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Red and white is always right : perspectives from a group of ambulance workers Liddell, Nicole E. 1993

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RED AND WHITE IS ALWAYS RIGHT:PERSPECTIVES FROM A GROUP OF AMBULANCE WORKERSbyNICOLE EVE LIDDELLB.A., The University of British Columbia, 1989A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF ARTSinTHE FACULTY OF GRADUATE STUDIESDepartment of Anthropology and SociologyWe accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIASeptember 1993© Nicole Eve Liddell, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature) ("Department of  AlA 44.71VCIrd(C/^c `F)./^ C/Z10-2_,0&-VThe University of British ColumbiaVancouver, CanadaDate 19.613DE-6 (2/88)iiABSTRACTFrom its European founders through to the "Chicago School" and up to the contemporaryconcerns of ethnomethodology, the study of work and occupations has been a centralconcern of sociological research. Based on data collected by participant observation andunstructured interviewing, this study presents an analytic portrayal of the work routinesof Emergency Medical Assistants in Vancouver, BC. Topics discussed include workroutines, local understandings of events, and interrelationships between emergencypersonnel, their colleagues, and others. A series of appendices provides details ofspecialized language, researcher access, and the researcher's personal relationship to thefield.TABLE OF CONTENTSiiiHistory of the B.C. Ambulance ServiceFormal Training of EMA'sMethodologyA Typical Shift in VancouverCharacteristics of Calls"Things I Did Not Learn in EMA School"Relationships Between Emergency Services PersonnelksPersonal Background and Confessional TaleGlossary of TermsOfficial Forms"Form 2""Property Loss Report""Release and Indemnity""Resuscitation from Pre-Hospital Cardiac ArrestAbstractTable of ContentsAcknowledgmentsDedicationIntroductionChapter OneChapter TwoChapter ThreeChapter FourChapter FiveChapter SixConcluding RemarBibliographyAppendix 1Appendix 2Appendix 31633435767107109113124127ivAcknowledgmentsWith this project so long in the making and involving so many people's goodfaith, I have a fairly long list of thank-you's to make. My first and deepest gratitude goesto Doug Aoki for his constant support, encouragement, editing, friendship and generalbelief in me. If it weren't for Doug I may have ended up in Education after all or, evenworse, married.Secondly I would like to thank all the members of the British ColumbiaAmbulance Service who helped make this project happen:Norm Bain^Tim Lehman^Ron StraightRene Bernclau Jeff Laurie Darlene RedmondNorm Bickel^Quinton Laws^Terry ReidBob Chamberlain^Paul Megannaty Dave RhomerDwayne Collins Ian McMillan^Gord RobbinsAndy Fletcher^Bob Milton DarylRichard Foster John Mothersil^DeanJason High Brian Porritt Rob WandGeorge High^Rob Sang Frank WiderI am grateful to those who had belief in this project enough to put up with me oncar, at the station, and generally have me 'in their face' for a block of their already hecticwork. In this paper I have used pseudonyms for their names to 'protect' any waywardcomments that may have been confidential, but those of you in the scene know who youare, and to the rest it won't matter. Special thanks to Arnold, Luke, Hugh and Dylan foryour insights.Further gratitude is owed to my committee of John O'Connor, Ken Stoddart, andNancy Waxier-Morrison. I appreciate your input and time, particularly those of you whoare not officially "on duty" at the time of the completion of this project.Finally I would like to thank Nancy and Frank, my parents, who were verysupportive through all my years of school and this project: making sure I was wellnourished, wearing clean clothes, and generally putting up with an absentee daughter.Thanks again, your daughter, Nicole.To all the Viking Warriors; may you win your next battle.V1INTRODUCTION"Most people know shit about what we do--By lOpm they're tucked intotheir nice safe beds while we're out here covered in blood and sweat at2am on Welfare Wednesday with 15 calls in the last 2 hours. You can'teat, piss, think, or even remember your last call--the street is hell."Since sociology's beginnings, laboring has been a prominent concern for boththeorist and researcher alike. For example, it can be seen as a thread that unites the workof the discipline's 19th Century European "founding fathers". Durkheim, in his classic,The Division of Labour in Society (1893), was concerned with the manner in whichdifferent styles of labour contributed to the integration of society. Marx agonized inWage, Labour and Capital (1947) about the ways in which forms of laboring producedthe alienation of workers. Weber's massive and influential The Protestant Ethic and theSpirit of Capitalism (1904-1905), can be read as an explication of the cultural and socialsources of the motivation to labour in the first place.A concern for laboring persisted as sociology moved from Europe to NorthAmerica, and into the 20th Century. On this continent, the disciplinary sub field becameknown as the 'sociology of work and occupations'. For many years it has been arecognized specialty within the American Sociological Association. Judging by thenumber of articles contained in the index of that association's flagship journal, -- TheAmerican Sociological Review, it remains a popular area of sociological research.Further, since 1974 the topic has had an entire journal devoted to it: The Sociology ofWork and Occupations.In North America, the investigation of this topic was pioneered at the Universityof Chicago by Robert E. Park (1864-1944), and later reached full fruition in a series ofpost-World War II dissertations directed by Everett Cherrington Hughes, also of thatuniversity. Many of these have become sociological classics: Fred Davis' (1959) studyof taxi drivers, Howard S. Becker's research on dance musicians (1963) and school2teachers (1968), and Raymond Gold's (1950) investigation of apartment house janitors'work routines are amongst these. Many other little known University of Chicagodissertations are lovingly documented in the footnotes of Erving Goffman's ThePresentation of Self in Everyday Life (1959).Early North American interest in laboring can be portrayed as differing from thoseof the European "founding fathers" in two significant ways. Firstly, while Durkheim,Weber, and Marx addressed the topic in a macro-sociological way, Park and Hughesurged their students to study laboring in a micro-sociological way. Basically, this meanta shift in emphasis from structural issues to human lived experience. The impetus forsuch a focus was largely anthropological; concern was with what Malinowski (1922)called "the imponderabilia of everyday life". Secondly, while the European "foundingfathers" studied laboring through the use of archives, official statistics, and othersecondary sources, Chicago School sociologists sought to understand it by using dataobtained first hand through immersion in the culture and social circumstances of thelaborers themselves. Rather than being "distant", sociologists operating within thistradition sought to get "close-up". In the editorial introduction to the journal, Urban Lifeand Culture, itself a phrase taken from one of Robert E. Park's lectures, John Lofland(1972) provides an unpacking of this somewhat ambiguous term;"The term close-up suggests that the researcher has sought throughpersonal participation, observation or intensive interviewing intimately toacquaint him or her-self with a discrete circumstance of an urban society.Ideally, the researcher has been close in the physical sense of conductingfor a significant period of time his or her life in face to face proximity tothe persons and circumstances under study. Ideally, the researcher hasalso been close-up in the additional sense of attaining intimate access tothe circumstances of concern and of giving searching attention to activitiesof everyday life. It then becomes possible for research reports to providethe kind of description and quotation that moves the reader "inside", as itwere, the world under study.To be close-up is to attempt to portray the "tissue and fabric of social life,"to use a leading practitioner's appropriate phrase. It is to convey the innerlife and texture of urban societies' diverse public and personal3circumstance, modes of life and social enclaves. This is in its nature aqualitative task, a task of showing the kinds of things that happen and theways in which things happen." (1972: 4)The present study is based on data obtained by getting physically and perspectivally"close" to a laboring community. The community of concern is that of EmergencyMedical Assistants (EMA's). The techniques used to get close were participantobservation and unstructured interviewing.While there are no like projects in the literature from Canada, two studies fromthe U.S. are significant. Mannon (1981) did a participant observational studysupplemented by formal and informal interviewing of a County Hospital service in theMidwestern U.S. in the late 1970's. The study focused primarily on the changes inresponsibility and scope of workers over the previous ten years. Mannon suggested thatthe job description changed dramatically with new technologies, training availability andwith the perception of the role of ambulance workers. For this reason, he argued, thevocation is emerging into a 'profession' and it is the perception of this emergent role thathe investigates through immersion into the world of its workers.Metz (1981) became an EMT (Emergency Medical Attendant)' for his participantobservational study in the East. His research was primarily concerned with features ofcrew culture such as language, inappropriate jokes, storytelling, and used aGoffmanesque framework to look at the 'faces' of workers. He also examined preferencesfor types of patients and calls, on-duty theft of medical supplies, the socialization of anEMT from the point of view of a 'rookie', and other like topics.Other studies on EMT's in the U.S. have utilized quantitative methods to examinesatisfaction indices among paid vs. volunteer ambulance attendants (Allison et al, 1987),unsuccessful cardiopulmonary resuscitation efforts (Genest 1990), and "burnout"prediction (Masalach and Jackson 1981), (Mitchell 1984), (Leiter 1991). From a social-psychological perspective Palmer examined workers' strategies of coping with death andI EMT's and EMA's are essentially equivalent positions with different names.4dying (1983), occupational behavior of paramedics and ambulance attendants (1983),their 'performances' in relation to the public, other workers, and victims/family (1989),and the idea of their role as "playing doe" being a deviant one (1990). Finally, James(1988) investigated perceptions of stress in ambulance personnel, and Hughes (1980)analyzed the ambulance journey (to the hospital) as being important becasue of the powerof evaluation by the attendant, and its subsequent impact on the treatment the patientreceives once at the hospital.This study is organized as follows. Chapter One presents a brief history of theBritish Columbia Ambulance Service, and the formal training of Emergency MedicalAssistants. Following is a discussion of the techniques used to obtain the data that permitthe portrayal presented in the subsequent chapter. The third chapter is a description of atypical shift. Chapter Four enters the interior world of ambulance workers and deals withsome of the local concepts they use to organize their occupational routines. Theseinclude some characteristics of calls and clients. The fifth chapter deals with the informalworking knowledge that Emergency Medical Assistants must come to learn and displayin order to be seen as competent amongst their colleagues. Chapter Six discussesambulance workers' interactions with other emergency services personnel, includingfirefighters, police officers, and hospital staff members. Some discussion is presented ontheir relationship with their peers, and those who dispatch their calls. Appendix Oneprovides what Van Maanen (1988) has called "The Confessional Tale". Since Whyte's(1955) appendix to Street Corner Society, the confessional tale has become a qualitativeresearch tradition; it permits the reader to place "the findings" of the research in thecontext, and provides information that assists in the assessment of its validity. A furtherseries of appendices provides a glossary of terms and codes, and some sample 'officialforms' utilized by EMA's.CHAPTER ONE"Well, the outlying areas were mostly a family run operation. Sort of theone man show deal—you know, police, fire and ambulance all rolled intoone. The city service was Metro back then—not very much trainingcompared to now—we did all right though."History of the British Columbia Ambulance ServiceThis chapter will briefly outline the history of the British Columbia AmbulanceService as it relates to the present day Emergency Medical Assistants and their roles. Itconcludes with the formal training that EMA's take in order to become certified at thevarious levels.In 1972 the Provincial Government proposed and approved "The EmergencyHealth Act", which in part mandated the provincial government take over the ambulanceofferings in Vancouver and its suburbs. This takeover was unique in that the governmenthired all the members of the previous regional services. The B.C. Ambulance Servicebecame, overnight, the largest ambulance service in North America.Vancouver had previously been serviced by 'Metro Ambulance Service', themembers of which were retained by the new government service. Prior to this Act, theambulance offerings were different in each city and township. Some municipalities ranthe service out of fire halls and some contracted the service out to private companies. Onthe private side, some services were family businesses such as Allen Gordon inWhiterock, Doug Sager (who invented the Sager Splint) in Chilliwack, and Harvey Bullin Surrey. In small towns the ambulance service was often just part of some privatecompany's offerings. For example, Milton Fernandez in Pemberton offered a tow truckservice, responded to fire calls, was empowered by the police, and was responsible for theEmergency (disaster) program in that area. Many of these services were alsoincorporated into the new B.C. system. In fact, some of these men are currently Unit56Chiefs of various stations. Many of the members of Metro Ambulance Service that wereretained are still with the Service as Unit Chiefs, dispatchers, and administrators.With the Emergency Health Act came the concept of a paramedic, or EmergencyMedical Assistants (EMA), which was an ambulance attendant certified to a level oftraining well beyond that ever required or provided in Canada before. The concept wasloosely based on the U.S. model, which was already in place in large cities such asSeattle, Los Angeles, and Denver. In B.C. the training program was partially developedover time and through trial and error, and to this day each graduating class gets differingtraining. The first EMA III class was given in 1973-74, as a modular two-year trainingprogram. The Emergency Physicians at Royal Columbian Hospital basically invented thecourse, guessing at what types of things paramedics should be taught. In this first classwere members of Metro service and others with street experience at the EMA II level.The first class learned everything from suturing to intubation, their contemporaries learna streamlined content of those protocols found to be most relevant to paramedics workingat the street level.An interesting difference between American and B.C. paramedics is in theirrespective licensing. In the U.S., all actions undertaken by paramedics must first beapproved by a doctor by telephone or in person, because they are licensed under thosedoctors who are thus ultimately responsible for the care provided by their paramedics. InB.C., the paramedics have a more autonomous license, similar to that of a medical doctor.B.C. paramedics have 'delayed orders', meaning that they are supposed to call the doctorat certain points in their issued protocols, but if the doctor is unavailable they arepermitted to do "what they think is best", within their protocols. The U.S. model isobviously problematic in that the doctors have to give orders for a patient they have neverseen, because the paramedics are not empowered to the same degree as their B.C.counterparts.7The B.C. system is considered by its own members to be "conservative" in its newprotocols in comparison to the U.S.. As paramedics and other levels of ambulanceattendants stateside are paid poorly on the whole, the staff turnover is high, andparamedics generally do not have as much field experience as those in B.C. In the U.S.,someone who has been working for five years is considered senior, while in B.C. onewould have to have five years part time experience and three to five years full time beforethey were no longer considered 'new'. For this reason, it was felt by the paramedics that Iinterviewed that B.C. 