Armed patients in the hospital

[Odd Job]

As many of you know, I am writing a book on gunshot wounds (forensic and technical aspects thereof mainly) and one of the things I am adding as an appendix is the handling of armed patients. In the Johannesburg hospital where I worked, we would frequently get armed patients coming into the X-ray department. Most of the time these patients would not be any trouble, but excpetions have and do occur. Now bearing in mind that most radiographers in SA are female and do not own firearms themselves, and also bearing in mind the type of security staff employed by most SA hospitals (unarmed), I have to come up with a protocol for the safe handling of these patients in the X-ray department. The premise being that most of the time the patient cannot be X-rayed while carrying a gun or magazines or sundry items related to the gun, for reasons of artefact and positioning and safety. With this in mind, here is what I have come up with. I would appreciate any feedback on this.
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APPENDIX A – X-raying the Armed Patient
(Advice for the South African radiographer)

In South Africa I have frequently had to X-ray patients who have arrived in the X-ray department carrying concealed firearms. The fact that the weapons were concealed explains why the patients were not challenged by security. Even patients attending medical casualty departments can arrive armed. A typical example would be a patient coming to hospital to attend a clinic. He is seen by the doctor, who may or may not notice the firearm during the physical examination. If the doctor notices the firearm but suspects that the patient will not be admitted, he will usually send the patient along to the X-ray department without commenting on the weapon.
When the radiographer takes the patient into the room, the patient may reveal the firearm, asking whether it will affect the X-ray procedure. You might say it is simple: we must take the weapon from the patient while he is having his X-ray. This is where we start running into problems. Firstly, who must take the weapon? An obvious choice is hospital security, but let’s think it over first and see if there are pitfalls:

a) There is time wastage while security responds.
b) Hospital security guards in South Africa are usually not familiar with firearms, being armed with batons only, in the majority of hospitals. It would be unreasonable for us to assume that the hospital security staff would be trained to the same level as airport security. While it looks good, legally, that the security guard had the firearm at the time (should there be an accidental discharge or loss of some sort) I don’t believe there is much merit for having the security guard take charge of the weapon, from a safety point of view. The patient would have to claim the weapon from the security office when he leaves the hospital; an inconvenience he will not take kindly to. There is also a remoteness about the security office which would make a patient worry about the whereabouts and integrity of his firearm. This may cause him to want to rush the examination or not pay proper attention to the radiographer. I would not be very comfortable handing over my weapon to a hospital security guard in South Africa.
c) An over-zealous security guard may ask the patient if he has a license for the weapon. In fact, most hospital firearm safe registers require that the serial number and license number of the firearm be logged. Depending on the circumstances, this can result in conflict.

The patient cannot keep the weapon on his person during the examination because:
i. There is the possibility that it will cause an image artefact. Support lanyards and holsters will also cause artefacts.
ii. In supine work it will be uncomfortable for the patient to roll over for any lateral views as he may roll over the gun.
iii. The patient may not have a proper holster and there is the risk of the weapon falling onto the floor during positioning. If the gun falls onto the floor it could discharge. Many gun owners do not even use holsters. They stuff the weapon down the back or front of their trousers or leave it loose in a pocket.
iv. Pistols are more popular than revolvers in South Africa. Spare magazines are usually kept on the opposite side of the body to where the gun is kept. These can also cause artefacts and will cause discomfort during positioning.

I recommend that you use these guidelines while handling a patient who reveals, or volunteers to hand over, a firearm prior to being X-rayed:

a) You have to accept that you do not know enough about firearms to be able to make every weapon safe. I accept that myself. Making a weapon safe involves removing all cartridges from the weapon so that it cannot be fired accidentally or intentionally. You cannot guarantee that any actions taken to make the weapon safe will not result in an accidental discharge, or damage to staff, patient, X-ray equipment or even the firearm itself.
b) You cannot assume that the patient is competent or fit enough to make the weapon safe, himself. He is, after all, at the hospital because there is some problem with him physically or mentally. The hospital surroundings are alien to him and he may be especially apprehensive because he is worried about his diagnosis.
c) No member of staff can swear that the weapon is safe to handle. It may have been modified or abused in some way that results in it being a dangerous item to make safe. The gun may have a defect that not even the owner is aware of, which could result in an accidental discharge if the weapon is handled. Even a trained professional would need the proper laboratory facilities to examine the firearm and comment on its structural and functional integrity. The hospital is no place to do this.

