Pistol-Packin` Patients

     You are dispatched to a person "not awake but breathing" at the local park. Upon arrival your crew, including an EMT student, finds an adult female unresponsive, with classic signs of anaphylaxis. After initiating treatment, you decide to conduct the rest of your physical assessment en route. As transport begins, your student starts an exam, and the patient begins to respond. Suddenly the student exclaims, "Hey, she's got a gun!"

     EMS providers may encounter patients who are armed. Awareness of a patient's handgun may come through the patient's admission or by discovery during the physical exam. This article deals primarily with patients who are armed legally and not behaving aggressively toward EMS.

     Absent other factors, the mere presence of a legally carried handgun should not indicate a threat to provider safety. Concealed-carry permit holders have a criminal conviction rate much lower than that of the general population.^1–3 Illegally carried handguns obviously present a different set of concerns. As a rule of thumb, the vast majority of off-duty law enforcement officers (LEOs) and legally armed citizens use holsters, while illegally carried handguns are usually found tucked in the waistband or pocketed without a holster. Many LEOs are required to wear badges next to their weapons. Only government-issued badges and documents are official.

     Citizens in 48 states can carry concealed weapons with a permit (the exceptions being Illinois and Wisconsin, plus Washington, DC). Permit holders account for more than 1.3% of the population.⁴ This means more than one in every 100 patients can be assumed to have a permit, although not all permit holders will be in possession of a firearm when seen by EMS. Usually citizens are required to attend firearms training and pass a background check before they're issued a permit to carry a concealed weapon. The prerequisites vary by state. Vermont and Alaska allow concealed weapons without permits, and unconcealed carry of handguns without a permit is legal in many states.⁵ Nebraska recently enacted legislation requiring permit holders to disclose and surrender their handguns to EMS personnel.⁶ However, most states have no such legislation, and patients with altered levels of consciousness may be unable to comply with such a law.

     EMS agencies should have protocols in place for dealing with legally carried firearms. Providers have a duty to themselves and their coworkers to make handguns safe until they can be secured or turned over to law enforcement. It is dangerous to leave firearms with ill or injured patients such as the one in our opening scenario—she may require immediate treatment, have an altered level of consciousness or be physically impaired by injury. The handgun may impede application of a backboard. Narcotic treatment may be indicated, such as for pain management.

     There is no cause for alarm when taking custody of a firearm. Handguns do not "go off" by themselves. A handgun will only discharge if the trigger is depressed or if there is a mechanical malfunction. Such malfunctions are extremely rare. There have been isolated cases of discharge when a firearm is dropped, usually involving old guns. Fortunately, there is an established set of rules to govern the safe handling of firearms (see Table 1).

     To maximize safety, EMS providers are encouraged to seek professional instruction prior to attempting to manipulate any handgun. Gun shops and trainers in your area may be willing to offer brief tutorials.

     The information in this article is meant only as a general reference to augment, not replace, hands-on instruction. The variety of handguns, especially pistols, available on the market and the steps required to unload and/or make them safe cannot be adequately addressed without hands-on instruction.

     Virtually all holsters are designed to prevent inadvertent trigger presses by covering the trigger. Most have retention features that prevent the handgun from being easily dislodged or removed. These features include buttons, straps and tight "friction" fit. Some holsters are secured to the body by solid belt loops, while others slip over the belt. Usually, holsters can be removed with the firearm safely inside. Lacking a holster, some knowledge of handgun mechanisms is necessary to maintain safety.

     You may find a holstered handgun at any point along the belt, in an elastic band or pouch inside clothing, under the armpit, on the ankle or thigh, hanging from a necklace, or in a pocket. Handguns are usually carried loaded and with extra ammunition. You may find other weapons as well, including additional handguns. Several manufacturers offer specialty concealment apparel with hidden pockets. Off-body carry options include purses, fanny packs, day planners and backpacks.

     What kinds of handguns may be found on patients?

     A revolver is designed to place a cartridge (cased bullet and powder) under the hammer for firing by using a rotating cylinder that may hold 5-7 cartridges. Cocking the hammer rotates the cylinder. Pressing the trigger causes the cartridge to fire. Most modern revolvers will cock automatically when the trigger is pressed, eliminating the need for two separate actions. Some revolvers do not have external (visible) hammers. The revolver is rarely seen with a manual safety device, as safety is assumed due to its heavy trigger pull weight. While some may be modified for a light (hair-trigger) pull weight, this only applies if the revolver is cocked. If a revolver is found cocked, be extremely careful. Only touch a cocked revolver if you must immediately remove it from a dangerous situation. A cocked revolver cannot be unloaded until it is uncocked. There is danger in uncocking a revolver even for experienced gun users. To uncock a revolver, it must be put through a firing sequence. For right-handed operation:

• Place the left thumb blocking the hammer. This is your safety.
• Hold the right thumb on the hammer.
• Press the trigger with the right index finger.
• Slowly lower the hammer completely, gradually withdrawing the left thumb.