'backs up' its protocols with experience, while Americanparamedics get more 'radical' training, while lacking the experience base necessary inorder to carry it off in the field.The next section will discuss in detail the content and formal training of today'sEMA, with a discussion of practical applications in Chapter Five.Formal Training of Emergency Medical AssistantsMinimum QualificationsTo become employed by the ambulance service initially, an individual must havea Class 4 drivers license with a reasonable driving record, a successful criminal recordsearch, and an Industrial First Aid (IFA)2 ticket. Grade twelve is a 'desired' qualification,but is not mandatory. Currently there is no recognition given to higher education such asa university degree, nor is there any type of evaluative interview of candidates; centrallyor otherwise. Once hired an individual would eventually be asked to take the EmergencyMedical Assistant I (EMA I) course, as space in the course becomes available in theregion of the station he or she was hired. To be eligible for the EMA I course, individualsmust complete the "EMA I Entrance Booklet", which consists of reading and questions2 Industrial First Aid is a course endorsed by the Worker's Compensation Board of British Columbia forindustrial work-sites. The course is approximately 80 hours of class time with practical and written examsat the end.8dealing with the understanding of operations of the ambulance service, particularly, whois responsible for which jobs while working 'on car', and the like. Below are the specificsof course content for the EMA program.EMA IThe EMA I course itself is offered in a three weekend or 'block' format, usuallyone month apart. A block consists of the Friday night, all day Saturday and all daySunday. The sessions cover a variety of topics and training modules, as outlined below.Weekend #1The first weekend begins with a small exam that reviews the written IndustrialFirst Aid (IFA) content. Candidates then review 'hard collar' (a device that fits around theneck, supporting the chin, and thus immobilizes the neck) application for spinalimmobilization, and 'Sager splints', a device used to apply traction to a broken femur.Next is how to complete "Form 2", the ambulance call record that is filled out for eachpatient attended. Other forms are also covered at this time, including forms involving;"Hepatitis B", "Cardiac Arrest", "Equipment loss", etc. Members cited view the amountof paperwork to be similar to that of the Army in its thoroughness. A comprehensivereview of CPR (Cardio Pulmonary Resuscitation) is next, including skills for adults,children, and infants. CPR 'on the run' is also covered, as is the 'do not resuscitate' ordersissued by doctors on behalf of the next of kin. The four conditions a crew member ispermitted to cease resuscitation efforts are also covered. Safe lifting is next, then a seriesof mini simulations of illness and injuries that the crew members are evaluated on.Finally, the candidates' written exams are returned, and they are given an evaluation inwritten form on a document called the "Mastery checklist for EMA I Block 1". Thisdocument indicates how well the individual has 'mastered' the items covered in thatblock.9Weekend #2The second block is thought to be the 'least pressured' block of the three bymembers interviewed. The mini-simulations are reviewed from the previous weekend,and many other evaluations are done. Members learn the application of the "SED" device(SAFECO Extrication device - a piece of equipment used to remove patients fromautomobiles) through lecture and practical work. They also learn the administration ofEntinox, laughing gas, and review maintenance of IVs (intravenous). They thenparticipate in a spinal immobilization review following the standards learned in IFA.Mini- simulations make up the remainder of the weekend, and constitute a large part ofthe block in general.Weekend #3The written final exam is administered this block, based on all relevant EMA Itheory from the block. Formal testing is then conducted on Sager splint and hard collarapplication. After these have been completed, the groups splits in to two; one group doesmini-simulation final 'testing', the other does the 'Driving Level 1' course. The groupsthen switch. The remainder of the weekend is used for licensing purposes, providing thecandidate was successful. This process includes photo taking, paper work for licenseprocessing, and the like.A final note is that some communities are equipped with automatic externaldefibrillators (AED) for re-starting the heart, and in these areas members would also gettraining on this equipment.EMA IITo be eligible for EMA II, members must hold their EMA I license for at leastone year, complete 25 calls as an EMA I, and must be an employee of the service for at10least one year. Members must apply for this training, and in so doing write an entranceexam and score 80% (This score has recently been increased to reflect the highcompetition among candidates). The content of this written exam is all the relevant booktheory from the EMA I program knowledge and practical experience, as well as thoseitems that are taken from IFA. After the score has been met, selection is dependent onspace in the region and seniority with the service.There are two course formats for EMA II, distance learning and a six week courseat the Justice Institute (JI). With the distance learning format they have workshops everytwo months at a central location (assigned to a certain area). This format is preferable foroutlying or sparse areas i.e.) Vancouver Island. The reason it is done this way is becauseof budget - it is cheaper to bring candidates down to Vancouver for 1 week rather than thealternative of six weeks.The EMA II full format course is six weeks at the JI, and candidates are housed ina hotel. The course begins with a review of basic anatomy and physiology,pathophysiology (why things happen), and signs and symptomology that will aid thecandidate in judgment. A course on over-embankment extrication and auto-extrication isnext, and a two day driver training Level 2 course. Candidates also spend a day inemergency taking reports from crew members, admitting patients, assessing patients,monitoring vital signs - all under the supervision of an RN (Registered Nurse).Next is a day in extended care where the candidate is 'buddied' with a nurse andcompletes all tasks he or she does in the course of his/her regular work day.. Dutiescovered are left to the nurse in question, candidates do whatever she or he see fit. Thecandidate also spends a day in the extended care ward, the purpose of which is to makethe candidate more comfortable with geriatric settings so such scenes are not problematicwhen the time comes. A day in 'PAR' (post anesthetic recovery room) is next, whichinvolves patient assessment, monitoring vital signs, and the member would intervene atany time if required. This designation is also under the supervision of an RN.11The bulk of the course matter in EMA II is patient assessment - from primarysurveys and new protocols. The protocols learned include intravenous application,MAST pants (Military Anti-Shock Trousers), Entinox, medications to treat diabeticemergencies, allergic reactions, shortness of breath, and overdoses.All practical testing is done with professional actors and is as real as possible.There are final exams at the end of the program, involving 80% achievement for bothpractical and written. There is no apprenticeship period for EMA II's after the completionof the module, they are back on car immediately to utilize their new skills.EMA IIITo be eligible to apply for EMA III one must have 3 years plus one day workingas an EMA II in a high call area. There are exceptions such as a member who teaches inthe Justice Institute as part of the time toward street time. The reason for such exceptionsis that administration does not want to discourage good people from wanting to teach theupcoming members. Some members feel such an arrangement is problematic in that theydo not have the same amount of experience with recognizing sick and injured patients.There is also a concern by some members that 5 years of street time are needed beforegoing into EMA III training.Applicants must be full time EMA II's, the eligibility does not apply to part timeEMA's.. The acceptance into the program is geographically determined partially, that is,.if they need EMA's in Prince George they will fill two of the spots with applicants fromthat area. The EMA III locations include Prince George, Kelowna, Kamloops,Chilliwack, Surrey, New Westminister, Burnaby, VGH, Airevac, Richmond, and LionsGate. There are also 5 stations on Vancouver Island.Infant Transport team has the same requirements, these teams are all Vancouverbased i.e., Children's or Royal Columbian. The program is essentially the same with a12different focus - kids up to 14 years of age. The primary focus is air transports ofpremature or unstable infants.The EMA III course itself involves a pre-reading package, ideally given 3 monthsin advance, some pre-assignments, an entrance exam that determines where the personstands for course teaching purposes. There is a formula used by the service to determine'who gets in' involving the variables of seniority, marks in the entrance exam, andpersonnel file content3. There is then an interview conducted with a panel including thelocal medical coordinator, a personnel department member, one or more physicians, and aambulance supervisor. The interview panelists try to determine how the candidate woulddeal with different situations such as interaction with other services, for example fireCaptains. They also want to determine how the individual would handle the authorityvested in them at the scene, his or her skills of professionalism, people skills, andleadership. Some attention is also paid to his or her ability to manage a scene such as ariot involving triage of a large number of patients. Once a candidate has successfullycompleted these obstacles, he or she begins the first of the 3 blocks which make up, theEMA III course.Block 1Block 1 is cardiac arrest management, which includes practical work and a writtenexam. It is expected that students coming in for this block will know airwaymanagement, intubation, and bag and mask ventilation very well. They must also beright up to speed on drugs administration as per their protocol manuals. Potentialproblems with drugs and patients are part of this block. Candidates learn intubation inthe hospital on a one week practice with an anesthesiologist as part of this block, and do3 This formula has changed with each class that goes through the program, and is a subject of muchcontroversy from both management and candidate points of view. There are many grievances filed withthe union with respect to 'who got in', indicated by members interviewed.13assessments in emergency on real patients. They get practically examined back at the JI,and do some case studies lastly, and the block ends with the candidate going on car againto experience at least 10 cardiac arrests. The candidate then gets assigned with two fullytrained ALS members for a 6 week apprenticeship on car. In this setting, they participatein calls with the two fully trained members and learn the 'on the street' working rules.Block 2Block 2 is common cardiac and other medical emergencies, and has pre-readingwhich is expected to be completed while the candidate is on car for his or her six weekapprenticeship. The focus of this module is on straight forward calls - those that are asthey seem. Candidates spend two weeks at the JI where they do simulated ambulancecalls using professional actors who simulate patients. The actors are given historical factsabout the mock illness or injury, so the situations are very real to life. At the end of thetwo weeks candidates go into a hospital (St. Paul's, VGH, or Royal Columbian)emergency for two weeks where they do 'work-ups' on specific patients and consult withemergency physicians as to protocols where required. They basically get to observe andpartially participate in what ever is going on at the time of their stay, and may be assignedsmall projects related to the patients they had seen. They have two days of written andpractical exams as part of this block to measure their successful mastery of the skills andconcepts. The candidates then go back on car for another six week apprenticeship.Block 3Block 3 is concerned primarily with respiratory emergencies such as anaphylacticshock, congestive heart failure and other complicated medical emergencies. Somepediatrics are also covered. Here patients have multiple problems, and the candidatemust learn how to assess such a patient, which symptoms apply to which problem, andwhich is more important to treat. Candidates also learn sedation of conscious patients for14the purposes of intubation. This block consists of two to three weeks in the academy, andone month in the emergency department of one of the above hospitals. A great deal isexpected of candidates at this level; they are required to develop a 'provisional diagnosis'and a working diagnosis, from which they develop a treatment plan of how they willmanage the patient.Also in this block candidates are required to do 12 assignments on case historiesof patients presenting symptoms - this constitutes 20% of their marks. At the end of theblock they go through two days of exams, some written and some practical, again usingprofessional actors. For the practical they are given a senior ALS member as a partner,but he or she may only do as they are told. These situations are as real as possible, withsuch things as phones to call the emergency physicians at the hospitals on, as would bedone in real life. The candidate then goes on car for another six week apprenticeship.After the final apprenticeship the candidate writes and participates in final examswhere he or she must score at least 80%. They then commence the final stage ofbecoming an EMA III, a brief 'internship' with one other ALS member where he or shedrives and the candidate does all the attending. If the candidate is performing to standardthe senior member can 'sign them off which allows them to be full fledged ALS. In somecases it takes more than one internship with more than one ALS member in order to get'signed off.It was felt by paramedics interviewed that if a candidate made it to the end of theprocess, they were competent. It was not felt that people slipped through that should not,and in this sense the recruitment process was sound.This chapter has traced features of the B.C. Ambulance Service up to the presentday, including the level of training received by today's EMA's. Of note is the fact that thenumber of calls in B.C. has dramatically increased since the inception of the provincialservice, yet there in that time there has only been a ten per cent increase in the number ofambulance personnel. As a result, the ambulance attendants have had to make many15adaptations in order to cope with the much greater call frequency. Clues as to strategiesemployed by attendants to cope with their work are evidenced herein, but they are not afocus in themselves. The next chapter will outline some of the problems I experiencedwhile trying to get 'inside' this very technical organization, and my justifications forfeeling that rapport was established.16CHAPTER TWOSo he said, "Hey Nicole, we'll give you $5 to put your tongue in Tom'sear." I said, "No way!" Luckily they were all drunk, so they would moveonto something else, and wouldn't think I was a poor sport.This chapter describes the process of getting into "the field" and the problemsassociated with being there and gathering data. Although I am aware of the work ofGolde (1970), Briggs (1970), Horowitz (1986), and others, I do not deal with the issue ofworking as a female researcher in a predominantly male setting in this chapter.Following William Foote Whyte (1943), I have discussed this in Appendix Two, andpresent the details of my research in a gender-neutral and technical way.Research PlanIn order to observe the activities of ambulance personnel with the minimum ofdisruption of normal routine, I devised a research procedure involving my participation inthe scene to be studied, following the tradition established by the Chicago school of