It should be obvious to you that if we are not going to let the patient hold the weapon and if nobody is going to make the weapon safe, then the best course of action is if nobody holds the weapon. If nobody is holding it and nobody is fiddling with it, then there cannot be an accidental discharge. Ideally, every examination room and X-ray room would have its own safe for storing patients’ valuables. Cost and logistical factors in the installation of such safes, as well as abuse of such safes and keys by staff, means it is impractical to have a safe in each X-ray room in South African hospitals.
You should follow these guidelines:

(continued)...

[Odd Job]

1) Nobody must attempt to make the weapon safe. The patient must be told before he produces the weapon, that it is not necessary for him to make the weapon safe.
2) The firearm must not be taken out of the X-ray room during the examination. The weapon is brought in by the patient and the weapon leaves with the patient. The firearm must not be left in the changing room, even if the patient leaves his clothes in the changing room.
3) You must not keep the weapon on your person. The weapon must not be placed in a staff member’s locker.
4) Ideally, you do not need to touch the weapon at all. You should ask the patient to place the weapon (preferably in its holster) on the floor at the foot of the erect Bucky where he can retrieve it after the examination. Any spare magazines or cartridges must be placed next to the weapon. While placing the weapon on the floor, the patient must not attempt to engage any safety catches or remove the magazine or any cartridges from the weapon. If he is having supine views done, the weapon must be placed on the floor at the foot end of the X-ray table, a few inches away from the table support skirt. This is so that the patient knows where the weapon is at all times, yet it will not be in a position that obstructs or affects the X-ray equipment. If necessary the radiographer should explain to the patient that X-rays have no detrimental effect on arms and ammunition. I have been asked by numerous patients whether X-rays can cause cartridges to discharge and whether the firearm will become radio-active because it has been in the X-ray room during the examination. The answer is, of course, negative in both instances.
5) If you take the weapon to place it on the floor then you must handle it by the grip only, making sure you hold the grip firmly with all your fingers. It is no use taking the gun if you are going to hold it gingerly as if it could bite you at any time. If the gun is handed over in its holster, then one hand must still be on the grip, while the other hand grasps the holster just in front of the trigger guard. At no time must the gun be handed over so that it points at the radiographer or the patient, regardless of whether it is handed over in a holster or not. The barrel of the weapon should be pointed at the floor during the hand-over and any carrying of the weapon.
6) The weapon must not be visible from the X-ray room doorway, or placed in a position where a passer-by could see it. No relatives must be allowed into the room. All handling of the firearm should be done behind closed X-ray doors.
7) If auxiliary personnel are available they should keep a watchful eye on the X-ray room. This is good practise anyway, because then the patient is not left alone while you process films or digitally manipulate images on the computer workstation.

The above steps are taken only when it is clear that the patient revealed the weapon or offered it up for safe keeping prior to the examination. In other words, the patient was obviously keen to cooperate. Also, the above steps are taken only if there is no reason for you to believe that the patient is going to be admitted. If he is being admitted, then he has no choice but to surrender the weapon to security or a relative.
The situation changes if the weapon is not revealed by the patient but is discovered by the radiographer when an item of clothing is removed, or during positioning. In this case the radiographer has to be careful how he/she handles the situation. It must be assumed that the patient had no intention of revealing the weapon or had good reason to keep it concealed. It may just be that the individual has an inherent distrust of all people when it comes to his firearm, or it may be something equally innocuous such as he did not think it would affect the examination. If he seems unfazed and is not agitated by the discovery of the gun, then he should place the weapon in one of the two places mentioned previously. Rarely, you get a taciturn individual who will not give up his firearm. If he will not cooperate even after you’ve explained about the possibility of image artefacts, then you must weigh up the situation carefully. Give him the option of depositing the gun with security, although it is unlikely he will do that. Depending on the urgency of the views and the patient’s condition, you may suggest that the patient calls a relative or someone he trusts to take charge of the weapon. In this case, the time wastage is caused by the patient and he must accept it. Page the referring clinician and advise him of the delay. Do not try to negotiate at length with the patient about handing over the firearm. There could be nefarious elements to his refusal: the weapon could be illegally owned or incriminating in some way. Remember that patients do not understand that the weapon’s history is unimportant to us and that we are there to provide an impartial but safe service. If he will not surrender his weapon, you are under no obligation to X-ray him. You have the right to work in a safe environment and it is your responsibility to ensure that the patient is safe while in your care. Having to repeat views because of known artefacts is abuse of ionising radiation and is a dose concern. If you explain all these things to the patient, he will usually comply even if it is grudgingly. Do not mention to the patient that you are worried that the gun could be dropped or accidentally discharged if it is not handed over. He is likely to be offended if you say something that challenges his competence as a firearm owner. Limit your concerns and explanations to the image artefact and positioning issues. Your goal is to avoid an argument.

