Trauma | the Goat Rodeo blog

The reason I don’t carry a gun has nothing to do with my political views, the NRA, or the second amendment of the Constitution. It has nothing to do with the fact that my professional life has involved caring for hundreds of victims of gun violence. I’ve operated on a lot more people that have been assaulted by McDonald’s fries and bacon cheeseburgers than guns. There are three reasons that I don’t own a gun. These reasons are fact, are unassailable arguments against my owning a gun, and almost never come up in discussions of gun ownership. The three reasons that I don’t own a gun are:

i. Guns only work when you pull the trigger.

ii. Guns only do one thing.

iii. I have children.

Very early in my surgical training, I was standing next to one of my fellow residents in the OR locker room as we changed out of our scrubs at the end of the day, both getting ready to head home. We were working at an inner city hospital in the late eighties, the place and time of a significant peak in gun violence. During summer on-call nights, I remember sitting on the loading ramp of the ER hanging out with the cops and paramedics, shooting the breeze and listening to the steady pop of handgun fire from across the city, the occasional tat-a-tat of an Uzi; some of it sounding like just a block or two away. It was Mogadishu, but with more snow and great Coney Island hotdogs. Anyways, I remember being in my first year as a resident and standing next to this second year as we got ready to leave, putting my keys back in my pocket as I noticed the other guy take a small handgun from his locker shelf and tuck it into his pants. I was shocked. I don’t think I had ever seen a “regular” person with a gun before. “You carry a gun?” I asked him.

“Yeah,” he said, slamming the locker. “You don’t?” I shook my head. “Well, good luck with that,” he said. As he left, I considered the fact that we were working in a very dangerous area, that my apartment a ten minute drive away was in an equally dangerous neighborhood, that one of our surgical attendings had his Camaro stolen twice in the past six months from the hospital parking garage. Just that day, there had been another newspaper article on the rising frequency of carjackings on the expressway I took home to visit my parents. Actually, I thought, he might have a point. The night before, I had been forced to circle my apartment building for twenty minutes, because when I pulled into the parking lot three dudes with Uzi’s slung on their shoulders were standing in my parking spot conducting a business transaction. One of the guys had politely suggested that I come back a little later, and I had taken his advice. Maybe having a gun wasn’t such a bad idea.

I briefly thought about the concept of owning a gun. It certainly wasn’t difficult as a physician to get a concealed carry permit. But after further consideration, I realized that for me, a gun would be a mistake. At that time, I came to my conclusion based upon Reason Number One: Guns only work when you pull the trigger. If you are carrying a gun, you have to be willing to use it. And by use it, I don’t mean pulling out your piece and waving it about at a possible assailant, saying “Back off, asshole, I’ve got a gun here.” That doesn’t work. That will get you killed. Carrying an unloaded gun doesn’t work. That will get you killed. No, if you decide to carry a gun, you have to be prepared (ie., trained and practiced) and willing to shoot a person. If you are not prepared and willing to shoot a person, you are worse than foolish to carry such a device, because the other guy must assume that you are carrying your gun because you are prepared and willing to shoot him with it. He will act accordingly. Which, by the way, also applies to any interactions with cops that you might have while carrying. If you carry a gun and you are pulled over for a traffic violation (see my previous blog post Trunk Full of Human Tissue), you must maintain both hands on the top of your steering wheel, window down, and greet the friendly officer with the statement “Good evening, officer. I have a loaded handgun under my seat for which I have a license. I will not move my hands from this steering wheel until you tell me to do so.” And say it all with a smile, or else you may be shot dead for speeding. I know this, because a driver was killed in my city during my residency under just this circumstance. Carrying a gun is a responsibility that must be carefully considered.

When I considered the implications of Rule Number One, I realized that it was stupid for me to have a gun, because I wasn’t willing to use it. Oh, I know what we all think, that you’ll find yourself in a situation where a Bad Person is spraying bullets at a busload of nuns and you’ll pull that gun out and blow him away, saving the day for all. But I knew better, and I still know better. Malice of intent is not an obvious condition. If you have a gun for protection, you have to be willing to shoot first. It is not a straight forward equation. Consider the following more likely scenario: You are walking to your car in an empty parking garage after a long day at work, your family waiting for your return home. As you approach, you see a man standing next to your car. You are carrying your gun. You yell, “Hey! Get away from my car.” The guy just looks at you with a defiant and threatening expression. Do you: 1. Say to yourself, “Screw it, I’m going back inside and getting security,” or 2. Pull out your loaded weapon and aim it at the individual. Perhaps you choose option number 2, hoping that your show of force will convince the guy to leave peacefully, preferably by raising his hands in the air and muttering something apologetic. But what if that doesn’t happen? It’s pretty dark, maybe the guy doesn’t see your gun. Maybe he didn’t understand your warning because your voice has become a falsetto, or he’s not an English speaker, or he’s hard of hearing. What if the dude instead bends down? Is he reaching for the twenty dollar bill he saw on the ground and that’s why he’s next to your car in the first place, or is he now removing a loaded gun from his sock? How long are you going to wait to find out before your shoot? At what point do you feel sufficiently threatened to pull the trigger? Because if you say that you will wait until the other individual has decided to persist in his threatening actions despite being warned with your raised gun, that you will wait until he straightens up and points his own gun at you, that you would wait until he starts to approach you in a threatening manner despite your repeated warnings, then you should not be carrying a gun. You will die. If you have a loaded gun, you must be prepared to use it at some point before you are fatally threatened, or you are just making the situation more dangerous for yourself. I realized with great certainty that I would never be able to shoot somebody just because I felt threatened. Which meant that a gun in my hands was worse than useless–it was dangerous. Bad idea. If you are carrying a gun, you will have to decide to pull the trigger. You also will have to spend the rest of your life living with your decision, right or wrong.

