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CHAPTER 1
People Work
A STRANGE SHOP FLOOR
Paramedics and EMTs work on people. The primary material that's labored by ambulance crews are human beings — their organs, their categorizations, their locations, and so on. Consider five seemingly disparate cases.
Stabbing at a Bar
Paramedic Edward and EMT Morgan arrived at a bar. Police and firefighters were already on scene and directed the crew to John, a white male in his late twenties who works as the bar's bouncer. He was lying in the parking lot. Someone stabbed him multiple times. John's inner left arm was sliced just below the elbow and there was a laceration on the back of his head. There were also deep punctures to his gut, flank, and lower back.
With the help of some firefighters, Edward and Morgan covered John's oozing wounds, loaded him into the ambulance, and gave him some fluid through an intravenous (IV) line. As Morgan drove to the hospital, John screamed through the non-rebreather oxygen mask that Morgan attached to his face. "Fuck," he shouted from the gurney, "Don't let me die! You need to get me to a doctor!" "We're going there right now," responded Edward as he spiked another IV bag. A firefighter also rode in the ambulance and helped Edward control the patient's bleeding. Midway through the transport, John's screams faded to moans before he began to nod off. Edward shook his patient to keep him awake. "Stay with me! Stay with me!" he shouted. It wasn't long until Morgan parked the rig. A trail of blood then connected the ambulance to the emergency department.
After transferring care to a team of trauma specialists inside the hospital, Morgan hosed blood off the gurney as Edward documented details regarding the call in his laptop. In addition to logging John's demographics (e.g., age and gender), Edward noted his "primary impression" of the patient (i.e., his field diagnosis) and listed the interventions he and Morgan performed (e.g., bleeding control, oxygen therapy via a non-rebreather mask, and fluid via IV). Edward uploaded this medical record known as a patient care report to a secure server and printed a copy for hospital staff.
Living Room Death
Paramedic Stacey and EMT Jeremy, along with the assistance of local firefighters and a paramedic supervisor, responded to a "code" (i.e., a cardiac arrest). The victim was a seventy-or-so-year-old black man who lay on the floor of his apartment living room. He was "PEA," meaning the monitor connected to his body via some sticky electrodes indicated "pulseless electrical activity." The man's body was hooked up to a Lucas CPR device, a special machine that delivers automatic sternum compressions.
Firefighters shoved nearby furniture toward the walls to make room for the "pit crew," the resuscitation team of five or so first-responders led by Stacey. While one firefighter paramedic intubated the patient by carefully guiding a plastic tube down the airway, Stacey drilled a hole into the old man's shin to initiate intraosseous infusion (IO). Once an IO was established, Stacey's team periodically administered medications like epinephrine directly into the bone marrow. They paused regularly to shock the patient with a defibrillator. For over thirty minutes, the pit crew attempted to revive the patient through a mixture of compression, ventilation, electrical shock, and drugs.
They eventually "called him" (i.e., determined death) before Stacey even had a chance to learn the patient's name. The paramedic and EMT returned to their ambulance without a body, where Stacey documented some intricate details of the case in her laptop before they responded to another 911 call. Among other things, she had to carefully report the timing of the pit crew's many interventions.
Septic at the Sniff
Paramedic Derrick and EMT Martin responded to a skilled nursing facility or what is colloquially referred to as a "sniff." They were greeted by a certified nursing assistant (CNA), a nurse, and someone from the sniff's management team. Firefighters were also on scene and introduced Derrick and Martin to their patient: Barbara, a seventy-five-or-so-year-old white woman, who lay in bed and mumbled. The firefighters had already collected some baseline vitals indicating a rapid heart rate and low oxygen saturation. The CNA and nurse also informed the crew that Barbra has type-2 diabetes, osteoporosis, and a pressure ulcer (i.e., a bedsore). They also stated that Barbara seemed to experience discomfort upon recent urination.
Derrick placed his gloved hand on Barbara's forehead and noted that she was warm to touch before he checked her blood sugar levels using a glucometer. Derrick also directed Martin to run an electrocardiogram (EKG) while Barbara was still in her sniff bed. In following through with the paramedic's wishes, Martin struggled at first to stick the EKG electrodes to Barbara's skin. It was covered in some sort of lotion. This may have helped thwart new bedsores, but Derrick suspected it was worsening Barbra's fever. After an unremarkable EKG, Derrick and Martin started to transport Barbara to the hospital, suspecting the early stages of sepsis, and Derrick gave her some low-flow oxygen on the way.
During the transport, Derrick typed away on his laptop and periodically checked on Barbara and the monitor that summarized her heart rate, oxygen saturation, and blood pressure. He used paperwork provided to him by the sniff staff to log Barbara's date of birth, medical history, current medications, insurance policy number, and other information.