The next two scenarios are unlikely but are nevertheless possible in X-ray departments offering an after hours service to a casualty department:
a) The patient refuses to part with the firearm and demands to be X-rayed immediately, or becomes aggressive.
b) The patient has a firearm and he is inebriated or under the influence of chemicals/drugs or exhibits behaviour that is not appropriate for one who is carrying a firearm in a public place.

The above instances represent situations where the radiographer cannot be expected to continue the examination or even remain in the company of the patient. This is a serious security matter beyond the duties and capabilities of the radiographer.
I recommend that someone discreetly calls security and advises them of the situation. Nine times out of ten, security will call the police if there is an unruly armed individual in the hospital. The radiographer should use delay tactics to placate the individual until the police arrive. Security should keep their distance but be ready to intervene as a last resort if the patient takes offensive action.
Usually this kind of patient will have been disarmed in the casualty department and would arrive in the X-ray department with an escort.
However, you cannot assume that an unruly patient will arrive with an escort, or that he is unarmed. Be careful at all times and expect trouble. There are many staff members in hospitals who are reserve policemen or who take part in shooting competitions and have NRA-approved certificates. They are usually casualty doctors or paramedics. They will be able to offer good advice if there is a problem with an unruly patient who is armed.
At all times when dealing with armed patients, try to maintain an air of calm confidence. If you exhibit shock, nervousness or fear, you will place doubt in the patient’s mind about his security and that of his firearm. Your confidence can be boosted by completing an approved basic handgun safety course. These courses are widely available in South Africa.

[Eghad]

The easiest method would be to have a locker(s) with a key in them that the patient can deposit his firearm in and take the key. Many jails use this type of system because officers can not carry a firearm into a jail or prison.

[joab]

The easiest method would be to have a locker(s) with a key in them that the patient can deposit his firearm in and take the key.

That's how I did it when I needed an MRI, but for the life of me I can't remember what I did with the key during the procedure, or possibly it was just an unlocked locker

[CDH]

Patients entering hospitals for care of any kind should NOT be armed. Their weapons should be safely lockered upon their check-in and returned when they leave. Period.

It is not always possible to know exactly WHY the patient is there. People in severe physical stress are also often (more often than not?) in phsychological stress as well, maybe even delirious.

I don't have a clue why this subject even came up. Do hospital patients, even in South Africa, have a need for defense from others within the hospital?

If protection of a patient is necessary for some reason, then it is up to the hospital to provide it, not the patient. The patient has other things to worry about.

Metal detectors at the entrance doors to the hospital would be a great help here.

It sounds like people in that South Africa hospital management team are trying to figure out ways to cure a symptom without addressing the real problem. Just take their damn guns away at the door! If a guard has to draw down on the patient to do that, then so be it.

Carter

[Odd Job]

It would help greatly if you gents read my entire posts before responding.

[Odd Job]

For those who missed the salient points, I will list them here very briefly:

1) Patients are arriving at the hospital armed. That is a fact. It can't be changed. I can think of any number of reasons why this happens. Two easy ones: he wants protection en route to the hospital or he didn't plan to go to hospital that morning when he armed himself.

2) Lockers are ideal, I said that myself. But logistics does not allow for that. Safes and keys would be abused by staff, not to mention the cost of installing these. The management would just say 'make him hand it in to security.'

[rms/pa]

wow,

when i unexpectedly ended up in the cardiac unit here, i was armed.
i asked the nurse what about my gun? as i was being undressed.
she gets a towel says "put it here and ask for me when you leave"
she puts it in the towel and disappears and comes back.

while waiting for discharge i read hospital regs which are firmly on the "call security" and paperwork line of thought about firearms. and the nurse comes back with mine in a towel. i asked her about the regs. she says "we do not trust security with firearms here."

rms/pa

[Heist]

It should be obvious to you that if we are not going to let the patient hold the weapon and if nobody is going to make the weapon safe, then the best course of action is if nobody holds the weapon. If nobody is holding it and nobody is fiddling with it, then there cannot be an accidental discharge.

Very logical. I liked reading that.

[gunslinger555]

I think some kind of check in is a good idea, like locked lockers that you can put your arms in when you arrive and get when leave, if you aren't impaired by medications and if you are you can keep them their until the meads wear off or someone picks it up for you.

[Oldphart]

I have gone through this very scenario in the past. The attendant told me to undress and put on the robe she furnished. I did so, rolled my gun up in my clothes and carried the bundle to the x-ray room where I laid it on a shelf out of the way yet visible to me. On another occasion when I was less able to take care of myself (we thought I was having a heart attack) I simply rolled it up in a towel and had my wife carry it in a plastic bag.
The first thing you have to do is realize the gun isn't really a problem. The patient may be but if so and if it isn't an emergency situation, you can call the police. I don't think I would do that unless the patient clearly showed signs that he was unable to control himself or his gun. Generally, explaining the situation to the patient will get you a whole lot further than trying to impose 'regulations' on him.
Another possible solution might be to have a class for those workers who might have to deal with firearms. If they know what they're doing with a gun it will be a lot easier and safer for everybody.
All in all, there are very few times when I would try to separate a peaceful patient from his gun.