urbanethnography. Research works consulted included that of Gold (1958), Douglas (1976),Lofland (1976), and Stoddart (1986).Before I could begin the research proper, I needed to obtain some preliminaryknowledge of the structure of the organization and the characteristics of the scene. Thispre-knowledge was necessary in order to determine how activities could best be studiedwith minimum interference. To obtain this preliminary information, I carried outinformal interviews with two ambulance attendants, each of whom was attached todifferent stations. I also 'rode along' for part of one shift with one of these intervieweesand another unknown crew member in order to access the scene to be studied.These preliminary interviews were very casual, even though I was 'up front' withthe interviewees, that is, truthful as to the purpose and topics of the project, and the natureof the research. The attendants were then asked how access to the scene could be best17gained. Both respondents straightforwardly answered that "observers were permitted toride on car" with the permission of the unit chief or a higher ambulance official, and bothfelt that riding as an observer was the best route to go. Both noted and denigrated otheralternatives, such as my attempting to obtain employment in the service. They gave tworeasons for dismissing this approach: one, it was very difficult to obtain a position at thetime, and, two, even if I got hired, I would be assigned to an 'Outstation' like Sechelt,where there was low call volume and "it wasn't anything like the city service".Additionally, they suggested that the time spent in between calls, whether at thestation or other locale, was very important—one could "pick up a lot by listening on theseoccasions". On the shift that I 'rode thire, it became apparent that the latter was in factthe case, and that I must therefore observe not only the calls, but also the 'rest period'.Through the experience of riding third I determined that it was possible to takenotes at the station in between calls without being obtrusive. Members had sets of thingsthey preferred to do in between calls, such as watching TV, writing letters and studyingor reading. I also learned that it was 'normal' for researchers to be 'ride-alongs'. Socialworkers, nurses, medical students, journalists, and ambulance attendant 'wannabes',among others, had previously accompanied crews and taken notes. And even if in thefield I found note taking to be problematic, the day's activities could be written up onreturning after each shift.On the basis of these preliminary interviews I decided to observe several differentcrews, with different levels of training, working out of different stations, rather thanperforming an in-depth study of just one crew. The attendants spoke of significantdifferences between the types of calls received and the clientele serviced in different partsof the city. This is not to say, however, that I thought I could get a 'representative sample'of all stations. Instead, I hoped I could draw a more richly detailed picture by observingsome of these differences. However, this decision created a tactical problem: because I4 Riding third refers to there being a third person in the ambulance, where there are 'normally' only two.18would spend a relatively short time at each location, and my integration into the domaincould be more difficult. This problem was addressed by selecting crews comprised of atleast one member that I knew fairly well, either as a past co-worker or as a current friend,or both. In this way my presence could be 'approved' from the start by at least onemember of the crew, which would improve the chances of the other doing the same.Further, the interviews revealed that there were critical differences in the level oftraining that different crews had, which determined both the type of calls they got and theclientele they serviced. "ALS" (Advanced Life Support)5 crews, who could administerapproved drugs and do advanced procedures, typically went to calls such as street peoplewho had overdosed on heroin, elderly people with heart conditions, and other life-threatening situations. In contrast, "BLS" (Basic Life Support) crews were typicallydispatched to assaults, motor vehicle accidents, and public assists.The attendants indicated that it would be important to observe both the day shiftsand night shifts in order to see the whole picture. The attendants' shift pattern or "block"of two ten-hour days followed by two fourteen-hour nights was cited as being"relentless". I decided that full blocks of shifts would be appropriate for the time in thefield. They would offer the opportunity of observing first-hand the conditions theattendants experienced.Three stations with different crews were selected for observation:#1 was a downtown station that covered 'the skids' of the east side of thedowntown core as well as the West End and parts of the 'yuppie' area. This station wasthought to get a 'nice mix' of calls. The crew was trained to the BLS level. The stationwas also known for its 'night life', that is, an abundance of calls after midnight. One ofthe crew members at this station was an acquaintance of mine for the past five years. He5 Advanced Life Support is a specialty available to crew members as they take EMA III training; thealternative is Infant Transport Team.19had been my teacher and my coach in first aid competitions, and we served together asexecutive volunteers for a non-profit society.Station #2 was on the South side of the city, which, in addition to its city duties,covered many of the "Airevacs", transports by small aircraft or helicopter in or out of thecity to the interior or the islands. While it was not certain that I would be able toaccompany the crews on flights, some information could be gathered about the flightsthrough stories and mild questioning after the fact. If I was permitted to accompany thecrew on flights, it would then be possible to experience some of the rural services of theprovince. Either way, I could ride with an ALS crew. The station was very busy at night,because it was responsible for ALS priority calls for the whole South side. The crewmember that I knew at this station had been a co-worker for 8 years.Station #3 was in the East side of the city, close to a low income neighborhood,Mt. Pleasant. The station covered a wide area, reaching as far as the border of the nextcity on one side, and into Kitsilano on the other side. The station also serviced, thedowntown core, overlapping with station #1. Because of its coverage, station #3 wasthought to have a 'good variety' of calls and clientele, as well as a high call volume. Thecrew member I was familiar with at this station was an acquaintance of ten years in thecapacity of instructor, co-worker, co-volunteer, employee, and friend.I was to function in the scene as an 'overt participant observer' (Adler and Adler1987: 52-60), accompanying the crews on all calls, assisting at the scene where invited,and completing shifts with overtime where required. As the situation permitted, I wouldquestion crew members regarding activities and events observed in the course of the dayswork. I would also endeavor to be present for 'shop talk' or informal conversationsbetween calls, and record the nature of such discussions when possible. The field ofobservation would consist, then, of any and all activities and events encountered in thecourse of tracking personnel following their routine work day.20Of note here is my difficulty in securing any shifts with a female attendant. Alarge percentage of the women working in the service were 'part timers', and therefore didnot have set shifts that could be observed. As rapport (discussed below) was consideredto be crucial, I thought it best to secure shifts with regular crews, and hope that some parttime female attendants would be on shift.It was hoped this strategy would allow me to observe activities in the setting froma structural perspective similar to that of the crew member, while at the same timeavoiding any 'rookie' treatment reserved for new crew members. In this sense, I hoped tobalance between seeing the world as the members do, and remaining objective enough tosee it as an outside researcher. This position in the field would be beneficial as one couldask questions as a novice might, and receive any instructions as to the 'facts of life' aboutthe job. However, I could also ask questions as an investigator, thus eliminating anyqueries as to why such a question would be asked in that context (Zimmerman 1966:361).In summary, this research strategy entailed my immersion into the field ofambulance work, on a full-time basis, at different stations with different crews. My priorknowledge of both the 'scene' and some of the crew members would assist in successfulaccess and integration, and avoidance of some potential pitfalls.Gaining Access to the SceneHaving developed the research strategy, the next problem I had was that ofsecuring access to the service. To this end I approached the members of the AmbulanceService mentioned above to tell them about the project and ask if they would support meriding as a third for a block (4 shifts - 2 days and 2 nights) each. Together we came upwith a timetable that would suit everyone's schedules and sorted out which days to askfor. Fortunately, all three members were on the same shift pattern or platoon, whichmade it simple to accommodate the shift to each station, and to work the same amount as21they did. It should be noted that crew members were surprised that I was interested inriding for a full block, as the shift pattern is regarded by them as quite 'brutal.'Consequently, many observers only ride for day shift or a part of nights, but these wereregarded poorly by members, who felt that those observers were 'wimpy' for not wantingto stay out all night. The attendants thought that those observers got a partial anddeficient experience of ambulance work. I would at least avoid that stigma.The next obstacle was to get approval to do the shifts, and all members consultedsaid approval was obtained through the scheduler of thirds, if the request to ride was forfull blocks. Unit Chiefs (Head of the stations) could approve an odd shift, but longerrequests had to go through the administration office.The first attempt to implement this step was met with little support orencouragement. I called the scheduler, and was told that the service was not lettinganyone ride third, owing to the great number of requests. He said the only way to goabout it was to write a letter to the Superintendent of the Ambulance Service, outliningwhat I wanted to do and for what reason. I then consulted a psychologist/sociologistacquaintance who had done research for the Ambulance Service in the past to discusswhat topics he felt the service may be interested in. The discussion did not bring to lightanything new, so a letter was drafted to the Superintendent.In the end I was able to avoid the bureaucratic process of waiting for a responsewhen I had the good fortune of a 'connection16 obtaining approval on my behalf A memowas sent to the scheduler by the Chief Superintendent of the service to 'extend her everycourtesy' on the shifts requested. I then called the scheduler with my requests, asinstructed, and settled the dates, times and stations. The only comments he made werethat tardiness was not tolerated, and that I was to wear 'dark slacks and a white shirt. Healso agreed to fax copies of the memos sent to the Unit Chiefs outlining the riding'schedule as proof of access. The latter arrived a few days later.6 For details of a further example of "its who you know" see Appendix 2 "Confessional Tale".22Field Observations: Occasions and Methods of Data CollectionThe purpose of this section is to describe and briefly comment upon the variety ofoccasions upon which descriptive materials were collected during the course of fieldworkat the stations. I have presented excerpts from field notes to illustrate the nature and formof materials available on these occasions.CallsA primary source of data in the field was the actual 'doing of a call'. Suchoccasions were opportunities to observe attendants' behavior and interaction with others,usually without being observed myself. On some calls I was given tasks to do; on othersI initiated activities myself, based on prior experience. In these instances I was moreinvolved with the call itself, and thus more aware of minute details of the skills andprocedures executed, statements made 'under the breath', and specific conversations withothers at the scene. I believe that these two types of involvement offered a good balanceof observation opportunities, and provided some rich detail7.Hospital 'hanging'A second data source available in the field was the frequent instance of 'hangingout' at the hospital. These occasions usually presented themselves after a call wasfinished and the patient was delivered to his or her destination. On at least two occasions,hospitals were visited to 'see if anything was happening'. These instances were valuableas many crew members were often present, from various stations throughout the city.Typical conversation topics included calls done, both 'good and bad'; activities on daysoff; other attendants' personal lives; problems with management; and scheduling errors.Attendants were also observed to interact with nurses, doctors, and other hospital staff on7 For specific excerpts from calls, see Chapter 4.23these occasions, which provided valuable content to my field notes. Such occasions weresometimes casual and sometimes 'showlike'; attendants were observed to 'perform' insome cases when presented with the opportunity. For example, in the presence of somemembers that were not liked, the chat would be curt and uninteresting, as if to indicatethat those individuals would not get the chance to be part of 'the gang'.I also noticed that some previous-told stories were slightly embellished orchanged in some way when being told to such a group. The alterations usually resulted increating a more 'off the cuff background for the story. For example, a longer version of astory involving heroic resuscitation efforts in minute detail may be condensed to the endresult - "Code 4". This compacting gave the impression that the call was 'routine', and theattendant appeared to not remember the details.Station 'waiting'Sitting around at the station waiting for calls served a very valuable researchpurpose in that 'everyday activity' could be observed. The station was like an office orlittle home away from home, and attendants were observed to exhibit very casualbehaviors. Differences between attendants were observed at the station. For example,those attendants who were full time often welcomed a quiet shift, and would retreat tovarious parts of the station to sleep, watch TV, or read. Part-timers would often makecomments regarding the quiet nature of the shift, and complain in a testing sort of manneras to whether others agreed with them. Other full-time attendants, however, had spent'too much time' at the station, and preferred to get out and, as outlined below, 'cruise'.CruisingCruising was a popular activity among some attendants studied. It usuallyinvolved doing 'the square' or 'the loop', which meant driving the ambulance along Davie24to Denman to Robson and back again (past several Starbucks coffee houses), or drivingpast the hookers in one of the two main areas they work. Other shifts, weather andseason permitting, allowed for a 'seawall cruise', or a 'beach crawl'. Cruising was viewedas 'stress release' by the attendants, although they may have said this to me by way ofself-justification. Cruising was considered 'entertaining' as members could 'watch thesidewalks', see others, and be seen. Coffee was a large part of many attendants' days aswell, and cruising gave them a vast selection of coffee bars to get a 'good brew'. Duringcruising, many comments about people or situations were overheard and relayed. Themood was usually very casual. Debates over 'hot topics', ranging from institutionalscapegoating to haircuts were often a part of the 'cruise'. These instances were veryvaluable as I could write verbatim, without being seen (I was seated behind the attendantsin an elevated chair) Many of the overheard stories and comments in this paper comefrom 'cruising' conversations.Socializing after shiftThe final opportunity I had for observing members was during social events aftershift. Since attendants did two day and two night shifts, they had a 24 hour period in themiddle of their block. This 'split' was a 'night out' for most members. This wastraditionally a night to get very inebriated. The stated rationale was that it would