My last 2 posts were about the loss of perceived neutrality by society of EMS providers and by extension public safety officials and medical providers. Over the holidays this has been a hot topic of discussion within the circles I regularly associate with. My friend of DT4EMS fame, Kip, recently filmed a short video (I am not sure if it is publically released yet so no link here, check out his website. DT4EMS.com) about “tacti-cal” vs. “tacti-Kewl” (phrases entirely of his making). In this video he basically puts my thoughts into much easier to digest form. But during the discussion, I started to wonder how, where, and when this all started. In the last post, and for many years prior I have lamented the change in the attitudes of public service and emergency providers in general post Sept. 11, 2001. But Kip’s video, coupled with a recent news article about the Afghanistan war, and the ongoing coverage of Putin’s Russia, has led to my “Eureka moment.”
Since September of 2001, the United States and many allied countries have been on war footing. In addition to the near constant attacks on Israel, as well as the whole Kamikaze attacks on the US, civil wars in Africa, and several instances around Europe and South East Asia, Islamic extremists have basically been attacking Western values at every turn. Let’s just dispose of the political correctness and call a spade a spade. I don’t see Catholic suicide bombers flying jets into buildings. I don’t see Jewish people selling women into sexual slavery, I don’t see Zen Taoists creating hate groups about women not playing the traditional role of subservience in society, and I don’t see Buddhists demanding the equivalent of Sharia law wherever they turn up from London to Sydney. Now I am not saying these other religions or even some cultures or countries are not without sin, I mean the US tortures prisoners with the support of the majority party in government… Let’s face it, that is medieval in belief and no different than what Islamists are doing, but it definitely contributes to an “Us vs. Them” situation. Basically the conflict of man vs. man, revolving on a set of moral/sociological principles.
All of this has created both fear and need for mental security. I don’t know any person in this world that doesn’t know somebody who has been affected by war in some way. Perhaps they were a soldier or sailor in a war. Perhaps they had a friend or relative injured or killed in war. Perhaps like me, they spent time as a contractor in a war zone. Maybe they are educators trying to reintegrate former men and women at arms into civilian jobs. As broadcast on the news yesterday, for 13 years, more than 3x as long as WWI and WWII, 4x longer than the War in Korea, 2x longer than Vietnam, and infinitely longer than the First Iraq war. This need for security, both physical and mental in daily living has polarized to the extreme all manner of social entities. Of greatest concern to me personally are medical providers and other forms of public safety forces.
When the Iraq war broke out, I was contacted by a student group from a university. The caller explained to me that her student group was looking for a speaker to add an opposing view to their anti-war rally. I asked what this had to do with me, she said she already had contacted both military recruiters and followed up with US military PR contacts, all who refused to speak. My question of course was “So why did you call me?” The explanation I received was that they had learned that many medical advances have come from war, so contacting a medical provider might provide what they were looking for. In the end, we agreed I would deliver a presentation of medical advances from war which was neither pro nor anti- war, and the listeners could make their own conclusions on the cost/benefit analysis. (Who in their right mind becomes the pro-war speaker at an anti-war rally right?) Looking back, these people were protesting what I would say was the beginning of a shift in civilian culture, one that does not seek war or conflict, to one that not only demands it, but doesn’t remember any other way.
When I accepted a contracting job in Afghanistan, primarily at Kandahar Air Field, with a little bit of Camp Leatherneck thrown in for variety, (actually corporate need, but let’s not quibble over terms)many people had basically said their “good-byes” to me like my death was already a forgone conclusion. I didn’t think of it myself as really going to war. More like yet another dangerous environment where people needed medical help, a rather normal event for me. I asked my prospective employer if there would be anyone directly shooting guns at me. I asked if anyone would be lobbing mortar rounds at me, and both occurrences were denied. I did not cross my mind to ask about artillery, so you can imagine my surprise when I first got off the plane and was given instructions on what to do in the event of a rocket attack. My boss and I had a brief discussion about this “oversight” and after the evening rocket attack, I decided it wasn’t intolerable. Eventually it became more of a nuisance rather than a threat, though towards the end of my time, the frequency and duration was making it actually dangerous. Before I went, I decided I should do some research before I got there. After all, you should have an idea what is going on if you expect to help. I looked up various sources on what happened to the Russians in their Afghan war. I studied various publications the military put out, but one that really seemed to be accurate was the psychiatric manual. In it there was a passage about how artillery had the greatest psychological impact on soldiers compared to any other aspect of war. The reason it gave is because every aspect of being bombarded is completely out of the control of the “victim,” defender, I am not sure the right word to use. There are even accounts of soldiers committing suicide from the mental stress of being shelled. But when you look at the modern world, especially in the US and Western nations, there is an overall feeling of powerlessness among the populations. Like the victims of being shelled, the stress over that which affects them beyond their control, contributes to things like PTSD, but it also creates efforts to control things.