The second fact is that guns are designed to do only one thing: Kill the person they are aimed at. These machines are very effective. Trust me, as I am an expert in this regard. I have seen the effects in great detail and on many occasions. Do not believe, when you decide to pull the trigger of your gun, that the result will be anything other than a loud noise and the other person being suddenly dead. If you don’t believe me, please ask any police officer, federal agent, or soldier. Even the most skilled and practiced professional does not claim to be able to disarm, incapacitate, or neutralize the threat of another individual by shooting to wound. And you are not a professional: If you shoot at someone, you’re going to kill him. You will spend the rest of your life living with the knowledge that you killed a person. Not comfortable with this fact, buy a Taser or carry pepper spray instead.

Finally, it is a fact that I have children. If you have children, your child will find your gun. It is inevitable. At some point, your child will know you have a gun, will know where the gun is kept, will know where the ammunition for said gun is kept, will know where the key to the trigger lock or gun cabinet is kept. Do not kid yourself into thinking that your weapon will be a secret or completely secure unless it never enters your home or car. You may realize this fact and choose to address this challenge head-on, teaching your children gun safety, that it is strictly forbidden for them to touch the weapon without your permission. Admirable, but not always sufficient, I’m afraid (see “Children and Guns: The Hidden Toll,” New York Times Sept 28, 2013 http://www.nytimes.com/2013/09/29/us/children-and-guns-the-hidden-toll.html) . Children, particularly children of the male type, will feel a strong urge to disregard your rules. If you were once a male child or are the parent of a male child, you realize this fact. Not only will your child be aware of your gun and capable of obtaining it, loading it, and discharging it in your absence despite any and all of your efforts to the contrary, your child may at some point have the desire to do so. Of course, you say, I would never have a gun in the house if my child were in any way mentally or emotionally unstable. This, sadly, is a fallacious argument. Your three year old son is capable of discharging your gun but is not mature enough to consider the consequences. Your teenager is emotionally unstable by definition. If your child were to develop a mental illness, you may not be aware of this fact until it is too late. The first warning sign of your child’s depression may be the sound of a gunshot from their bedroom. You may not be aware of your child’s mental instability until you hear his name on the local news. If you have children, a gun in the house is dangerous. Period. You may choose to reduce that risk by taking all appropriate measures, but you will never eliminate it. Of course, the same thing applies to that bottle of prescription pain killers that you have on your bathroom shelf.

So that is why I don’t carry a gun. You are encouraged to come to your own decision, no problem. Just don’t ask me to let my kid have a sleep over at your house.