allowthem to sleep all day, which made the shift changeover easier. On split nights the groupof participants gathered at a bar or restaurant for beers and snacks. If the night went well,they ended up 'going dancing' at another establishment, which is what happened on myfirst 'split'. That party went on long after I had left, and I don't know how they made itthrough the two subsequent nights.On these social occasions I participated in conversation and generally tried to fitin. This was not too difficult as many of the members that showed up were acquaintancesof mine. There was a great deal of show on these nights out: yelling, singing, chanting,25obnoxious banter with wait staff and other patrons. Those attendants that were full timeseemed to be the ring-leaders of the group - the younger ones often paid attention to their'commands or suggestions' in the hopes of living up to the past members' stories of thepast nights out.As these occasions were not official, that is, part of the work day, I can not infertoo much about their behavior or activities in reference to their membership as ambulanceattendants, but the observations were useful in other ways. The stories that got told wereparticularly interesting, for the differences from versions recounted earlier in the block,for their delivery, and for the reactions of other attendants. My observations of theseoccasions were written down after the events, unlike the typical procedure outlinedbelow.Writing in the fieldI utilized a small spiral notebook to write down observations and thoughts whilein the field. Initially, my writing occurred back at the station when our crew returnedfrom a call. This technique worked for part of the time, but in busy times we often didnot get the opportunity to return to the station until four or five calls had been done. Thiswas obviously problematic as there was so much detail to remember, and the callsmeshed into one another. The attendants themselves were not much help on this count asthey often could not remember what type of a call they had just done. To offset thisproblem, I began taking the notebook along on the calls, and storing it in the clipboardpocket or on one of the shelves in the ambulance while on scene. This approach workedvery well as I was able to take notes en route to the next call or while 'cruising' withoutbeing obtrusive. The seat where the 'third' rides was behind the line of view of theattendants in the front seat, and therefore was perfect for recording conversations virtuallyas they were occurring. Sometimes, when the crew would stay at the hospital for aprolonged period of time, I was also able to return to the vehicle to write, and in some26cases, take the notebook into the hospital to record the goings-on. At the end of each shiftI would return home and transcribe my field notes onto the computer in an elaboratedform. While my memory of the day was still fresh I would write down every observation,description and memory of the calls, the people, the comments, and the conversations.On a couple of occasions the field notes were blurred or too scribbled to read. In thosecases I filled in the gaps as best as I could. In total, I made over three hundred pages offield notes, which represented one hundred and seventy-five hours in the field: scheduledshift time, overtime hours, and social time after shift.For the most part, my note-taking was either not noticed or regarded asunimportant by members. While writing at the station or in the proximity of attendants, Iadopted the stance of being very involved in my notes rather than appearing to belistening to the conversation at hand. In this manner I was able to record conversationsalmost verbatim without the attendants knowing. For example, if my name was broughtup in conversation to 'check' to see if I was listening, I would pretend not to hear until thesecond comment, then look around with a 'huh?". When asked directly if I was recordingthe conversation I would usually make a joke or be sarcastic, "what exactly do you thinkyou guys are saying that is important enough to write down?". The latter tactic workedevery time it was used, and usually offset any other questions. When asked the subject ofwhat was currently being written, I would usually reply "my impressions of yesterday".This response worked well to dissuade any further questions as the attendants seemed tobe interested in what was going on today rather than what had been done yesterday. Ialways stopped writing when questioned and engaged conversations when addressed, inorder to demonstrate to the attendants that what I had been writing really wasn't thatimportant, and that I was more interested in the attendants themselves.However, there were some instances where the taking of notes was specifically'noticed'. At station #1 I met with a problematic member who was somewhat 'devalued'by his co-workers because he was a "real union man". This individual asked "Arnold" on27a number of occasions what his relationship to me was, and why I was there. In Arnold'sestimation, this individual thought I was a 'management spy'. For the duration of fieldwork this individual did not participate in any conversations in my presence. When I wasat his station, he conspicuously spent most of his time reading in another room. Arnoldthought this turn of events was great fun, and regaled many other attendants with storiesof the situation. The tellings were always met with snickers of approval and headsshaking about the 'paranoia that exists'. So while I definitely disrupted the scene, at leastfor a few of the members, those very disruptions were smoothly re-integrated into thescene by most of the others. The very suspicions of a few were redirected so that theacceptance of the researcher was actually significantly increased. In other words, thesedisruptive events were accommodated by other members by means which maintained andeven augmented my rapport with them.The Problem of Maintaining RapportA persistent concern of overt participant observation is the establishment andmaintenance of rapport with informants. To address this problem I did several things.Firstly, as mentioned above, I selected crew members with whom I had previouslyestablished rapport. These attendants would vouch for me. Secondly, I had someknowledge of "what to do" in the case of accident or illness, through my experience infirst aid and CPR. Thirdly, I had some prior knowledge of the workings of theambulance service studied through the above-mentioned 'ride along' and conversationswith attendants—in a more general sense than the strictly medical one, I had a sense ofwhat to do and what not to do. Finally, although I informed the attendants about mywork, I was also able to use my previous background to seem just as interested inlearning the work aspect of the job, which was the usual reason that people 'normally'rode third. I was able to switch back and forth between these two roles so the linebetween them became blurred.28A different contribution to rapport came about because the attendants saw me asan educated person who was a 'new ear' to listen to their opinions on the 'problems of theambulance service and management' and other issues.Several developments in the field also added to my successful development ofrapport with the members. Firstly, Arnold, the first crew member I was to ride with, wasassigned a very senior paramedic for the first day of my riding. This paramedic, Dylan,took an immediate interest in my project when briefed, and was fully supportive for theduration of the field stay. He would tell me stories that he thought would be of interestand related bits of history about the service, and gave me access to situations that I wouldhave otherwise been excluded from. This reception by a central and distinguishedmember helped tremendously with the my acceptance by other members. For example, atthe hospital, between calls, members would talk about past calls, issues of currentinterest, and general gossip. When embarking on the latter topic attendants wouldsometimes pause and look at me, at which point Dylan would intervene with a pointed,'go ahead' or a simple nod and smile.As with Dylan, a link to full-time, respected members of the scene helped with theother crew members' acceptance of me; just as Bill Whyte was brought in to the scene byDoc and therefore accepted, (Whyte 1920) and therefore was "O.K.". Further, thisacceptance carried over to the scene of accidents and incidents with respect to otherEmergency Services Personnel, such as police and firefighters.An illustration of the rapport the researcher achieved was given by cases of'devalued colleagues'. Beyond gossip, there were a number of members who crewmembers truly did not want to work with because of their personalities or lack of jobskills. On several occasions I was brought into conversations about these individuals -before, during and after a shift with them. In these situations I was issued warnings andadvice about dealings with certain individuals:29"Stay away from this guy Nikki, he has so many complaints against himwith the women's committee, it's not even funny." (Luke)"This guy's a real jerk." (Dylan)"This guy's an MO." 8 (Arnold)I was also asked opinion questions about an aspect of their performance or personality:"How were the nights with the MO?" (Lewis)"So how was Freddie's call?" (Tom)And I was included as a possible solution to the problem:"I'm attending, she's driving." (Arnold)"We'll use her notes to get him." (Lewis)A final note on rapport is the observation that many of the attendants worked withseemed to like having me around. As has been the case with many other researchers,Stoddart (1993), Zimmerman (1966: 386), members came to regard me as 'theirsociologist' and quite enjoyed the attention the study offered. A small validation of thiswas the sincere invitations to return to the field 'at any time' and the offer that I wouldalways be welcome.Another similar instance was the talk of peoples' reactions to me. On severaloccasions the crew members seemed to enjoy having me as an observer, as I wassomething of an anomaly. Police, fire, hospital staff, other attendants and even patientsall "wanted to know who the third is". A third was something of an attraction when s/hewas not a 'rookie' it seemed, and some attendants seemed to revel in the possession ofone. As mentioned above, some felt special to be the subjects of study, and they went outof their way to make comments about the research to others. For instance, Arnold was ofthe opinion that another attendant, Freddie, who was disparaged as an "MO", would bevery paranoid about having me around. Arnold said that Freddie would be convinced that8 "MO" was a derisory slang acronym for Mental Outpatient.30management had sent me to investigate his work performance, after receiving somecomplaints.To illustrate Freddie's perceived paranoia, Arnold played tricks on him at the firstopportunity he had. When some ambulance supervisors came to visit the station, Arnoldwent rushing out of the living area into the ambulance bay, as if something was up withthe supervisors. Freddie looked around the room, then jumped up and quickly followedArnold through the door, with enough lag time to miss Arnold re-entering the roomthrough the other door. Freddie was then caught and engaged in conversation with thesupervisors, something that he apparently dreaded. Arnold thought this was great fun andthat it served as 'proof that paranoia existed in Freddie.My acceptance in the field was supported by members' actions towards me. Therewere several instances where my opinion was sought by attendants, which implied thatthey valued my opinion in some way, or at least saw me as an acceptable sounding boardfor rhetorical questions.When riding third with an ALS crew, one of the attendants, Dylan, had been verysupportive of my project. He often interjected with useful observations, stories, andcomments. After a call I was assisting him to clean up the ambulance while we werewaiting for his partner to return from the hospital. He told me that he was due toparticipate in a panel discussion on the topic of 'ambulance interaction with hospital staffat the end of the month, and would appreciate any comments or observations I had. Itook this conversation to, in a small way, support my successful integration.The reflexive question that was often put to me, by Dylan and several others, was"How am I doing" or "How are we doing", while on a call. I would sometimes make acomment when appropriate, such as when I thought the patient needed another blanket, orneeded further clean-up. These were always taken note of and I really felt as though Iwas part of a team.31Finally, the various warnings I received from some crew members about thesanity of two others led me to believe that I was accepted and trusted—and protected—bythese crews.As further 'proof of my acceptance by members, there were several instancesdaily where my assistance was enlisted for tasks or provision of emergency aid. As in theresearch of Stoddart (1986) my role could be seen as fitting into the category of'Disattending: erosion of visibility by display of symbolic attachment' (110-111). As inthe case of Sudnow (1967) assisting the morgue attendant to transfer a dead patient in thehopes of reducing his feeling of 'being observed' (in Stoddart, ibid.), my participation inthe scene can be argued as parallel. Mundane examples are when I assisted with theprovision of medical oxygen, and in some cases, put it on the patient alone transferringthe in-car oxygen to portable for transport, and back again once in the hospital.Slightly more knowledgeable examples include my having assisted in 'doingchemstrips' on scene which involved taking a sample of the patients' blood and putting iton a litmus type paper to determine the blood sugar level, as per the scale listed on thebox. I also started and stopped the heart monitor machine for the ALS crew, and rippedoff read-outs at the appropriate time. I carried IV's at the right height, assisted with liftsand carries, gathered patients' belongings, assisted nurses with transfers on to beds andthe changing of patients, and other related hospital duties.More involved examples include one occasion at a Motor Vehicle Accident(MVA), when I was assigned my own patient until another crew could be freed up from amore serious patient. At another MVA an attendant told me I could 'take over' insplinting a broken ankle with a pillow splint. Further, when acting as second crewmember on the Airevacs I participated in, I was enlisted to assist in the administration ofnarcotics, the suctioning of fluids from a patients' airway, and the ventilation of a patientthrough use of a 'bag and mask'. On these occasions I was also made responsible forobtaining the required equipment to accompany our crew on the helicopter or plane. I32was sent to get physician instructions, notify nurses of changes in conditions orrequirements, and the like.Finally, a note of 'proof of acceptance at the scene was the periodic treatment ofme as though I were a 'third' trying to learn the 'tricks of the trade'. For example, on anumber of occasions an attendant would explain a piece of equipment or technique, usinglanguage that only those with training in the field would understand. Further, attendantswould take the time to show me 'their way' of a completing a task such as taking a bloodpressure, or another 'trick'. Finally, a number of members would 'quiz' me as to myknowledge during or after a call, asking me questions as to what I thought was wrongwith the patient. This, I feel, was proof of my role as a novice in the field, and thus,successfully integrated.In summary, I achieved some degree of success in gaining access to the everydayactivities performed in the setting. This ethnography can be seen as 'adequate' in thesense outlined by Stoddart (1986) for the following reasons. Firstly, I was able to portraythe scene of ambulance work with minimal interference by my presence as a researcher,evidenced by the situations depicted above in my role as 'Disattending: erosion ofvisibility by symbolic attachment'. Secondly, that every attempt was made to understandthe domain from the point of view of the members, avoiding the problem of'ethnocentrism'. Thirdly, the data on the domain was gathered unobtrusively, throughoverheard conversations, comments, and direct, informed observation, and are thereforewas not in danger of 'methodogenesis'. Finally, the majority of detail herein wasprovided by 'valued' and informed members of the domain, thus avoiding the possibilityof 'unentitled informants' tainting the information gathered.33CHAPTER THREE"So what's a typical day?""A typical day? A