Drunk and Drowsy in Downtown
Paramedic Rob and EMT Logan were summoned to a downtown sidewalk to aid Darrell, a "frequent flyer" known to both ambulance workers by name. It was unclear how this fifty-five-year-old black man got there or why he was leaning against the side of a building with his eyes closed. However, it was clear who called 911: a security guard who roams these business-hugging sidewalks. He was unable to convince Darrell to leave the area on his own, so he reported the seemingly intoxicated person to dispatchers who in turn sent Rob and Logan.
After kicking the bottom of Darrell's shoes and struggling to converse with the slurring man, Rob determined that he was too drunk to leave. So, the crew loaded their patient, who carried a strong smell of alcohol and vomit, into the ambulance, where they then hooked him up to a monitor to collect a baseline set of vitals: blood pressure, heart rate, and blood oxygen saturation. Logan sat on a chair next to the gurney and began a patient care report on the laptop while Rob asked Darrell about his medical history. The workers also ran an EKG before they determined Darrell to be a low-priority case. The man mumbled the name of a hospital across the county, but Rob refused to take him there. Instead, Rob let Darrell chose one of the three closest hospitals. The patient then said the name of a large public hospital a few miles away.
Logan left the back of the ambulance and took the driver's seat. Rob stayed in the back with Darrell. During the transport, Rob continued the medical record started by Logan. The computer program soon forced him to enter a primary impression. He was given some closed-ended options and selected the category that seemed to best summarize his patient's state: "ETOH," an acronym for ethyl alcohol. Rob told Darrell he drinks too much, but Darrell just moaned some incomprehensible speech in response. The crew eventually rolled their patient into an emergency department, where a nurse and physician happened to also know Darrell by name.
Home with a Cold
Paramedic Drew and EMT Marco responded to a house where they found Alicia, a twenty-one-year-old black woman, standing just inside the doorway. Alicia confirmed that she was the person who called for an ambulance and she listed her symptoms: a headache, some generalized body pain, a sore throat, and a nonproductive cough.
The conversation between crew and patient continued inside the ambulance, where Alicia reclined on the gurney. As Drew talked with this patient, Marco placed a pulse oximeter on her finger and a blood pressure cuff around her bicep before he started a medical record. All measured vital signs — heart rate, respiratory rate, blood pressure, and oxygen saturation — were within normal limits. Drew then told Alicia this was "not an emergency," but she still requested a ride to a hospital, and more specifically to the hospital a couple miles from her house. Marco moved to the driver's seat and drove to that facility.
During the short transport, Drew continued the patient care report started by Marco. However, he paused for a moment to tell Alicia she was most likely going to be triaged into the emergency department waiting room. "For real?" asked Alicia, apparently surprised. Drew responded with a smirk, "I bet you thought you'd get in quicker if you called 911, but you won't." Alicia didn't respond and Drew continued to work on his laptop. At the hospital, Drew had Alicia walk in with him through the ambulance entrance without a gurney. Drew spoke to a nurse and recommended a waiting room triage. The nurse concurred.
THE PEOPLE WORKERS
Ambulance workers often say, "no call is the same." The five vignettes above confirm this point in many ways. We find a stabbing, a cardiac arrest, a sepsis alert, an intoxication, and some symptoms of the common cold. These variably urgent problems are scattered across a bar, an apartment, a skilled nursing facility, a sidewalk, and a house. The outcomes of these cases are different too, from a corpse being left on scene to someone being walked into the emergency department waiting room. There's also some notable range in the social positioning of patients: white and black, young and old, housed and unhoused, and so on.
Yet, despite all this variation, I hold that we can still offer a generalized description of ambulance labor. Sure, ambulance work can be reasonably labeled as a form of "care work" or "service employment." But, as already noted, I think the productive activities of paramedics and EMTs are best summarized as people work. Sociologist Erving Goffman developed this concept to make sense of staff inside "total institutions" like asylums and prisons. The concept nevertheless works in any setting where the primary material of labor, that which is practically transformed through the social relations of production, is people. I'm especially partial to Goffman's concept because it forces a simultaneous consideration of both the material and the classificatory moments involved in production.
Whether laboring living or dead bodies, there is a definite physicality to people work: surgeons cut into flesh, morticians dress corpses, and prison officials feed inmates. Ambulance work is physical too. Crews pry open jaws, stick needles through skin, and compress sternums. They also lift bodies onto gurneys, roll them into ambulances, and drive them across town.
