper that used the Census of Fatal Occupational Injuries to produce the 10 apparent homicides over 6 years, but none of them appear in the National EMS Memorial Service records.

Would any of these homicides have been prevented if anyone had been carrying concealed? There is not even enough information provided in the paper to determine if they were actually EMS providers, so we do not know. Were some of them struck by drunk drivers, reckless drivers, or intentionally struck by vehicles?

Those could be listed as homicides if the people were charged with vehicular homicides.

The JEMS article includes information not in the original paper –

10 from homicides, most of them shootings;[1]

The JEMS article was an interview with the primary author of the paper, so he may be the source, but the article does not mention where this extra information comes from.
 

Image source.[2]
 

You assume that concealed carry would somehow improve things, but I do not see any reason to believe in your Goldilocks scenario.

However, I do admit that the rate of murder is slightly above zero.

Granted, I had to wade through a few pages of Google search results to find that. I found a number of other cases where providers had been shot, but survived. It is a small number of deaths, but it is non-zero.

OK.

I was wrong.

The number is tiny, but it is not zero.

With all of the attention that the attack on Brian Stow received off duty, I figured an attack on someone actually on duty would receive much more attention.

> Within 20 feet, the concealed handgun is dangerous to the person carrying, because the best response is something other than drawing and trying to shoot.

Always? Every single time. Care to write the Universally Correct course of action down? Hell, we could make this part of the protocols.

I did not write best every time, did I?

> Now the idea is to be stabbed fewer times?

No. The idea is to take action which results in the best possible outcome for me, my partner and my patient. All things being equal, being stabbed fewer times is better than being stabbed more times. Being shot fewer times is better than being shot more times. Not getting into a dangerous situation is better than getting into a dangerous situation. Diffusing a situation is better than having to engage in a fight. And shooting somebody who presents a clear and present danger to my life and well-being is better than being severely wounded or killed.

And winning a million dollars in the lottery is better than not winning a million dollars, but you make it seem as if you have the ability to choose a winning ticket. Buying a lottery ticket changes your odds of winning the lottery by such a minuscule amount, that your odds of winning essentially do not change.

Why do you assume that carrying concealed is making things safer for you, or for anyone else?

You appear to be just making the scene less safe.

If you knew that the attack would happen, you would not be there.

Since the attack is happening, things are already out of your control, but you think that attempting to draw a concealed handgun will make things better.

> I want to avoid a violent encounter, rather than get on the scoreboard.

So the only options are to either magically avoid violent encounters or view life as a video game? Please! Given the two options that you present, I would prefer a magic aura which prevented all violent encounters around (or especially involving) me. However, that isn’t realistic. If you want to argue in favor of the continued prohibition against EMTs carrying weapons to defend themselves, please do so. But let’s not go over into magic thinking land where a tool of defense is *never* useful and cannot *ever* be the best course of action.

Why do you need to misrepresent what I write? My point is to make fun of your attitude.

Your approach seems to be to get on the scoreboard with the magical thinking of the protective aura of your concealed handgun.

I do not view your approach as reasonable.

Now let’s look at what The Unwired Medic wrote –

I’m sorry you’ve only heard of EMT’s being shot by ex-lovers at their stations. Take a few minutes to do a simple search on the web of line of duty injuries and deaths due to medics beings being shot. In less than five minutes of searching, I came up with about a dozen on-duty shootings, including three LODD’s within the last decade.

I have asked for data before, but this is the first time anybody has ever provided any.

What statistic is justifiable for us to then be allowed to carry?

There are far more factors than that to consider, but with millions of EMS calls each year, that is a very low incidence to address. Defensive driving, exercise, and a massage would probably be much more effective at prolonging your life than attempting to draw a concealed handgun on an EMS call during an attack.

I’m NOT saying it is the right thing, but I’m also not saying it isn’t.

OK.

You are saying that you are not saying anything.

Your own articles continually show us the follies of doing what it is we do in EMS because of proof of danger and harm, but you usually offer statistical and quantifiable evidence, but this time, your answers appear to be as circumstantial about being against as anyone else’s is for.

I do try to show the folly of introducing unnecessary risk into patient care.

The potential benefits are so small that they cannot be measured – and that is assuming that the dangers are not much greater than the potential benefits.

Why do you ignore that risk, and exaggerate the potential benefits, even though you claim that you have no opinion?

All you appear to have proven this time is that the police don’t have to be there for anyone. Why do we mess around with procedure X when statistically, we’re unlikely to even see a full 1% usage of procedure X in our career lifespan, and then cannot unequivocally prove procedure X had any impact on survivability? Because it has the POTENTIAL to improve survivability, and we’re held accountable to that potential in a court by our peers.