I spent summers during high school and the first half of college working as a bike mechanic. I love bicycles, and since I’ve always been the kind of racer with all the natural gifts to consistently finish last, I spent a lot of time fixing and tuning other people’s bikes. The guys who taught me how to fix bikes were professional, passionate mechanics, dedicated to their craft and absolutely, batshit crazy. As a young and impressionable adolescent, I was schooled in the ways of life, women, and bike repair by this motley gang. Amongst other things, they taught me how to kill a fly twenty feet away in midair by creating a flame thrower from a large squeeze bottle of WD40 and a butane lighter. They also taught me how to put out a fire in a confined space filled with flammable liquids. And how to swear. After the first year working with these proud professionals, I began to realize the difference in approach possessed by certain mechanics. When I was confronted by a difficult challenge, I’d seek advice from one of the older, wiser mechanics. Of course, they were all older and wiser. Often, this mentor would advise me to simply remove the malfunctioning part and replace it. Quick and easy. However, a couple of the more senior, seasoned mechanics, the guys who were still doing this after many years (with brief interruptions doing time in jail due to other, part-time occupations), would show me how to actually fix the offending part. Often, this repair would involve the deft application of a hammer and screwdriver, or a hammer and wrench, or hammer and an awl. Always a hammer, deftly applied. The repair was elegant, effective, and a lot cheaper than replacing the whole part. It wasn’t long before I realized that there was a world of difference in the approach these two types of completely competent mechanics would take to a difficult problem. Both would end up with a perfectly functioning bicycle. The “replacement mechanics,” however, cost the shop and the customer a lot more money. These guys were also the ones who always were in need of some special tool or wrench, the little used tools that were always squirreled away somewhere. They spent a lot of time looking for the exact tool that was needed to remove a bottom bracket or a gear cluster. The other guys though, the “fix-it mechanics,” never seemed to need more than a hammer and a couple of basic tools to make the most intricate repair on the most expensive Italian racing machines. And they did it cheaply, quickly, and half the time while hung over or higher than a kite. This impressed me. I always strove to be a “fix-it mechanic” whenever I could. I also built myself a damn nice racing bike from all the parts the “replacement mechanics” chucked into the broken bin. Still consistently ended up last. Many, many decades later, I have found the same phenomenon amongst surgeons; surgeons of every type and specialty. I can truthfully say that it is very, very rare to find a truly incompetent surgeon. In my nearly thirty years of practice, I can think of only one, as a matter of fact. Oh, I’ve run into a lot of surgeons that I wouldn’t let operate on my dog, don’t get me wrong. Many surgeons are arrogant (see Mommas, Don’t Let Your Babies Grow Up To Be Surgeons post on this blog), lack any semblance of beside manner, or are incapable of admitting when they screwed up. Some lack good judgement or have personal issues. But not truly incompetent. When faced with a sick patient needing surgery, almost every surgeon that has successfully completed an accredited residency will manage to do the right thing. But like in the bike shop, they don’t all do the same right thing. I remember a case during my training that illustrates the point. I was a fourth year resident on the trauma service. In my training program we saw a lot of trauma, so by the fourth year we were fairly competent in patching up holes in people made by various firearms. On a summer Sunday morning, a young man was brought to our ER with a recently acquired gunshot wound to the flank. I forget the exact story, but I can confidently say that the young man was simply shopping for groceries with the several hundred dollars rolled up in his pants, given to him by his grandma, when he was jumped in the alley by two dudes. It was always two dudes, because the victim would’ve blown away a single attacker and gone on to the grocery store to buy his grandma’s groceries, no problem. Pretty much the same story every time. Anyway, this otherwise healthy seventeen year old comes to the ER bleeding pretty impressively from his flank wound and in shock. My Chief is tied up with a list of operations left over from the night before so he asks the attending to staff me on the case. Usually, this would be a great opportunity for me as almost every attending surgeon at this hospital was an expert in trauma care and a great teacher. Almost every one. On this morning, I have the bad luck to be staffed by a newly hired attending, a young general surgeon fresh out of residency/trauma fellowship at a very prestigious Midwest academic medical center. Unfortunately, it was the kind of medical center that doesn’t see a lot of penetrating trauma. The kind of program that writes a lot of textbook chapters, publishes a lot of esoteric medical papers, but doesn’t do a lot of operating. My attending, Dr. Maisy Blue, is not happy. It is early on a sunny Sunday morning and she was planning on spending the morning in the call room “catching up on work”; she is quite distressed that the Chief has “dumped” this case on her. As we explore the patient’s abdomen, we discover that he has a through-and-through gunshot wound to the kidney with a collection of blood (hematoma) rapidly expanding within the capsule enveloping the kidney. The good news, though, is that the bullet has only injured the single kidney and otherwise exited the young man without incident. Pretty straightforward case, one that I’d participated in on a fairly recent occasion. I confidently outlined my plan to isolate the blood vessels carrying blood to the injured kidney, to be followed by repair of the organ. “No way,” Dr. Blue, counters, appearing quite uncomfortable with my plan. “He’s lost too much blood already.” She is clearly distressed as we watch the hematoma expanding. “It’s going in the bucket. He’s got another one, right?” I quickly check to make sure that this young man is not one of the few individuals born with only one kidney and confirm to her that he indeed does have another, uninjured kidney, but– No ‘buts’ about it, Dr. B has already begun to dissect the capsule surrounding the injured kidney, resulting in a large gush of bright red blood. She clamps her hand around the kidney, holding pressure. “Take it out, Geller,” she instructs. Which I do, clamping and tying the necessary blood vessels. Once freed, Dr. Blue ceremoniously plops the kidney into a stainless steel basin. “Done,” she pronounces. “You can close with the medical student, right?” No problem. Young man did great, went home to his grandma three days later with a really cool scar and one perfectly good kidney. Which should do him nicely for his whole life, really. Unless somewhere down the line he gets kidney cancer, or has the bad luck to get shot in the other flank. Should be fine. I just would rather fix it, that’s all I’m saying.