bunch of transfers wasting the taxpayers' time andmoney and endangering lives. Probably a van full of immigrants withneck pain, hopefully something decent like an OD or a diabetic."A Day in the Life ...Every participant in an occupation has a sense of what is "normal" or routine for aworkday. This chapter describes Emergency Medical Assistants' sense of the ordinaryshift. As will be seen, the extraordinary reinforces the notion of usual.A typical shift in the Vancouver stations studied involved the following routine.Attendants arrived for 'early relief half an hour prior to the time their shift was due tostart, which allowed the previous crew to avoid that 'last call' that would take them intoovertime, if they so chose9. Permanent crew members had lockers in the station wherevarious pieces of their uniforms were kept, and they generally supplemented this supplywith items returning from the cleaners. They changed into their issue uniforms,consisting of white shirts with patches on each arm stating "British Columbia AmbulanceService", blue pants with a lighter blue piping down the side, and boots. Some memberspurchased their own black boots or high topped black shoes, while others wore the issuedpair. Uniform additions included navy blue vests, navy blue sweaters with the samepatches on the sleeve, and various jackets. All attendants wore a 'supply belt' or 'fannypack', which generally contained a small penlight or flashlight, a pair of 'super scissors',gloves, oral airwaysm, and a pen. Stethoscopes were either hanging from the belt, worn9 Generally competition for overtime was not a problem, crews worked it out between themselves withoutdifficulty.10 An appliance used in unconscious patient to ensure they have an 'adequate airway', that is, the positionof their airway was allowing oxygen exchange voluntarily, or assisted by the attendants.34around the neck. or stored in the shirt pocket. Some attendants also wore baseball stylehats with the ambulance service logo on the front.Once dressed, the crew members generally gathered in the living area of thestation and chat with the outgoing or incoming crews about the calls done over the pastwhile, media coverage, topics of interest concerning the job, etc. Some read a newspaperor a book; others watched TV. At some point early in the shift the car (ambulance) wasexamined and re-stocked with supplies. The amount of oxygen in the tank was measured,and some crew members rearranged the order of items throughout the car to their liking.If the crew was an Advanced Life Support (ALS) unit, the drug kit was be examined,restocked, and brought on car as well. Once this job was complete the crews eitherrelaxed and waited for a call at the station, or went out 'cruising' in the ambulance.The decision as to who drove, and who attended on that shift depended on anumber of factors. For a Basic Life Support (BLS) car, if the crew working together wereregular partners, they each usually did one day and one night shift. If a partner of aregular crew was off because of illness, holiday, or recertification, it was generally theregular attendant who made the decision. For ALS car, if the regular crew member wasoff the replacement may not be qualified to ALS level, and the regular attendant may beforced to attend. This arrangement was not mandatory, but on calls involving advancedprotocol the ALS member was ultimately responsible for the scene, and therefore maywish more control by being the attendant)'11 The circumstance of having only one ALS member on car, whether for holiday, recertification, or "tospread the ability around", referred to as "de-pairing", was regarded as problematic in at least two ways.Firstly, as EMA's have no formal evaluation of skills or protocols save 'recertification' every two years,they need another ALS member to help them evaluate how they are doing. The nature of the business issuch that 'every case is different' as all human beings are different, and ALS members studied preferred tohave the 'back-up' of another brain trained to the same level. Secondly, it necessitates the ALS member tobe the 'attendant' at every scene requiring those skills, and does not allow the preferred alternation ofdriving and attending. "De-pairing" also leaves the ALS member 'in charge' at every scene, and ultimatelyresponsible for everything that goes on while on car. Such one-sided responsibility was regarded asstressful by ALS members, and did not give them the opportunity to 'relax' as the driver. This issue is ofserious concern for ALS members encountered while in the field.35The person who was attending generally was responsible for the set up or re-stocking of the car, or at least they had adopted this role to ensure supplies were adequateand in a suitable order within the car. The person who drove was responsible for radio ortelephone communication with dispatch, and he or she was the one responsible for gettingthe crew to the address given.Calls were received at the station via the 'hotline' (telephone reserved exclusivelyfor the purpose of incoming call notification), or by radio either in the ambulance or on ahand held model. The procedure for receiving a call by telephone was to answer thetelephone stating the number of the station called, then listening for the information onthe call. Slips of paper were used to write the address of the call, or some attendants useda small book to record such detail. A typical telephone exchange is featured below, basedon overheard conversations of both dispatch and crew members."Ring, ring.""Station 42." (Crew)"O.K." (Crew)"Code 312 to 3917 Heather Street for a fall, response number is 123456."(Dispatch)Crew member hung up last.or"Ring, ring.""42." (Crew)"Routine to Shaughnessy, 4th floor, ward E2 for a transfer to the helipad.Response number is 123457." (Dispatch)"Helipad at Grace or the airport?" (Crew)"Grace." (Dispatch)Crew hung up last.Information transfer on air by radio followed the standard procedures for radiocommunication. Dispatch initiated the call to the car in question, as follows below."42 Alpha." (dispatch)12 All codes and uncommon terms are explained in the glossary and appendix.36"42 Alpha go ahead." (crew)"42 Alpha Code 3 for a collapse to #201-1040 West Broadway, no ALS at thistime. Your response number is 23456." (Dispatch)"42 Alpha." (Crew)Sometimes more communication was required at the scene, in which case thestandard radio procedure was followed. Some cars were also equipped with cellularphones, which were used primarily to contact the emergency doctor on duty at thehospital the patient was being transported to, to let them know what was incoming, or inthe case of a "Code 4"13. In all cases observed it was the attending member who spoke tothe doctor on cellular, as they had the first hand information and knowledge.Once a call has been dispatched, the crew then went about getting to the address.Sometimes a road map book was consulted to find the exact location of a street, or toconfirm the best route to get there. As dispatched, calls were either "Code 2" (routine),meaning that the crew was to get there obeying all rules of the road including the speedlimit, or "Code 3", meaning that both lights and sirens were used, the car was permitted tospeed, to go through intersections following the approved procedures, and the like.When en route in a Code 3 situation, the attendant helped the driver atintersections and tricky spots through the use of hand signals or verbal cues. Handsignals were important as the noise in the car was quite loud, and some attendants woreear protection to combat it. Hand signals would be used in cases where the attendant hadchecked his or her side for oncoming traffic or motorist compliance, as an indicator thatall was clear. The driver was responsible for sounding the horn when at intersections orwhen reminding a motorist to pull over, and did so very skillfully with the index fingerwhile driving with two hands, or sometimes, one hand and a coffee.An interesting phenomenon experienced was when the car got 'canceled' part wayto a call going Code 3. This would happen if another car that was closer 'cleared'13 A Code 4 is a 'suspected death' as it must be officially confirmed by a physician. Initial contact andrequest to stop resuscitation efforts was made by telephone, but the physician would verify the death inperson once at the hospital.37(became available as the previous call was completed) its last call and was able to getthere faster, or if the situation changed because of more information, etc. When a car wascanceled the driver usually pulled over abruptly, shut off the lights and sirens, andattended to the dispatch call. It was generally the driver's job to speak to dispatch, butsometimes an attendant would speak on his or her behalf. Sometimes jokes were madeabout such a situation, sarcastic comments such as,"Don't touch my radio."Or"Hands off that radio."When a cancellation occurred the car was usually re-assigned, as in the formatbelow;"44 Bravo 10-20?" (dispatch)"44 Bravo Maple and 25th." (crew)"44 Bravo cancel and take instead Code 3 to a collapse, 3421 Vine Streetin Vancouver. Your response number is 34567." (dispatch)"44 Bravo." (crew)Crew members observed were consistently pleased with the cancellation of a call."44 Bravo, cancel." (dispatch"44 Bravo." (crew)"Excellent! A well timed mission." (Dylan)and"44 Bravo, routine to abdominal pain" (dispatch)"Oh no, we're going to get it tonight!" (Dylan)(A closer car cleared on the radio...)"Come on, yes, yes!" (Jordan)"42 Alpha, routine to abdominal pain." (dispatch)"Some of your best work Mr. Smith, my favorite call, the one I don't haveto go to!" (Dylan)The exception to this enthusiastic response was for calls that "would have been good".For example, a MVA (motor vehicle accident) that many cars were being dispatched to38may have had the potential to be a 'good call", and crew members were periodicallyobserved to be disappointed if they did not get to attend such calls.Upon arrival at dispatched calls, the driver parked the ambulance in such aposition that the back doors would be accessible, and that the car was close to thedestination. The attending crew got out and went to the scene immediately if it was aCode 3, and if it was more routine, paused to help carry equipment. The driver wasresponsible for getting the cot where required, and would get any other necessaryequipment.Once at the patient's side, the attending crew assessed the injury or illness,instructing the driver to get equipment readied, help with assessment, and the like.Depending on the patient, treatment of sorts may be given at the scene or the patient maybe taken to the hospital more immediately. Central to a call was the completion of the"Form 2". This form was the official record of the call to a patient, and must be filled outin its entirety before the three copies were separated to protect the crew. Included on theform (see Appendix 4) were spots for personal information of the patient, the date, timeand location of the call, the response number assigned by dispatch, the patient's age, pastand present medical history , allergies and medications, his or her doctor's name andlocation, his or her current 'chief complaint15, the patient's respiratory rate and bloodpressure reading, including pulse rate. The treatment provided was also recorded, whichhospital (if any) the patient was transported to, and any additional information relevant tothat particular call. For example, at the scene of an MVA the patient's license platenumber was recorded, the type of car, and the responding police officer's badge number.The completion of the form was not always done by the attending member, theother crew often filled it out along the way, or a 'third' such as myself may assist in some14 A 'good call' was cited by attendants in this study to include calls where the member was challenged,where the patient 'deserved' an ambulance, and where there was some excitement involved. See Chapter 4for a more detailed examination of the subject.15 Crew members determined the 'chief complaint' by asking the question "What is bothering you the mostright now?39areas of the form. Depending on the type of patient, the form may be almost complete bythe time the crew and patient reach the hospital, or, if the patient was 'labour intensive'the form may be nearly blank. In busy areas paperwork was a concern to crew membersas it was difficult to keep up with. In addition to Form 2, there were other documents tobe filled out, depending on the type of patient. Some were formalities, for example, for adeath, others were for current research, for example F.A.S.T. (). Doing paperwork soonafter the call was important as members frequently could not remember what call they didlast, let alone details of a call gone by several hours ago.The destination for the patient was linked to the patient's medical history anddoctor. Where possible, crews would transport the patient to the hospital where he or shehad records or where his or her doctor worked, or both. If no records existed and thedoctor was not local, the patient was usually asked which hospital he or she preferred tobe taken to. Where the car was very close to a particular hospital, the patient would notalways be given a choice. Once the hospital was decided dispatch was notified of thedestination.At the hospital, the attending crew presented the patient's case to the admittingdesk, while the driver stood near the cot with the patient. Based on the type of patient,the admitting or 'triage" nurse assigned a bed in emergency or sent the crew to thetreatment room. In cases of a life-threatening nature, the crew would have radioed aheadto inform the hospital of the incoming, and the operating room may be readied for theimpending arrival of the patient.The crew then took the patient into the area assigned, and transferred him or heronto the hospital bed. The nursing staff usually assisted, but this was not found to beconsistent across hospitals visited. The oxygen tank was then transferred from theportable unit from the ambulance to the wall unit, and the patient may be given an IV16 Triage refers to the prioritizing of patients requiring care. In hospitals studied there was generally oneperson assigned to this duty.40(intravenous) if he or she did not have one put in already (not all crews were certified todo this). The patient was also put into a hospital gown if he or she was in emergency.Some hospitals issued emergency bracelets for identification of the patient, others issueda plastic credit card.When the patient was safely in the hospital bed, the crews' job was officially over.Once they completed any paperwork required, they were free to 'clear' (let it be knownthat they were free from the call) with dispatch, and be available for other calls. Crewmembers observed were often seen to prolong this step, and remain at the hospital for anumber of reasons. The rationale given for this was that "they know where we are if theyneed us (dispatch)". Members were observed to remain at the hospital longer to "catch upon paperwork", to watch emergency staff at work to learn new information or skills, tosocialize, and to avoid calls that they did not want to do.In cases where the crew were loitering at the hospital it was shown that dispatchdid indeed "know where to find them". Several times the crew was summoned by phonefrom the hospital "hotline" to return 'on air' (onto the radio inside the ambulance) toreceive a call, or were given instructions to do a transfer17 from a ward in that hospital."Doing calls" as illustrated above followed a routinized format across crewsstudied. Some shifts were, of course, busier or quieter than others, but the general formatheld. During night shift there were more attempts made to return to the station to attemptto sleep, but this generally did not become a concern until after 3 am or so, when the barpatrons had gone home and there would likely be "no more good calls" (as above).Another important part of the crew's shift were their attempts to eat. Some crewmembers felt the attempts were followed by a 'Murphy's Law'; a crew could have no callsall shift but as soon as they wanted to eat they would get called away just as their numberwas about to be called at the deli. Such instances were often joked about, "Maybe we can17 A 'transfer' refers to the physical moving of a patient from one location to another. In the case of thisambulance service, the call generally meant the 'taxiing' of a stable patient from one hospital to another,from the hospital back home, or visa versa.41use our numbers when we get back". Other members were less understanding andcommented as such, "Now this was what adds