At its essence, ambulance work involves a manual regulation of body and space. We can think of this as unfolding in two ways. On the one hand, ambulance crews regulate spaces in bodies. Much of their labor involves them tweaking people as independent structures divided into anatomical and physiological regions. For example, they inject fluid into the veins to lift falling blood pressure, stream oxygen into the airway to counter low oxygen saturation, and cover wounds to prevent blood loss. On the other hand, crews also regulate bodies in spaces. They move people from homes, sidewalks, bars, sniffs, and other places to the ambulance and then transport them to hospitals.
Still, people work cannot be reduced to manual labor alone. As several paramedics and EMTs liked to tell me, there's also a "mental aspect" to their work and it's inseparable from a "physical aspect." Paramedics and EMTs are trained to link external symptoms to internal problems (e.g., fever, elevated heart rate, and low oxygen saturation as indications of sepsis) and internal problems to targeted treatments (e.g., countering low oxygen saturation with oxygen therapy). The patient body becomes a text of sorts. It's something to read and interpret. But it's also a text to code and revise. Much of the more mental aspects of ambulance work can be equated to classificatory labor. Crews work to classify suffering.
This classificatory labor is perhaps most visible during documentation. Ambulance crews construct medical records — informative receipts that summarize assessments and treatments — and they do so by reading people through an institutional-specific scheme that identifies and distinguishes human suffering in a particular way (e.g., diagnostic categories). They, in a sense, "check a box" and this is intertwined with their physical interactions with patients. While the five vignettes that opened this chapter certainly involve different classifications in terms of primary impressions, logged vital signs, and level of urgency, none is without some formal classification. And essentially no cases conclude without some official record keeping. Ambulance crews even document cases where they interact with potential patients who refuse treatment or transportation. Thus, in many ways, people work is paperwork.
The remainder of this chapter sets out to describe a few basic features of ambulance-based people work. I further detail some of the instruments that crews use to work on people. I then offer a summary of how ambulance calls are generally run, and this provides us with some more insights into how crews handle their patients. Yet, as I'll continue to make clear, there's a lot of variation in how calls are run. This is at least partly so because the material to be labored is not uniform. Crews see different kinds of people (e.g., racialized and gendered subjects) and this shapes the productive process in important ways.
TOOLS OF THE TRADE
Nicknamed "rigs," "trucks," and "buses," ambulances can be described as mini hospital rooms on wheels. They're loaded with instruments for examining, adjusting, moving, and documenting people. We don't need to take a full inventory of what's inside, but a quick glance at some of the rig's equipment will give us a sense of what can happen in the ambulance.
Let's start in the back (figure 4). At the center is a gurney, which is easily loaded and unloaded through the back doors. A waterproof — or rather a blood, vomit, and fecal proof — mattress sits on top and is covered first with a cloth blanket and then with a paper sheet. The sheet is disposed of after each transport and the blanket helps crews drag their patients off the gurney and onto a hospital bed should such a maneuver be necessary. A portable oxygen tank is also attached near the head of the gurney in case a patient happens to require any low- or high-flow oxygen. Additionally, a few pouches are strapped to the gurney and they carry nasal cannulas, spit masks, and other items.
As a ride-along, I usually sat in the captain's seat immediately next to the gurney's head. This provided me with a head-to-toe view of patients while they lay on the gurney or, far more commonly, as they reclined in the semi-Fowler's position (i.e., around a forty-five-degree angle). This seat also offered me a great front-to-back view of the ambulance's main interior.
Cabinets covering the wall to the left of the gurney contain various needles, tubes, masks, drugs, gauze, and other tools. A monitor usually sits on a nearby shelf, but it's frequently moved. When on scene, for example, crews often hook the monitor to the back of the gurney. This boom box shaped device has defibrillation capabilities ("Clear!"). However, as the beginning of this chapter demonstrated, it also includes a number of instruments for "objectively" assessing the body (e.g., blood pressure cuff, pulse oximeter, and EKG electrodes). One of the side pockets of the monitor includes a glucometer and a set of lancets for checking blood sugar.
The wall to the right of the gurney includes a bench that paramedics usually sit on as they examine and treat their patients. A stethoscope and a pair of shears are often nearby if they're not in the paramedic's pocket. Underneath the bench are additional tools, including leather limb restraints, a patient urinal, and some roadside flares. Most paramedics set a few items on the bench for easy access, like a small bin with some IV needles of various gages.
There are some additional shelves near the head of the gurney by the bench. Among other things, they hold a "med bag," which carries a majority of the rig's medications like Benadryl (for allergic reactions), Zofran (for nausea), and Narcan (for opioid overdoses). Drugs requiring more security, like fentanyl (for alleviating pain) and Versed (usually for sedation during severe psychiatric emergencies), are locked in a safe above the shelving that holds the med bag.
(Continues…)
Excerpted from "Bandage, Sort, and Hustle"
by .
Copyright © 2020 Josh Seim.
Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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