I mention all of this because I think it is important background. You see, public safety and emergency medicine gets a lot from the military. It imitates the military often without any thought of whether it is the right thing to do outside of a war zone. Some of it fits, some of it definitely doesn’t. But it often takes a long time for anyone to realize and change what doesn’t work. The other thing to consider is that emergency medicine, related disciplines like trauma surgery, and public safety attract the same personalities as military persons. It provides a similar environment and perhaps the thing most important to me, a certain comraderie. These civilian positions also attract and give preferential hiring to military people. So it is not amazing to discover that the people involved with these jobs after more than a decade, a whole generation, are becoming more militarized.
These seemingly unconnected ideas, threats and actual violence against civilian populations, differences in culture and beliefs, the mental stress of factors beyond control, an entire generation who has experienced constant war, the mentality of providers, and the mental security and behaviors of the military, are all playing a dominant role in the values and culture of medicine and public safety.
Some are beneficial, like damage control surgery, tourniquet usage, defined chains of command during disasters and such. Some are harmful, such as the creation of a caste system, the moral aversion to diversity in people and their lot in life, and the treating of non-military matters as if they were a military mission or somehow using military tactics will solve any problem created. Unfortunately, the later is simply not realistic.
This plays out in emergency circles in many ways, such as the focus on acquiring “tactical” training and equipment to acting like moral police enforcing the values of the providers in the name of safety and protection. Dressing up and pretending to be a military special forces operator has become “cool”. It is said that imitation is the best form of flattery, but consider that if some random person dresses up all military, they run afoul of “stolen valor” laws, but if a police officer or even a “tactical” doctor do it, well, that is entirely a different matter; especially in the name of personal or public safety.
Back in earlier times when providers did things like dress up with all kinds of equipment far in excess of what was needed, “just in case”, did things like put light bars on their personal vehicles, invested in communication equipment that would make the SETI project seem pitiful, and drove around town with all kinds of medical gear in the event they were called upon to “save a life,” we had a derogatory names for these people. We called them Rickey rescue, or whackers. There was no mistaking it was not a behavior that was acceptable, and I suspect there may even be some mental issues with such people. Today though it has been renamed “tactical” and it is cool. Tacti-Kewl.
After all, how can dressing up like an urban special forces operator, showing up at medical event with prefabricated tourniquets, some OD green chemical bandages, and tactical black SAM splints, not be the epitome of a top quality medical operator?
There is no shortage of crazy training for it either. I was employed at one agency with it’s own tactical training. How to intubate and use a bag valve mask dressed in full tactical gear in all manner of insane positions, from under furniture to upside-down in the dark. I often wonder though, What does the combat gear or OD green colored bandages really do in any world, much less the civilian world? It is not like during an active school shooter event anyone will be providing care while obfuscating them from vision. It is not like the drunk guy stabbed in the bar will benefit from not having his bandage seen in the parking lot. Even providers themselves go to great lengths to appear more military. Nothing says “bad ass” like all black battle dress, body armor, a balaclava, a bunch of black or OD green medical gear hanging off of you, and bright reflective lettering that says “police”, “EMS”, or “fire department.” Because when you are dancing around in your all black ninja suit so nobody can see you, it is important not to be misidentified by other ninjas and thought to be a bad guy. Of course you could just have some bright white or other high visibility color with a big red cross on it too…Not very ninja-like I know…
This brings us to root problems; the idea of prevention vs. reaction, and public safety vs. medicine. Let me just get the easy part out of the way first? If you are a medical or nursing provider, working in an ED, on an ambulance, or wherever, you are not a public safety provider. You are a healthcare provider. If you actually learn something from military medics, they will tell you direct patient care cannot be provided for under fire. You will not be providing care under fire, you will be providing care in some form of cover. So you don’t really need to wear the ninja suit. Secondly, even if you find yourself in this situation, it will be extraordinarily rare. You don’t need to be prepared for it every minute of every day, even if you are responding to scenes. None of the care providers during the Boston Marathon Bombing were all dressed up waiting for all hell to break loose as they providing special event care. Somehow they managed to do quite a great job.