stress to our day, no time to getnourishment - back to back calls" 18 Because of such time constraints, crews wereobserved to eat a great deal of 'fast food', that is, things that could be taken out quickly.Sit down restaurant meals were not attempted the entire time I was in the field, and rarelydid I witness an attendant bring his or her own food in to the station. There were noguarantees that the crew would return to the station in proximity to meal time, so mostelected to purchase food on the road.At the station in between calls, crews were observed to do a number of things tooccupy time. Activities observed were polishing boots, watching TV, reading, studyingambulance protocols, eating (often junk food from the 'pay as you pig19'), gossiping,telling jokes and stories, talking about calls, slamming management, to name a few. Thetime spent in the station was very informative as I overheard a variety of topics andopinions. Full-timers were always observed to be happy about a 'slow' day shift, andwould jokingly reprimand the part-timers who said things like, "sure was slow today, Iwonder when we will get a call?" It was a belief by full-timers that if one made mentionof the slow day, a call would come in soon after.On night shift the situation was a little different. In the busy downtown stationscrews knew that they would be busy for a portion of the evening, usually the midnight to3:30 am time slot. Because of this knowledge, crews 'stayed up' until this time slot wasover, to save the irritating condition of being awoken by the phone. To stay up meantwatching TV, reading, doing paper work for some, and 'cruising' the streets or seawall,sitting at a scenic location (e.g. Starbucks, Kits Beach) for others. The latter options ofbeing out on the street seemed to be more popular on good weather nights,18 In the busy stations a crew's inability to obtain nourishment could be seen as detrimental as it was citedas adding stress to their day, 'making them feel rotten', and generally contributing to an already unhealthylifestyle necessitated by shift work, fast food, and high stress work.19 Most stations had a 'candy store' arrangement that was on the honor system. It was commonly referredto as the "pay as you pig".42understandably. Further, this 'cruising' was regarded by some attendants as a possibleway of getting a 'good call' - if they were in the vicinity of a busy area, something waslikely to "go down", and they may be able to "horn in on the call".In this chapter I have discussed a typical shift at the high call volume stations Iparticipated in. Some aspects of 'crew culture' discussed have been similarly cited byMetz (1981) in his study of a U.S. ambulance service. Interesting parallels exist betweenthis study and mine in the sense that some social aspects of ambulance work seem to beinsensitive to locale-at least in North America. For example, story-telling at the stationwas viewed as serving the purpose of information transfer between crews with respect toobstacles (such as road construction) preventing crew from getting to a call (1981: 45).Metz also viewed stories as serving of entertainment or 'shock value', particularly formore senior members (ibid.). Likewise, derogatory comments and stories of managementwere also found to be popular amongst crews (ibid.). Finally, the universal habit of crews"stretching a run", that is, not 'clearing' with dispatch as soon as the crew is finished withthe previous call was cited as 'routinely done'. Metz observed attendants as taking thisextra time to obtain food most commonly, also a chief complaint of the attendants Istudied.Preferences for types of patients or calls is a subject that has been widelydocumented in the medical sociological literature, and was briefly alluded to here. Thenext chapter will address the topic in depth, bringing in some of the findings of otherresearchers in similar subject areas.43CHAPTER FOUR"A good call? One time I had one in this area where a guy hadjumped in front of a train and had both his legs amputated--it wasexcellent. Way better than the usual shit--wanking MVA's andlower GI problems."The sociological study of occupations has colored in a significant aspect of workthat, despite its 'everyone knows that' nature, is useful for its comparative andgeneralizing properties. This feature is the perceived quality of duties associated withwork, that is, the 'preferred' as opposed to the 'undesirable'. In the medical professions,such labeling is often reserved for the patients themselves, as they are the primary aspectthat is beyond the actors' control (Jeffrey: 1979; Becker et al: 1961). However, actorsemploy strategies to exert control on outside influences toward an end that is 'preferable'in their estimation. Where such strategies cannot be employed or are not effective, it isnonetheless interesting to examine the dialogue around the subject, as will be discussed.This research project is also concerned with how attendants regard patients, orrather, patients as part of the bigger 'call'. Found through participant observation andoverheard conversations were the various categories treated below.Characteristics of CallsAmbulance attendants were frequently heard evaluating the calls that theyreceived, talking about past calls, and wishing for future calls that would meet theircriteria of being worthwhile. These discussions and comments are the essence of thischapter, that is, the social aspect of calls vs. the technical aspect of those same calls.Further, this treatment will include the evaluation of patients from this same 'social' pointof view, and their resulting treatment. 'Regulars' encountered in the course of researchwill also be touched upon.44Good CallsI was originally oriented to the attendant's definition of a 'good' and 'bad' call withthe following excerpt from a conversation."One you don't have to carry the person to the hospital and all that crap. Abad one is when you have to transport them and they are just whiners, likeMVA's. A good scrap is O.K., you get to watch the fight and don't have totransport, it is bad if they get facial fractures, though. A good stab woundor gun shot where they aren't dead yet (is a good call)." (Luke)Despite attendants' thirst for these 'good calls', they were aware that such 'cravings' wouldnot be regarded as appropriate by all personnel. One night shift a group of paramedicsfrom England were visiting with some ambulance supervisors. In conversation Arnoldwas asked what type of calls the station generally got, he responded,"Lots of heroin overdoses, AIDS related problems e.g. shortness of breath,etc., not too much pediatrics, some elderly falls, ped struck (pedestrianstruck), elderly complaints, a nice mix." (Arnold)When the English paramedic left I asked Arnold what a real nice mix was, he respondedwith the excerpt below,"Very little general weakness bullshit—lots of MI's (myocardialinfarctions, heart attacks), stabs still alive, that's a good mix for me."(Arnold)AIDS related problems, elderly complaints and falls are all 'general weakness bullshit'according to some attendants studied. Further, attendants were cited as liking pediatriccalls because they got their skills and knowledge tested. At other times they claimed tohate calls involving children, which may indicate that it is seen as inappropriate to likesuch calls because they are treating children.Further clues as to what constituted a 'good call' were available through storiestold, comments made at the scene or following, and direct conversation."Can't you guys (Police) find us something decent - give someone a throw-away knife or something." (Arnold)45"Well, we could shoot someone, but I wouldn't want to waste my bullets".(PC)Good calls were identified by attendants as meeting certain criteria, as outlinedbelow. Calls that were challenging in some way were regarded as good, that is that theattendants had their skills tested for a trauma call, or got to do 'protocols' (set proceduresinvolving advanced equipment, drugs, or both). For example,Wishing for good calls,"These whiners are bullshit, I'm craving a good call." (Arnold)"What would you like to get?" (me)"Well, once in this area I got a good call, this guy jumped in front of atrain and got both his legs amputated. It was great.""41 Alpha, Code 3 for a fall #403 1121 West 40th" (Dispatch)"Maybe she fell from suite 403 down to the first floor!" (Hugh)"That would be excellent." (Junior)"If that woman had pulled a couple more feet into the intersection thatwould have been a good call." (Arnold)"Yeah, she would have been sitting in her son's lap." (Freddie)"No, she would have been splattered all over the place and it would havebeen a great call!" (Arnold)and"52 Bravo, Main and Columbia for an OD" (Dispatch)"Damn!" (Hugh on 41 Alpha)Stories of good calls,"Great block last at 46; 2 fatalities, delivered a kid, a stabbing and ashooting. That's a shit-hot block!" (Luke)and"Did you guys have any good calls yesterday?" (Hugh)"Yeah, we got a suicide - full cardiac protoco120." (Bart)and20 Full cardiac protocol involved intubation of a patient, defibrulation, and drugs. Such a procedure took45-60 minutes to complete, and involved the use of intravenous.andand46"Any good calls?" (Roy)"Urn, one MVA with triage." (me)"Oh yeah! I heard about that one. How many fatalities?" (Roy)"None at that one." (me)"Oh." (looking disappointed) (Roy)An extension of the above criteria without trauma would be a call that hasconvenience or entertainment value. For example,"You get to watch the fight and don't have to transport." (Luke)and"44 Alpha, cancel." (Dispatch)"Excellent, get to speed, then go to Starbucks." (Arnold)"Now that was a well timed mission." (Dylan)A call that got canceled was generally considered a 'good call' except when thecall they were dispatched to was a good call. The latter rarely happened as such 'goodcalls' were observed to require more than one ambulance to attend. For example,"May the word of the day be 'CANCEL'." (Tracey)and"My favorite kind of call, the one I don't have to go to." (Dylan)Another phenomenon with respect to calls is that of the 'Code X. This codeliterally means 'do not transfer'. This was considered a favorable outcome by all crewsobserved, particularly in the case of a patient who was not seen to need an ambulance.Attendants were cited as liking to go to calls, do 'something', but not have to take thepatient to the hospital."Fucking A, off to Starbucks we go, nice code X." (Arnold)and"Good call. Didn't have to pack him down the stairs, those are good calls.Get to do something, like diabetics21, but you don't have to pack 'em downthe stairs." (Bart)21 Diabetic problems often involved a 'quick fix' solution of dextrose and fluids intravenously. Such apatient would be back to normal quickly, and may not need to go to the hospital.47A note about 'Code X' was that the terminology crept into their everyday vocabulary. Ionce overheard a phone conversation of Bart's where he was arranging to meet a friend ata bar. The conversation went as follows,"Let's go to Johnny B's then we'll Code X if there is nothinghappening."Similarly, a 'Code X dump' is when a crew goes to a scene, and passes the transfer of thepatient off to a more junior crew. For example,"Excellent! (in unison) Code X dump!" (Dylan and Jordan)It should be noted that crews were in favor of transporting any patient who were seen toreally need an ambulance (see below). For example, patients with heart problems,traumatic injuries, and those in respiratory failure were cited as requiring an ambulance,and crews were enthusiastic to see the call through to the hospital.Another feature of a 'good call' was cited by attendants as being a call to someonewho really needed help. Attendants were sympathetic to those who actually requiredemergency ambulatory service, as opposed to those who abused the system. Forexample,"That was a good call, he was a really unhealthy guy. I thought he wasgoing to die right there when we sat him up." (Bart)and"Good call, too bad we couldn't do anything for him. I thought we weregoing to be able to, he had an organized electrical impulse." (Dylan)and"Did you hear that poor dear apologizing for bothering us? Yeah, that wasa good call, he was having a heart attack while apologizing! (Hugh)Calls may also achieve 'good call' status for their story-telling attributes. Forexample,48"Have you heard the Black and Decker story? Well, this guy goes to visithis dad in his machine shop, and decides to kill himself by drilling himselfthrough the head with a drill. The paramedics were able to keep him alivefor an organ transplant - guess who got his liver? The Western CanadaSales Rep for Black and Decker." (Arnold)"Yeah we were bagging22 this girl that jumped out of her 6th storyapartment, she was so messed up that every time I did bagged her brainsquirted out of her ears." (Hugh)"Went to this call, couple had been playing 'hide the soap' in the bath. Shelost the soap in her 2001th body part". (Hugh)"Went to this mace call, I didn't want to transport because of the smell.Once I put a guy in a body bag and zipped it up so he wouldn't stink up thecar...that didn't go over too well at the hospital." (Luke)While call 'quality' was largely determined by chance and dispatch, attendantsroutinely employed strategies to help control the calls they do. One method was to go toan area where the potential for a good call was higher. For example,"Let's make our way speedily to Robson and Jervis, maybe we can horn inon a good call and if not, we can hit the Bread Garden for a hotchocolate." (Richard)and"I think we'll cruise down toward the east side and see if we can pick upsome of the action." (Arnold)Another method was to drive slowly en route to a 'bad call' in the hopes that the crewwould be canceled and re-dispatched to a Code 3 which had more potential. Forexample,"42 Alpha, routine for a lower GI problem." (dispatch) (the car noticeablyslows down)"Let's go slow on this one, maybe we can catch a Code 3 out." (Hugh)and22 "Bagging someone" involves the use of a bag and mask apparatus which is used to ventilate a non-breathing patient.andandand49"Let's back pedal on this one, I hate that place." (Richard)and"Throw out the anchor on this one, maybe we'll catch a Code 3." (Junior)A final strategy referred to by attendants was the shifts worked. The time of dayto get good calls was considered to be between 12 midnight and 3 am. These shifts were'guaranteed' to host a good call or two, so one had to both work the shift and work withsomeone who was willing to stay for overtime if one was supposed to be off at midnight(Charlie shift). To this end, part-timers were cited as better partners as they needed themoney associated with overtime. Full-timers were often more interested in being withtheir family when planned, etc."Once the bars are closed, you might as well go home, no good calls."(Bart)Bad CallsI was oriented to the attendants' idea of a 'call that was not good' by theircomments en route to a call, after a call, or in conversation. 'Bad' calls had a number ofpossible criteria that seemed to be universal across attendants studied. These criteria andnames given by attendants to such calls will be outlined below.The first feature of a bad call was a call involving a patient who was not seen toreally need help by the ambulance. It was felt by attendants that many of such patientsshould be seeing their family doctor or going to a clinic for such problems. Attendantswere seen to be irritated by such calls as they knew that if they were tied up with a 'bogus'patient, someone else in 'Code 3' condition may be having to wait, and possibly reducingtheir chances of survival. Such patients were referred to a 'whiners', 'wanks', or just 'badcalls'. For example,"This guy's a real whiner, he calls the ambulance regularly to check on hiscast instead of going back to his doctor." (Tracey)and50"I'm getting sick of all this wanking, this lady needs home care daily, notan ambulance. If we go back my chat won't be as nice." (Arnold)and"We had better get a decent call soon, I am sick of these sniveling MVA'swho could drive to the doctor." (Lance)Many patients of such calls were part of the category of 'regulars' to the ambulanceservice. Attendants often recognized the address given by dispatch because they hadbeen there many times, or recognized the situation dispatched. For example,"42 Alpha routine to 900 Jervis for a hip problem" (dispatch) "Gabriella!The crazy German lady, Jesus Christ, I haven't seen her in a while, whydon't we take this one?" (Arnold to Freddie)and"42 Alpha, routine to a man-down in a wheelchair -public assist."