I don’t see any accountability.

I regularly criticize that What if . . . ? fear mongering.

That is one of the greatest harms of EMS. We need to stop this dependence on scaring people with stories of monsters in closets and deal with reality.

This is lowering ourselves to the level of alternative medicine.

The same could be said of firearms carry. The jury should be out until there’s more proof one way or the other, otherwise, it’s all conjecture and opinion.

What a load of nonsense.
 


Picture credit.
 

Maybe you have not read what I have written, or you have not understood what you have read. I apologize if I have been unclear.

If I have at any time suggested that we should use something until the danger can no longer be hidden, I was completely wrong.

That kind of thinking is reckless and irresponsible.

We should not be encouraging reckless and irresponsible EMS.

Why do we like to assault patients with dangerous, untested treatments?

Why do we demand evidence of harm before removing them?

Why are we so dangerous to patients?

Some of the following treatments have been deadly. None have been shown to be beneficial. How much evidence of harm did we need to get rid of these What if . . . ? treatments.

Thalidomide – over 10,000 children with major birth defects.

Bleeding to remove bad humors – how many thousands died for this?

Removing children’s tonsils to prevent infection – how many children died from this unnecessary surgery?

X-rays of our feet in shoes to get a good fit – how many cancers from old, high-dose radiation?

Trendelenburg position – no benefit, but it impairs respirations and increases the risk of vomiting and aspiration.

Furosemide for CHF – how many unnecessary intubations to be able to treat the fluid in the bladder, rather than the fluid in the lungs?

High-dose epinephrine for cardiac arrest – more ROSC, but less survival.

Lidocaine for cardiac arrest – more ROSC, but less survival.

Amiodarone for cardiac arrest – more ROSC, but less survival.

Standard-dose epinephrine for cardiac arrest – more ROSC, but less survival.

Antiarrhythmics for patients with PVCs after having a heart attack – how many tens of thousands died due to this dangerous treatment?

Steroids for spinal cord injury – still unproven, but still being pushed by one doctor.

And on and on and on . . .

When we assume safety and demand evidence of harm, we should be prevented from treating patients.

Assuming safety and claiming that a lack of evidence of harm is the same as evidence of safety is dangerously incompetent.

We need to stop being dangerous.

We need to stop making excuses for being dangerous.

We need to stop worrying about What if . . . and start dealing with reality.

For a reasonable approach to protecting ourselves, read what CombatDoc wrote –
 

Footnotes:

[1] Fatality Study: EMS Is a Dangerous Profession
By Kim Oriole, JEMS InfoMail Reporter
JEMS
Link to Download in PDF format

[2] Occupational fatalities in emergency medical services: a hidden crisis.
Maguire BJ, Hunting KL, Smith GS, Levick NR.
Ann Emerg Med. 2002 Dec;40(6):625-32.
PMID: 12447340 [PubMed – indexed for MEDLINE]

Free Full Text Download in PDF format from paramedicduquebec.org

.

Comments

  1. Brenda Cowan FF,EMTB, Lexington KY Fire Dept. Shot and killed in the line of duty AFTER Leo’s deemed the scene safe. A horrible tragedy, but these things do happen. Just providing info for your consideration.

    • LEOs had not cleared the scene as “safe”. They were responding to a “subject down next to the road” and it wasn’t relayed to the fire department units in time that this was potentially going to involve a suspect.

    • And your example involves a fire crew that was ambushed, therefore negating any possible benefit of carrying a concealed weapon. This entire argument is ridiculous at best. Spend more time on raising paramedic education levels and less time trying to be Dirty Harry.

      • Just to be clear…. my comments were intended to correct the previous comment about the circumstances surrounding Brenda’s death. I personally think that most paramedics, emts, & ffs would not benefit from CCDW. I think our focus should be on avoiding the need for a weapon, but I also understand there would be times it MIGHT save someones life.

        • And I was further clarifying the situation.

          As far as the might save someone’s life argument goes, we could undoubtedly save a great many more lives by eliminating any and all use of lights and sirens, but you don’t hear a great uproar over that do you?

        • JB,

          I think our focus should be on avoiding the need for a weapon, but I also understand there would be times it MIGHT save someones life.

          What about the possibility that it might result in EMS killing someone who was not doing anything wrong?

          Is that any less likely than the possibility that concealed carry might save someone’s life?

          We have two very unlikely situations that might result from giving EMS more things to distract from patient care.

          I think we are better off avoiding preparing for the lottery odds possibility and spending our time on what we are supposed to do.

          .

  2. Since Ambulance Driver wrote about this and the change of law in Virginia many EMS bloggers have been writing about EMS carrying a firearm while on duty. Many argue what you have, that medics can keep can’t intubate properly so how can we trust them with a gun.

