Bringing Good Medicine to Bad Places

Nov. 26, 2007 — -- Trauma surgeon Dr. Dave Ciraulo doesn't always do his best work in the operating room.

Then again, few doctors find themselves in situations in which their patients may have been their assailants just minutes earlier. But these scenarios are not uncommon in the life of SWAT doctors like Ciraulo.

"I remember a call where a suspect had barricaded himself in a building with two AK-47s," Ciraulo said. "As the SWAT team was evacuating the officers, they had to shoot the suspect. Within a minute and a half, I began resuscitating him."

It's not unlikely for SWAT doctors to find themselves walking the fine line between saving lives and protecting their own lives -- with deadly force.

"There have been a few times I have been the shooter and then a few seconds later, I have to change gears and get the guy's chest open and control bleeding," Ciraulo said. "When that role changes, I'm the doctor.

"It is difficult to put into words, but at the time, it is very automatic. When the dust settles, I don't necessarily think about the 'bad guy' as being 'bad' -- he's a person and I feel bad that he got hurt."

These physicians, who are part of Special Weapons and Tactics, or SWAT, teams, often receive much of the tactical training of the officers in the team. But they bring to the scene the medical support that could save the lives of their team members and others.

SWAT Docs Crucial in Violent Situations

Before the Columbine school shooting incident in 1999, the presence of doctors in such teams was rare. However, today most tactical teams, including police forces, SWAT teams and military teams have a doctor on board.

"[The Columbine event] really brought things to the forefront," said Ciraulo, who is also attending physician and professor of surgery and critical care at Maine Medical Center in Portland. "In building a specialty team, one has to ask the question: How do you get medicine into environments that aren't safe?"

Unfortunately, it seems many environments -- including office and school buildings -- are becoming increasingly unsafe.

"In my final year of residency, a good friend of mine's wife was killed in an office shooting," said Dr. Matthew Sholl, another SWAT doctor and attending physician in emergency medicine at Maine Medical Center.

"They had just had a baby. The perpetrator was a disgruntled worker with an AK-47. He started shooting randomly at people in the office, and she was killed," he said. "What hit me was, I couldn't imagine being a SWAT officer and going into that kind of situation without medical care on scene."

Police support the idea.

"Having the medical expertise on the team is a plus for everyone involved -- both officers and suspects," said Mike Williams, assistant chief of the Chattanooga, Tenn., Police Department and former SWAT team commander.

'First, Do No Harm'

A heated debate has developed over whether or not arming doctors is appropriate. Upon graduating from medical school, doctors take an oath to "first do no harm."

But in the dual roles demanded of them in the world of tactical medicine, this line is sometimes crossed.

"When you're out there, it's like the 'military physician model,'" said Ciraulo. "Your first mission is to protect yourself, your team and the people you're trying to rescue. At that time, you're functioning more as on officer. The role changes when someone becomes a victim."

There are differing schools of thought as to how tactical the medical personnel should be. Some medical providers have expertise not only in resuscitation and injury management, but also in carrying and using deadly weapons. Others are trained only in medical support and must rely on their teammates for protection as they attend to patients.

"Opinions vary, but we feel that it isn't fair to take an unarmed medic into a building where hostilities may still be present," Williams said. "So our medics are armed and know how to use their weapons."

Sholl, who worked with the FBI in Boston for seven years, comes from a different school of thought.

"There is a lot of debate out there whether or not to arm doctors," said Sholl. "If you arm doctors, there can be role confusion. Most of the time you haven't been trained as an officer, and therefore you don't have authority to shoot someone. You are there to provide medical care."

This doesn't mean, however, that Sholl stays out of danger on the job. While he does not go directly into the "hot zone" with the first group, often he will be in a "very warm zone."

"I always have a sniper covering me and two agents with me, providing protection," said Sholl.

"I remember a call where we had to apprehend a serial rapist and murderer," he said. "I was immediately behind the agents at the door. When they went to the third floor to apprehend the suspect, I was on the second floor, waiting.

"The suspect ended up shooting himself, and once the scene was secured, I went up to attend to him."

Few Physicians Picked for the Team

The medical members of a tactical team have to fit in well with other team members. They are expected to train regularly with their teammates, which means that they need to be top physical condition and must understand all of the tactical planning necessary for their missions.

"The selection process and the decision to bring the medical personnel onto the team are very involved," said Williams. "If it isn't a good fit, it won't work."

On the Chattanooga SWAT team, medical members "have to go through basic SWAT school and have the same physical and firearm requirements as the rest of the team," he said. "They have to know why and how the team is doing what they're doing.

"They are always on call and train together bimonthly long into the night. These people receive no extra pay for their work and are committed to respond at a moment's notice.

Ciraulo agreed that the demands of being a SWAT doctor are intense.

"This is not something that can be a freelance job," he said. "You have to be assigned to a team and train as a team. The intensity can be quite high, and you have to know and rely on your teammates."

A High-Risk Practice

There is also another consideration for doctors who put themselves in harm's way -- the very real possibility that they will become the ones in need of medical attention.

"The ghosts that come out when you go to sleep are the kind that say, 'Wow, that could've been me today,'" said Ciraulo. He describes times when he has left for an early morning call and has "that feeling like I might not be coming home today."

But SWAT doctors have weighed the risks. And they see their services as crucial.

"I'm a physician. I've got a lot of skills and special knowledge and can be a safety net for these guys," said Sholl. "After my friend's wife was killed, I realized, this is essential.

"I recognized that this is a public service -- not only for the SWAT team, but for the citizens that need them. It's also for the 'bad guy,' because he deserves to be judged by a jury of his peers in a court of law and doesn't deserve to die in the field."