(dispatch)"Fuck, I hate this prick." (Arnold)"Is this the old Indian guy that's all gibbled?" (Freddie)"Yeah, we're cheaper than a cab!" (Arnold)A more obvious version of a call that should not be using the ambulance service was thatof the following,"Yeah, Brutus the humanitarian did a big rescue the other day. This ladyflagged down the ambulance because her dog was in respiratory failure.Brutus bagged the dog and gave it a shot of epi, what a waste." (Hugh)Another type of call that was uniformly detested by ambulance personnel studiedwas the transfer. This call involved transporting a stable patient from hospital to hospitalor hospital to home. Such calls were viewed as a waste of attendants' skills, and was amuch debated subject in terms of a way to streamline the ambulance service (bycontracting the service out) and save money 23 . It was perceived by attendants thatdispatch 'picked' who was to do transfers for the day, based on some evaluative criteria ofthe crews' skills. For example,23 This possible solution was cited as the $10 000 dollar question. It was the opinion of several attendantsstudied that patient's physicians could help save time by spending 2 minutes briefing the crew prior to thetransfer to save them time on the form 2. Only once while I was in the field did I witness such a courtesyon a transfer in the lower mainland; the crew was most impressed by that physician.51"If Tommy's (dispatch) on today hopefully Bravo can do all the transfersand we will do all the good calls." (Arnold)Further, evidence of this is when crews teased one another about doing transfers, as if itwere below them,"Look it's Alpha 42 doing a transfer!" (Junior) (Arnold turned around andgave our car a dark glare)"If looks could kill!" (Hugh)Another feature of a bad call is one that involves personal risk to the attendants ofsome kind. Such situations could involve bugs or beasts,"I got a bad call one time, this guy was just crawling with lice. There wasno way I was going to jeopardize myself or my ambulance, so I zippedhim up in a body bag with just the 02 line hanging out. The emerg doctorwasn't impressed." (Luke)and"Fuck, did you see the roaches in that place? I had to keep hoppingaround to keep 'em off me. I can handle bugs for about 20 minutes or so,but small rodents like mice, rats, etc., I'm out of there." (Junior)Other situations would include risk to person in the way of injury,"Here's the nightmare call for you. I got called to the Convention Centeronce for back pain from a fall, it turned out to be the convention forOvereaters Anonymous of the U.S. Everyone in the room weighed over3001bs and one of them had back pain and wanted to be lifted? Whatabout me?!" (Arnold)and"41 Alpha, Code 3 to Brandiz Hotel for shortness of breath." (Dispatch)"Fuck, I hate that place, the cot doesn't fit in the elevator so you end uppacking them down the stairs. The last thing I need today with my back isto pack someone down the stairs." (John)Finally, Arnold came out of the hospital from using the hotline to get a call,"This is not a good call. 17 year old girl seizing on Hastings, on LSD,puking all over the place. Probably some hooker with HIV. Everyone getyour gloves on." (Arnold)52Another type of call that is considered undesirable by attendants observed is thatof the unsuccessful SIDS (Sudden Infant Death Syndrome) case. Regular crews weregenerally at odds with any call involving children because they receive very little trainingon kids. There was a real contradiction in wishes with respect to calls with children, thesame attendants were overheard saying that they "wish they could get some moreexperience with kids", and "I hate doing those calls, I never get enough to keep my skillsup"."I wish I had more training, for fuck's sake. ..Larry had a SIDS on dayshift, I hate those calls." (Luke)From the story-telling side there were a few examples of 'calls from hell' overheard at thestation or hospital after the fact. For example,"Here's a call from hell, 3 vans collide, one full of Ukrainiansthe other two are full of Chinese, none speak English." (Debbie)and"We just did the call from hell. A psych patient who had slipped throughthe cracks for a couple of years, living in a house stacked to the rafterswith shopping carts of garbage. The place was stacked so high we had towade through it." (Lance)"What was medically wrong with him? (Me)"Well, when you've shit your pants for four days a better question is whatisn't wrong with you."(Lance)"I hate calls like that, even though you are clean you feel like stuff iscrawling all over you."(Tim)A final example of 'bad' calls were those that were seen to take attendants awayfrom their 'real' work, even if it was at no risk to the public. The most central example ofthis feature is the call where the attendants were seen as 'witness' to something, andwould therefore be required to appear in court. Unlike the police, court time was notconsidered a bonus in terms of overtime, rather, it was considered to be 'inconvenient'.For example,"That guy was a ratbag, you can tell by his shoes. It doesn't matter one bitthat he is a personal injury lawyer, he will be fighting with ICBC - that'swhat insurance companies are for."53"I guess we'll be getting a call for this one in court" (Freddie)"Eh, we didn't see anything". (Arnold))The above excerpt also brings to light a strategy employed by attendants to avoid such acall to duty in the statement 'we didn't see anything'. Another example of such a call isthe 'union call'. On such calls the ambulance is called to verify the claim of the memberof a union,"42 Alpha, routine to the busloop for an assault" (dispatch)"This is going to be a union call" - (mimicking) "I get the rest of the dayoff if I call an ambulance, don't I?" (Bart)"Yeah, we'll be Code X'ing this one." (Arnold)A Note on 'Regulars'Attendants who had been working in a particular area for some time were awareof the category of patients referred to as 'regulars'. Regulars were those patients whoused, and sometimes abused, the ambulance service on a regular basis. Such patientswere recognizable by address, symptom, or situation, and were often referred to by nameor other determining characteristic. These patients were treated differently whenrecognized, for their past history often pre-disposed their current condition. For example,one lady called the ambulance service on a regular basis to come and help her out of bedto go to the bathroom, or visa versa. She was considered hazardous to the rest of thegeneral public as a crew was then 'tied up' and not able to respond to a sick or injuredpatient. This lady would be spoken to quite strictly regarding the proper use of anambulance service (To go to the hospital), and such 'chats' would be passed on to othercrews via radio so the 'ante' could be raised on visit number two or three.Another example is that of a native male who drank ginseng regularly, and passedout on buses. He would be recognizable by his location and description, as the address isnot relevant. Likewise, an elderly native male who uses a wheelchair was encountered bythe service regularly as he often fell out of his chair from drinking. This call was54dispatched typically as a 'man down in a wheelchair', and was easily recognizable withinthe vicinity he was known to live. A further note on such a patient was the crewmembers' ability to remember what happened last time, and avoid unnecessary calls.Specifically, this patient was questioned as to whether he had his key to the elevator forhis building, and was made to produce it for the member to see 24. This check wouldensure the service would not be receiving a call half an hour later for another 'publicassist' call.Another feature of knowledge of 'regulars' is in the diagnosing of the patientthemselves. For example, one elderly German lady who was a regular of the service forfalling down and hitting her head would be asked the question, "What year did you cometo Canada in?". As the attendants knew the answer from previous calls her answer wouldspeak to her level of consciousness and help them decide how valid her complaint was.Similarly, a 'regular' call from the same block would save time in history taking as theyhad done the same recently.Other 'regulars' were not treated with such tolerance. There were several storiesabout street regulars that crews compared notes on and even refused 'to carry' (to thehospital). New members were oriented to such patients by these stories with commentssuch as, "There I was treating her like a human being and it was Christine". "What aboutthat one with the Barbie dolls?", "I don't transport her - ever". "Ever? - Wow."In this chapter I have discussed crews' preferences for call and patient type, thecategory of regulars, and have given some examples of the kind of situations encounteredby attendants. Some topics herein are well documented in the sociological literature, andwarrant some reference.24 Crews were observed many times over to provide 'public assists' for people who did not have anythingmedically wrong with them. While such calls are an unfortunate use of an emergency medical service, itshould be noted the 'social work' service provided by these crews. On a number of occasions crewmembers would 'lecture' regulars in a guiding way, for example, counseling the patient to check into adetox program, to remind pregnant females that 'booze and babies don't mix', and the like.55The topic of evaluation of patients parallels easily to the evaluation of calls withrespect to ambulance attendants. The subject occupies a central place in the medicalsociology literature, beginning with Martin's (1957) concern with preferences for typesof patients among student physicians. In Boys in White, Becker, Hughes and Geer (1961)found through participant observation the evaluative category of "crock" patients, addingcolor to the previous bland survey research. Roth (1972; 1973) examined the 'moralevaluation' of clientele in the emergency room setting, as did Jeffrey (1979), whodiscovered the category of 'rubbish' to the literature. The "gomer phenomenon" wasdocumented by Leiderman and Grisso (1985) in reference to frustrating patients inhospitals who were difficult to diagnose, were longer to return home, and the like.Both Mannon (1981) and Metz (1981) did useful participant observationambulance studies by going through the process of becoming an ambulance attendant.Their work outlined some of the perceptions of patients by ambulance attendants, framingthis evaluation in terms of 'runs' made by the ambulance, and whether or not they wereuseful, or deserving. Palmer's (1983) work observing and interviewing ambulanceattendants touched on this topic partially, but focused on the personality of the attendantsthemselves, and their obsession with 'trauma calls', labeling these workers 'traumajunkies'.Another topic cited in the literature with parallels to my study was that of'regulars'. Metz (1981) found the attendants he observed to find regulars "amusingbecause of their quirkiness" (1981: 120), as did some of the attendants I studied.However, both groups of attendants generally categorized such patients as "Shit Calls" inthe case of Metz, and 'bad calls' in this project. The recognition of regulars bydispatchers and attendants due to address, situation, or symptom was also found to existin each of the 1981 studies above.How an attendant comes to understand the meanings of such terms as "good call","bad call", "nightmare call", "union call", and later use them is an interesting topic in56itself. Such things are learned on the job by watching, listening, and learning from moresenior attendants. The formal training an EMA receives in the classroom does not touchon such 'street knowledge', an attendant must learn through the informal 'apprenticeship'.The next chapter will outline other 'need to know' features of the business of working asan ambulance attendant, following this theme through.57CHAPTER FIVE"Those EMA II's from the interior can only dream about seeing thepatients we get all the time down here. They are a liability for the first twoyears -- all they know is what they learned in the classroom. You don'tknow dick until you've worked downtown."This chapter will examine activities observed in the field as displays ofknowledge of the job of being an ambulance attendant, that is, the 'working rules' that onecomes to know. Specifically, activities and actions will be examined in light of thecategory 'things I did not learn in EMA school.' Both the technical and the social aspectswill be addressed.An important preface to this treatment is the fact that the organization itselfnecessitates the transfer of the majority of these 'working rules.' When members areoriginally hired they have nothing more than an Industrial First Aid ticket, a driverslicense, and perhaps some time 'riding third.' They are expected to perform calls based onexperience they have not had, and training they have not yet received. Depending on callvolume and who their partner is, the skill acquisition time period may be lengthy. It isnot until these people have been working for some time 25 that they get the opportunity toattend an EMA I course, and even then much material is not covered.The BasicsA newly hired attendant must quickly learn the basics of ambulance work.Understanding the schedule and shift patterns, finding the station, and knowing where topark are among the first challenges. Next is getting along with one's partner, andrecognizing that all members are not perfect26, ensuring the ambulance is stocked, notingwhere each piece of equipment goes in any given ambulance, and knowing the procedure25 The waiting period differs for each attendant depending on the region they have been hired in, theirUnit Chief, their perceived skills, and the like. Attendants studied experienced a range of one weekend to ayear and a half.26 For a complete treatment of this topic see Chapter 6 under 'devalued colleagues'.58for determining which member drives and which attends. Next would be theidiosyncrasies of the station itself - 'pay as you pig' (candy store on honor system),voluntary station fees ($0.50 per shift or $2.00 per block), entering and exiting theambulance bay, phone line features (Call alert, multi-line phones, etc.), maintenanceduties, in house research projects, and the geographical location of the station. The orderin which a car takes a call also needs to be learned, as it may be different for each stationor even each shift. Once an attendant has sorted out these basics, the actual 'doing ofcalls' can be attempted, and the working rules associated with them.On CarAn interesting aspect of working 'on car' is being in the ambulance itself, and thefreedom that affords. New attendants learn from others the various 'tricks' or methods tomake the time between calls more advantageous, convenient, or less boring. Small thingssuch as managing a coffee while driving Code 3 and honking the horn simultaneously areas much a result of practice as they are realizing that such activities are approved. Aninteresting example of 'tricks of the trade' would be the purchase of food. It is notpossible for ambulance attendants to go to a sit-down restaurant and order a meal in thebusy areas of town. Rather, they have to go for quick in and out food sources, and keepthemselves available at all times by monitoring the portable radio and parking theambulance in an accessible area. An accessible area is often an area where it is illegal topark, attendants justify this by the slogan "Red and white is always right". New membersneed to learn these justifications.Another lesson to be learned is that of 'cruising.' Within the city stationsresearched, it was popular to spend some of the time in between calls in the car drivingaround the area they were responsible for, and in some cases, adjacent areas of interest.'Cruising' past the hookers was recognized as 'mandatory' by crews studied when in thatarea, as was 'doing' 'The Square' or 'The Loop.' These two terms refer to a rectangular59route in the heart of the downtown core that included the popular Denman Street, DavieStreet, and Robson Street. Visiting various Starbucks or other established coffee houseswas also regarded as important by most crews studied, a new comer would have to betolerant of such excursions. A similar activity that would need to be condoned by thenew attendant would be 'doing the seawall.' This activity was done late on quiet nightsand often took crews technically 'out of area', but was viewed as an entertaining and stressrelieving 'thing to do.'An important aspect of 'cruising' was knowing what to say when dispatch askedthe car's '10-20' (location). One had to think quickly to answer with a suitable locationthat was both within the car's legitimate area and not too far away that a response timewould appear off. Further to geographical locations was an in-depth knowledge of thearea one is working in. The quickest routes possible must be identifiable quickly, as arepossible obstacles the car may encounter, for example, road work, dead-end roads, andthe like. Attendants had to be comfortable with street maps, and aware of theirshortcomings. Maps were found to be incorrect or have confusing representations ofstreets while in the field, and the new attendant would need to be wary of that fact.Doing CallsThe members' criteria of a 'good' and 'bad' call would also be important to a newattendant, as well as other call designations by members. For example, knowledge of thedefinition of a 'union call' or a call with U.S. citizens would be necessary, the former for apre-warning for diagnosis, the latter to clue into the view by members that Americans are'suit happy' and one should thus transport to hospital and treat for the worst even in themildest cases. An additional important aspect of this knowledge would be the strategiesemployed to help control call assignment. (See chapter 3). Examples of the latter wouldinclude driving slowly to an undesired call in the hopes of 'catching a Code 3 out', taking60food to dispatch to ensure the crew is in good standing with them, and driving to an areaof town with high likelihood of 'good call' volume.Being on a call has a multitude of features that are required to be learned on sceneby a new attendant. 