    I think people missed the point of ADs post. We wouldn’t be arming every medic or EMT. We would just allow those who ALREADY POSSESS carry permits in their state to continue to carry on duty. They have already been approved by the state to carry a firearm in public, concealed. Why can’t those persons continue to carry while at work as long as they follow their employers guidelines? These are people who have training with firearms outside of work, not fresh medics out of school

  3. I started out with an enormous line-for-line reply written to post here, perhaps matching the volume of your b=obviously one-sided, berating reply, but have decided that would result in senseless bickering rather than educational discourse. Fact: Our society is predicated on the notion of assuming innocence before guilt.

    Guilt must be proven. I didn’t create the system, but I live in it. Now, interchange “safety” with “innocence” and “harm” with “guilt”, as it would be done in the courts, “When we assume safety and demand evidence of harm, we should be prevented from treating patients.” That, my colleague, will be the last day medicine progresses. Rather, when does the benefit outweigh the risk? Incidentally, I tend to think of safety as a verb and a mindset, and proper application prevents harm more often than not and it almost never requires a gun. One of your sidebar quotes struck me as resonant with our “discussion” here… “All things are poison and nothing is without poison, only the dose permits something not to be poisonous. – Paracelsus.” Who gets to decide the dose? And if you disagree, what then? You label the declarant as ridiculous with bad arguments? Honestly, I expected you to be more open minded, but again, I am somtimes labeled the heretic who has a different opinion or way of doing things. In your haste to proclaim your righteousness, you never bothered to look at the cumulative results of previous experiences and weigh the facts of all sides wearing the blindfold of justice. I had a medical director like that once. Still, I don’t disagree with everything you have written, but neither will I further attempt to convince you there is another side besides yours. Is that enough equanimity?

    • Unwired Medic,

      “All things are poison and nothing is without poison, only the dose permits something not to be poisonous. – Paracelsus.” Who gets to decide the dose? And if you disagree, what then? You label the declarant as ridiculous with bad arguments?

      Nobody gets to “decide” what the dose is; that is what research is for. Not anecdotes, not theory, but properly blinded and randomized research that produces objective DATA. After that research (or “trial” if you will), can we decide if the treatment is safe (“innocent”) or harmful (“guilty”). After all, even though we presume “innocent until proven guilty”, many people awaiting trial are still held in jail.

      • Interesting points, indeed, and I think the armed EMS issue is being held without bail pending trial (great analogy mpatk!) as it should be. Every physician gets to prescribe the dose of a medication for their patient, and we as EMS extensions of our physician medical directors get some latitude or take the physicians’ directives there too. Research does not decide doses. Research helps determine inefficacy, safe ranges, overdoses, and fatal ranges of doses. Therefore, I reiterate: Who gets to decide the dose of this poison for EMS? Perhaps the medical directors? Administrators? Why not keep it local? Why not make it state? Why not leave it to the feds? What about the guy who works at the tip of the spear? Politicians? Lawyers? Doomsdayers? Conspiracy theorists? Special interest groups? Some other unmentioned option? Don’t forget, society makes an enormous amount of bad decisions to find a good decision. E.g., fire codes, law, warning labels.

        I have taken collegiate research courses before, and unless my professors were wrong, much research does not and cannot occur until something has happened. It’s often retrospective unless you can control all variables, AND get IRB preapproval, and fund controlled studies. The IRB should make sure the study is fair, does not cause undue harm, and produces objective outcomes. Without theory, you have no hypothesis to test (and sometimes anecdotal evidence gives you something to make a hypothesis with). You can’t sum that up in two sentences. That’s not even an abstract to research. Without action of some kind, you have nothing to research (read: trial), and therefore no results to evaluate (read : deliver a verdict on). This topic has absolutely no controls. It is painfully apparent how few are willing to look at this topic objectively, and I admit, I am even swayed in one direction (but I truly am trying to look at this as if I were undecided). The panacea should be objectivity, which we all must be capable of to write an effective medical chart, yet so few of us can display it in this forum. The mass of applicable research (read: trial evidence) is going to be done by society-at-large, not EMS. Why? No one will fund it. No one will be in the control group. No one will be able to control all the variables, least of all emotion, which science can not quantify, so it mostly chooses to ignore. One side looks at it and decides “guilty” and the other looks at the same thing from their perspective and cries “innocent”. This is beginning to sound like a lot of other studies that EMS adopts as proof of how it works this way outside EMS, so it must work the same way inside EMS too.

        • The Unwired Medic,

          You write a lot to say nothing.