But what about the others? The Fire Service is public safety. That is true, and in some places it also takes on the role of medical provider by virtue of EMS operations. But despite some misconception, they are 2 separate functions. The emergency medical care is healthcare. It is basically medicine, and even in initial schooling, the morals and ethics of medical care are taught and practiced. A medical provider is neutral in all respects. They are not there to judge a person. They are not there to enforce morals. They are not there to accuse or collaborate with authorities for prosecution. They are there to provide aid. Firefighters need to ask themselves “am I operating right now in the capacity of a medical person?” When the answer to that is “yes” they are not acting in a manner of public safety. The approaches, tools, and attitude must be that of medicine. Otherwise, they are no longer neutral, but an agent of the State. Those types of people are not too popular. I would go as far as to saying despised. Furthermore, even when acting as agents of the State, they are not law enforcement officers. They do not have powers of arrest, they are not obligated to take anyone into custody. Their authority is absolutely minimal. They certainly are not the moral police akin to the religious police forces of countries like Saudi Arabia.
EMS providers are medical providers. They are not public safety. This is where most confusion comes in. They have extremely limited public health roles. They have no law enforcement role. They do barely anything to protect the public at large. 99.9% of what they do is provide medical care to individuals. Even in massive disasters, triage and rationing are medical activities.
Some like to think they are public safety, I am not sure why? Maybe it makes them feel important. Maybe because they are publically funded and do not want to call themselves socialized healthcare. Maybe they think they are a part of some great institution. “The public safety forces” that sounds military! They are cool. Tacti-Kewl. Maybe they even have a military style uniform with some collar brass. Because you know, the EMS leader has the same responsibility and career chronology of say a admiral or general in the military. (or colonial or captain for that matter, equally laughable) Imitation is good flattery. You ever see one wearing a white lab coat? How about a white lab coat with collar brass? (or even a nurses hat with a red stripe) It must really make them feel like they belong to somebody. I just can’t satisfactorily understand why they need to do this.
Also in the event of major disaster, their primary role doesn’t change. They provide care to individuals. Nobody is giving albuterol treatments to a mass of people. Nobody is controlling the bleeding of society. Most doctors and nurses I know have more than 1 patient at a time, so even being forced to care for more than 1 is not “public.”
So who cares right? If they want to play make-believe, why should anyone stop them? Well… there is public perception. If they don’t want to be treated with public animosity and even violence as agents of the state, maybe they should stop acting like one? Maybe if they want people to trust them and respect them as “helpers” they could stop acting as moral judges and betraying the trust of patient/provider neutrality and confidentiality? Maybe if they want respect as healthcare providers by other healthcare providers they could start adopting their values instead of military ones? Maybe it is just good customer service?
Let’s reflect on that customer service aspect for a minute. Most elderly people do not want to see a doctor or a nurse with a rainbow Mohawk, face piercings, and full body tattoos. But doctors and nurses usually work in healthcare facilities, so people going to them (and in a way their home) have to accept some level of diversity they don’t like. But EMS is invited into the homes of others. They may not want to invite various people into their homes. When somebody they do not trust enters their personal space, it creates stress for them. Things like gender or race are not the decisions of providers. How they dress, how they act, body art, etc. are choices. What effect would tactically dressed EMS providers have on an elderly patient with chest pain? With Psychiatric patients? With even your common drunk? How would say a holocaust survivor react to a bunch of people in all black with helmets coming into their home to “help” them? How would people who came to your country from various warzones where soldiers who mistreated them dressed similar respond?
Let me ask this question? Do you think my ability to care for people is in anyway altered by what I wear to work? Do you think my knowledge or ability is altered based on if I am in the hospital or out of it? If mine is not, why would anyone else’s be? I don’t need to dress up like a soldier to help people. I don’t need to act like a cop to get respect from patients. Dressing up in an armored ninja suit like a Special Forces operator would not win me any respect from my colleagues in the medical community. So if you are a healthcare provider or acting in the capacity of one, why would you do it?
Life does not have to revolve around war. It is in fact nicer when it doesn’t. Perhaps you have never known or have forgotten? The military does not have the solution to your fears and anxieties. Not everything it does works in the non-military world. Nobody is trying to reinvent Sparta or another “military first” state like North Korea. If you don’t want people to respond violently to you, why would you dress and act like people who perpetrate violence on others? Why are you worried about patients you might see once in your lifetime instead of what you do everyday?
There is no such thing as “tacti-kewl”, it’s just being a whacker sometimes, while wearing a ninja suit. Set the example, if you don’t want others going around pretending to be military, don’t do it yourself. By the way, pretending to be a police officer is a criminal offense most places. Acting like or being a convicted criminal will not do much for your healthcare or public safety career.