[mgdavis]

Rather than having lockers installed, you could get a padded case, like a Pelican brand case or a briefcase-style padded box like these. It could be padlocked, and should prevent exessive handling. Patient walks over, places handgun, magazines, knife, etc in the box, box is closed and locked, attendent hangs onto key until exam is finished.

[Blackwater OPS]

Basically, the plan you have laid out is to put the gun on the floor, and have the individual move it when he moves. I don't really like the idea for a number of reasons, but I realize you are limited as far as options. My suggestion for a slight modification that should be possible without to much trouble is to instead have the person place the weapon and related items into a bucket/tray(like they have at airport security). There should be something handy in the hospital that could be used for this purpose. This way the firearm would be protected from the floor, hands of careless people, and could still be moved around with the person and kept in sight of same.

The rest is very good, esp. not making the gun "safe"(less handling is MUCH better), and what to do if the person is unruly. IMO if they are acting in way that the police must be called I would suggest leaving them alone in the room and waiting somewhere else rather than trying to delay them. If in fact they want to leave the hospital at that point, it's no skin off your back. Seems to me being left alone in an x-ray room(or any other hospital room for that matter) for long periods of time is a pretty common thing. Just my 2 cents, YMMV.

[Odd Job]

@ Blackwater OPS

Thanks very much, that is the sort of reply I was looking for. I note the bucket idea as an alternative to having the weapon as-is on the floor. The bucket/drawer probably won't get stolen by the staff like a case would.

As for leaving a guy alone in an X-ray room, there are a few problems with that. He might fiddle around with the equipment if he gets bored, or he might come out of the room to see what's taking so long and find the radiographer doing bugger-all in the processing area. There will be strife then.
I'm inclined to go through all the motions but not expose, while waiting for police. He won't know the difference. That way if he suddenly collapses at least there is some supervision involved. I'm trying to strike a balance between leaving him alone entirely and still trying to make sure no harm is done to him or me.
The reason for the patient's bad behaviour is often not immediately apparent. Here is an example: one night I was called to the medical casualty department to do a portable chest X-ray on a 50 year-old woman. She was a stocky Portuguese woman on a stretcher and when I arrived she was looking around but not talking, and was on oxygen. The nurse left as soon as I took out the X-ray cassette. As I sat the woman forward to position the cassette, she started puking. That was a big problem, seeing as though she had on an oxygen mask and now she could choke on her own vomit. Some of the vomit escaped through the right side-hole of the mask and got me on my leg. There was nothing I could do, I had to rip that mask off her face and turn her sideways. My shoes got a load too. I shouted for the nurse and she brought me some paper towels and I wiped the woman's mouth. I had her securely and she was settling down so the nurse stood back.
After a minute or two I helped the woman lie back and I leaned forward to ask her if she was alright.

BAMMM!!!

She punched me just under my right eye, such a fierce blow that I got that yellow flash in my head and I reeled back. It was an impressive shot, I tell you. It was a very hard hit and I stepped a few paces back because she was still swinging. Next thing is, she cupped her hands between her legs, urinated in them and threw the urine in my general direction. Some drops got me on my neck and shoulder. That's when I told the nurse that I had reached the limit of what I could endure with that patient. I told her I would come back later if she was sedated. I couldn't believe it: I had been puked on, punched and urinated on by this one patient. I was really sour about that. However the patient went for a brain scan later that evening and a tumour was found with some recent bleeding around it. The poor woman probably didn't mean to hit me like that, probably didn't even realise what she was doing.

So there you have it. People often don't act within their usual parameters. Of course you do still get the perfectly compos mentis moron such as the guy who arrived at the trauma casualty department with a gunshot injury to his foot and couldn't be seen by any doctor immediately because we just happened to have three simultaneous resus patients on the boil, one MVA and two gunshot chests. This guy with the foot wanted to be seen immediately and demanded that one of the doctors leave a resus patient and come to him. Even though the situation was explained to him, he didn't care for the other patients and produced a pistol and demanded to be seen immediately. One of the nurses managed to talk him out of doing something silly and said she would fetch the doctor. I can't say on this board what happened next, but the result was the guy was disarmed and he ended up waiting just like any one of us would have.

[rms/pa]

triage, the coldest concept in the world when you are on the down side of it.

rms/pa