          The reason this would be difficult to study is that the events are so rare that they would never reach statistically significant numbers.

          I have taken collegiate research courses before, and unless my professors were wrong, much research does not and cannot occur until something has happened.

          What is that supposed to mean?

          If we want to propose a treatment, we create a testable hypothesis (no scientific theory is needed) and attempt to get approval for the prospective study.

          Try to get a new treatment approved without some evidence. It will not happen often.

          Too much has been learned through the abysmal failure of wishful thinking-based treatments.

          This does slow down the drug development process, but it also prevents the deaths that would be required to remove the dangerous treatments that would otherwise be approved.

          Very few of the treatments drug companies test will ever be tested on humans, because they cause harm to animals.

          Of those that make it past the animal testing phase, many will never become approved treatments, because they lack efficacy, lack safety, or both.

          The days of Dr. Sadists Miracle Oil being sold are still with us, but they just use the Quack Miranda Warning –

          These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.

          As PalMD explains –

          Anyone who wants to sell you something that’s a load of crap must use this statement to cover themselves legally.

          Quack Miranda Warning
          White Coat Underground
          Musings on the intersection of science, medicine, and culture
          PalMD
          Article

          .

    • The Unwired Medic,

      Fact: Our society is predicated on the notion of assuming innocence before guilt.

      Guilt must be proven. I didn’t create the system, but I live in it. Now, interchange “safety” with “innocence” and “harm” with “guilt”, as it would be done in the courts, “When we assume safety and demand evidence of harm, we should be prevented from treating patients.” That, my colleague, will be the last day medicine progresses.

      Quite the opposite.

      These treatments should not be used until we have good evidence of efficacy and safety.

      Presuming the safety of treatments is ridiculous.

      Almost all treatments turn out to be dangerous and ineffective.

      These need to be limited to controlled trials until there is evidence of safety and efficacy.

      Rather, when does the benefit outweigh the risk?

      We will only really know that when we study it in controlled trials.

      Otherwise, we tend to fool ourselves, because we remember the successes and ignore the failures.

      This is why so many people believe the full moon affects call volume, or affects the severity of calls, or affects the type of calls.

      None of these are affected by the full moon, but people regularly (approximately every full moon) that they have more calls during the full moon, or that they have sicker or more seriously injured patients during the full moon, or that they have more psychiatric, or pregnant, or some other type of patients during the full moon.

      This is not true.

      If we accept this kind of common sense approach to treatment, we will kill a lot of patients.

      We deceive ourselves.

      We should not kill our patients to protect our egos.

      Incidentally, I tend to think of safety as a verb and a mindset, and proper application prevents harm more often than not and it almost never requires a gun.

      Yet you are suggesting that we abandon requirements for demonstration that a treatment is more beneficial than harmful before using it.

      That is not a safe approach. That is a cavalier approach.

      One of your sidebar quotes struck me as resonant with our “discussion” here… “All things are poison and nothing is without poison, only the dose permits something not to be poisonous. – Paracelsus.” Who gets to decide the dose? And if you disagree, what then?

      You need to be able to present evidence of safety and efficacy at a specific dose.

      Otherwise, it is just witchcraft.

      You label the declarant as ridiculous with bad arguments? Honestly, I expected you to be more open minded, but again, I am somtimes labeled the heretic who has a different opinion or way of doing things.

      I labelled the declaration as ridiculous.

      Be more open minded is one of the common sales tactics of frauds.

      Frauds want us to ignore the evidence.

      Frauds tell us that relying on evidence is closed minded.

      In your haste to proclaim your righteousness, you never bothered to look at the cumulative results of previous experiences and weigh the facts of all sides wearing the blindfold of justice.

      What cumulative results of previous experiences?

      Is this objective information that you are claiming to present objectively, while using the sales pitch of the quacks?

      I had a medical director like that once.

      You had a medical director who wanted real evidence and not just hunches?

      Excellent.

      Still, I don’t disagree with everything you have written, but neither will I further attempt to convince you there is another side besides yours. Is that enough equanimity?

      Equanimity?

      equanimity

      noun
      ▸a calm mental state when you deal with a difficult situation

      Why would I care how calm you are?

      My objection is to the ridiculous argument that we should presume safety, rather than demand evidence.

      My objection is to the ridiculous argument that we should presume efficacy, rather than demand evidence.

      This attitude kills.

      Killing our patients with equanimity is not admirable.

      I killed the patient, because I didn’t care enough to find out if the treatment works or if the treatment is safe, but I am not going to let that bother me. I have equanimity.

      Killing our patients by not discriminating between safe and unsafe is not admirable.

      Killing our patients by not discriminating between efficacious and not efficacious is not admirable.

      .

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