     To unload an uncocked revolver:

• Press the cylinder latch, located behind the cylinder on the left side, forward, back or in, depending on the design.
• Push the cylinder open from the right, tip the barrel up, and allow the cartridges to drop free.
• Occasionally the ejector rod, located at the front center of the cylinder, must be depressed to facilitate unloading.

     Fully automatic pistols, which fire multiple times with one press of the trigger, are rare, but may be encountered with some specialized protective or law enforcement agencies. Most of these look like small submachine guns. Semi-automatic pistols are loaded by inserting a loaded magazine, then manually cycling (pulling back) the slide. Pressing the trigger and firing the pistol causes the slide to cycle and places another cartridge in the chamber, making it ready to fire again by another pull of the trigger.

     There is no industry standard for the operational controls on pistols. A pistol may or may not have a manual safety. If available, this is usually located on the upper left side at the rear (near the thumb). On many pistols, up means safe, and down means fire. Some have the opposite function. Most have an indicator such as a red dot or other icon visible to indicate readiness to fire. Some safeties have an uncocking feature, which requires a downward press. Many semi-auto pistols have no external hammer. Some are designed to be carried "cocked and locked"—that is, cocked with the safety engaged. The uncocking procedure for these carries the same danger as revolvers. Having the pistol owner's instructions or a working knowledge of the pistol is mandatory prior to unloading. The magazine release is usually located at the rear of the trigger guard on the left side, but may be on the right or at the bottom of the grip. The magazine may drop rapidly or may have to be pulled free. Removing the magazine does not remove the cartridge already loaded into the chamber. The slide must be cycled to remove this cartridge. The safety may have to be disengaged to cycle the slide. Failure to remove the magazine prior to cycling the slide will only cycle another round into the chamber, so be sure to remove the magazine first.

     What do you do with a discovered handgun? If it's holstered, leave it there. This is the safest way to remove and handle a handgun. It is not necessary to unload a holstered handgun; unnecessary manipulation increases the risk of discharge. Cut the belt or holster away if necessary. Be aware that a growing number of handguns can be key-locked with a key supplied by the manufacturer. These keys are universal by manufacturer—i.e., all Taurus keys will actuate all Taurus locks.

     Absent a holster, a case designed for handgun storage is mandatory to prevent inadvertent manipulation of the trigger. This can be kept in your drug locker or another lockable compartment. Store the handgun in a lockable pistol case; these can be found at many sporting goods stores. Lock the case with its integral lock or a padlock, with the key kept on the ignition ring. This is also a recommended safety measure for holstered handguns.⁷ If possible, secure the cased handgun in a locking cabinet, such as the one used for your medications.

     After turning your patient over at the emergency department, have security take possession of the handgun, and get a receipt. Coordinate the hospital's firearm policy with your own, and make sure the patient is made aware of the disposition of their property.

     Some patients may be reluctant to surrender their handguns. They may not want an untrained person touching their gun, or to risk its misplacement. EMS providers may also, for a variety of reasons, be barred from possessing handguns. In such cases, give custody of the gun to a relative who may legally possess it, leave it in the home or locked in the trunk of a car, or unload it prior to transport. If none of these solutions are acceptable to the patient, EMS may have to request an LEO.

     EMS safety is paramount. If at any time a crew is not comfortable with an armed patient or a scene seems unsafe, withdraw and wait for an LEO. For more on handling armed patients who are violent toward EMS, see the sidebar Bad Intentions.

     While armed patients may not be encountered frequently, their handguns require knowledge and training to be properly handled. Your first priority is to end your shift safely. No EMS agency wants its personnel to become victims of assault, or to be responsible for mishandling a weapon that hurts someone. Be aware of your surroundings, and know how to handle firearms safely.

     Col. Jeff Cooper, one of the 20th century's foremost experts on small arms, developed four basic rules for the safe handling of guns:

1. Always consider all guns to be loaded.
2. Never point the muzzle at anything you aren't willing to destroy.
3. Keep your finger and other objects off the trigger and out of the trigger guard at all times.
4. Always be sure of your target.

     For more, see www.thegunzone.com/therules.html.

1. www.largo.org/Lott.html.

2. www.azccw.com.

3. www.txdps.state.tx.us/administration/crime_records/chl/convrates.htm.

4. Philip Van Cleave, president, Virginia Citizens Defense League.

5. www.handgunlaw.us.

6. www.unicam.state.ne.us/legal/SLIP_LB454.pdf.

7. www.midwayusa.com.

     Alan W. Rose is a paramedic with Medical Transport LLC, and works in Southampton County, VA's EMS system. Reach him at paramedic70002@yahoo.com.