'Street sense' is an important part of doing a call, advice such as howto approach a door safely, to trust no-one and believe everyone is trying to kill you,knowledge of which parts of the ambulance frame would stop bullets, and the like.Experience adds to this knowledge, stories are often passed down to new members offlying flower pots narrowly missing heads, knives running full speed out of an ajarapartment doors, etc. Learning to quickly survey a room for potential weapons ordangers is also prominent when working in 'bad' areas of town, as well as knowledge ofhow to dispose of any spotted weapons without escalating the situation. Similarly,attendants need to pick up on personal dangers such as bugs, either on the patientthemselves, or in the room or site of the patient.Another feature of the scene learned through 'apprenticeship' is preparing for thearrival of the ALS car. Crews may be required to delegate a fire department member tostand at the door to wait for the ALS crew, or may prop the door open by folding back thecarpet. Where the elevator is required, attendants need to know how to 'lock it up' for theimpending arrival of the other crew, and other such 'local' features of building and homesin their region.The next aspect of doing a call with respect to learning the working rules wouldbe the treatment of patients. New attendants would quickly be oriented to the fact thatnot all patients are treated equally, if they are treated at all. Here the stigma of socialclass is evident, those who live in the 'skids' are to be treated with a different set of'working rules' than those residing in other areas of town. An alert for "knives, guns,bombs and bugs" were among the first concerns with such patients, falling into thecategory of "ensure no danger to oneself'. However, it should be noted that all patientsrequiring emergency care were, of course, treated with the seriousness deserving of any61patient. Of note is the fact that many of a crew's 'serious calls' such as drug overdosesinvolved patients from bad areas of town. Regulars, that is, those individuals whoroutinely called the ambulance, were also treated differently than a 'stranger' patient. The'regular's' past medical history influenced the way he or she will be currently treated, andnew attendants would need to learn about such individuals where possible. Thealternative could result in embarrassment to the 'rookie', some regular patients are capableof 'tricking' the unsuspecting attendant into a warm bed in emergency. Hospital staff andother crews would be quick to point out such an oversight, and rile the attendant in thefuture about the incident.Another feature of the treatment of patients would be the 'handling' of patients thatwere obnoxious, mentally unstable, violent, under arrest, practitioners of illegal narcotics,or those who tried to sexually assault the attendant. While various attendants wouldhandle such situations differently, the new recruit would be able to glean fromobservation and participation what types of strategies are employed, and thus accepted atsome level. Bedside manner is another aspect of the treatment of patients that must belearned on the job - attendants learn what questions to ask from a medical point of viewin EMA class, but nothing else. For example, the visual survey of a room may host allimportant clues as to the patients real medical problems. On one call a young man wasthought to be a 'gentleman under strain' without any real problems because of the fact thathe; 1)was unemployed; 2) had his own blood pressure cuff; and 3) had a number of bookson Christianity around his room. The attendants guessed from these clues at the scenethat there was probably nothing wrong with him other than his own sense of guilt at beingunemployed27. Such skills of observation are again learned by experience on calls, andthe observation of more experienced members.27 In this case the patient was taken to hospital 'just to be safe', but the attendants perceptions wereconfirmed, there was nothing medically wrong with him at that time.62The phenomenon of the 'fatherly chat' is another feature of the work of ambulanceattendants that is not taught in EMA school. A person who has just been revived from aheroin overdose, for example, may get a lecture from the attendants in private about theevils of the sellers of narcotics, the quality of the narcotic itself, or the deals they mayhave to make with God on the way to the hospita128. While such 'chats' are a verylocalized phenomenon, attendants working in that area of the city may be exposed tothem and expected to perform similar tasks in the future. Another example of a recipientof a 'chat' would be an individual who abuses the services of the ambulance. Thisindividual is not sick or injured, and does not need medical attention. They may be,however, lonely, making 'the chat' quite delicate. One must be firm yet offer alternativesto solve their problems such as homecare volunteers, a nursing home, or the familyphysician.On the scene of a call there are a number of 'need to knows' that the new attendantmust pick up. When obtaining a history about a patient, my field research showed it to beimportant not to fully trust fire fighters, family, homecare workers, or even nurses withthe 'diagnosis' of the patient. On several occasions such individuals were found to impartincorrect and possibly detrimental information regarding the patient. Thus, the transfer ofinformation must be taken 'with a grain of salt.'Another aspect of doing a call that must be learned on the job is the enlistment ofhelp from other emergency services personnel. For example, one must know how torecognize the Captain of a fire crew, and how to treat him29 in order to facilitate thecooperation of his crew to complete tasks. Secondarily, an attendant must be aware thatpersonnel such as fire may not always perform to standard, they need to be watched andcorrected if necessary. On one call for an cardiac arrest, three different fire personnel28 As documented in Metz (1981), attendants were observed to 'harass' drunks or junkies' while attendingthem. Metz (119) cited observing attendants to 'confuse' drunks by pretending to arrive in an adjacent city,or by giving them such a rough ride they would be sick to their stomachs. In this study, attendants referredto 'making them repent to God for their sins' on the way to the hospital.29 At the time of this research, there were no female Fire Chiefs in British Columbia.63were observed to landmark30 incorrectly for CPR. The attendants had to correct theplacement.On calls where a crew may be backing up the ALS car, a crew member must befamiliar with the advanced crew's equipment and procedure, despite the fact that they arenot taught it in the EMA I program, nor, often, are they supposed to perform such tasks.Examples would be setting up the 'leads' of the heart monitor, knowing the location andappearance of the 'pediatric kit' on the ALS vehicle, pressing the correct buttons for readouts to be produced on the monitoring equipment, and the like. One also needs to beaware of the practicalities of assisting ALS, for example, it was commonly held by somemembers that certain 'Airevac' flights required 'Gravol'31 - the new attendant would needto be aware of this potential pitfall. The listed expected features of the scene areinteresting as most cases involving ALS are time constrained, and there is virtually notime for instruction.32To The HospitalWhen preparing to transfer a patient to the hospital, once must also be aware ofthe family or friends present, how they are feeling and how they will get there. While theAmbulance Service does give general guidelines as to who may accompany the patientvia ambulance and under what circumstances, it is sometimes necessary to bend the rulesor at least investigate further. Crews were often heard telling friends and family to "obeyall laws and take your time getting there", indicating that the crew was concerned aboutthe mental state of these individuals, and their readiness to drive. Another situation thatmay arise is a case where the person that is injured or sick may be the only one in30 In cardio pulmonary resuscitation, a technique used to circulate oxygenated blood in a patient who ispulseless, the heel of the hand must be placed on the sternum two fingers above the zyphoid process (apiece of cartilage that could break off if compressed) to avoid further injury to the patient.31 A motion-sickness medication.32 Unstructured interviews with members revealed that at one time EMA 2 candidates received an "ALSOrientation" whereby a paramedic would go over the typical tasks that would be requested forperformance, differences in equipment, and what not to do on the scene when aiding ALS. This practicehas since been dropped, but would seem very valuable.64possession of a valid driver's license. In such a case, cabs need to be organized, friendscalled, and in some cases, the rules for transporting bent. Crews were also observed toensure others did not have any underlying medical problems, such as heart conditions,that may manifest themselves because of the current strain of the situation. Suchsensitivity must be learned from experience in the field.Once at the hospital, there are several tasks that must be picked up if one is to "getalong" with staff there and be regarded with respect. Firstly, the patient that the crew isdelivering must be 'worthy' of the hospital, or the crew needs to have a very goodexplanation. Some hospitals refuse to admit patients unless they have a family physicianbased out of there, the new attendant must be aware of this potential obstacle. Further,some patients will not be admitted if their injury is not deemed an 'emergency' and theward is very busy. The result of breaking these working rules was perceived by someattendants as the possibility that the nursing staff may not think twice about sending for a'transfer', a most undesirable call from the ambulance members' point of view. Secondly,the crew must know how to assist the nursing staff, for such skills are not taught in theEMA program. Taking off patients' clothes and replacing them with a hospital gown,assisting with intravenous', and any other duties the hospital staff deem necessary are all'need to knows.'When finished a call at the hospital, the crew member must learn where to getequipment to clean up the ambulance, and the 'tricks' associated with that One suchexample is the use of paper/plastic pillow cases as garbage bags. Such usage wasobserved universally with all crews studied, and yet it was not taught in an EMA course.Another feature of clean-up was the replacement of supplies. Seasoned attendants knewwhich hospitals one could get supplies such as linen, hard collars, triangular bandagesand splints; and which ones one could not. This 'local' information was very important tothe working relationship with the hospital staff, and the smooth efficient running of ashift on ambulance.65Other FeaturesIn addition to the above 'need to knows' the new attendant must learn some skillsand knowledge in the area of psychology. For example, in the event the patient dies onthe scene, and the hospital is never reached, the attendant must be equipped to deal withthe family or friends of the deceased. The EMA program does not touch upon thepsychology of death, so attendants must learn this knowledge and skills from otherattendants. Another example is that of a patient who has been sexually assaulted orraped. Attendants studied purported this to be 'the worst call a guy can get', and stated thebenefits of having a female partner on such calls. The new male attendant would need tohave the skills to deal with such a situation, given that a female attendant is not always onscene. A new female attendant would have to come to terms with the situation that maydeeply affect her.A final group of 'need to knows' for ambulance attendants is a variety ofadministrative and social features of the job of being an ambulance attendant. Forexample, one must know how to ask to have overtime paid out, know what percentage ofpay one receives when off on sick time, and the like. One must also know how to fill outovertime forms, and under what circumstances they should be filled out. While this isclearly laid out in the union contract, the practical application of such 'rules' is oftendifferent. Further, one must be aware of the consequences of answers to research projectquestions that are active at each station. For example, if a question wants the attendant tostate what the response time was to a call in an 'adequately staffed area', they may want toanswer in such a way that it will appear that their area is understaffed.Interaction with the media is another skill learned on the job. Often it is the UnitChief who takes on the responsibility to train new attendants when the time comes, butthis is most often reactionary. The wise recruit watches others on the news, paying closeattention to the comments and reactions of more senior attendants. Finally, an attendantneeds to get used to the "awful" shift patterns, complete with sleep deprivation, and the66strategies employed to offset this, such as the 'split night drinking fest.' The latter isreported to be a tradition within a busy platoon, to go out 'on a bender' so one is able tosleep the next day through, and ease better into the nights.This chapter has outlined some of the skills and knowledge an ambulanceattendant must quickly acquire in order to successfully complete the tasks associated withthe job. While basic skills are taught to attendants through their formal training, the arepart of an informal 'apprenticeship' period, and come about due to 'demand' rather thanrequest examples. Many of these acquired skills are directly related to how one getsalong with others at the scene, at the station, or while on car. The next chapter willelaborate on these relationships, and illustrate some of the 'street smarts' put into practice.67CHAPTER SIX"They're a fucking pain in the ass. If they did something that helped us outit would be OK like get the elevator, hold the door open, not park theirflicking truck in front of the best access. All they do is slow us down."It is generally held by lay persons that the three primary emergency serviceagencies, Police, Fire and Ambulance, work hand in hand to address any problem thatmay arise in the community, with a flair of teamwork, respect for each others' area ofexpertise, and with a similar commitment to helping others. Indeed, their dispatchers arecentralized under the 911 umbrella, and they are often shown on scene by the mediaworking together. However, the relationships between these agencies behind the scenesfrom the point of view of ambulance attendants is less than ideal in some cases, and inothers - tenuous. The following chapter will elaborate on this theme from the side ofambulance personnel, based on "overheard" comments and stories, direct observations ataccident/incident scenes, and informal interviewing and conversation. Of note is the'local' nature of these comments and perceptions, they reflect only the areas covered bythe ambulance crews in question, and may not be applied to the region more generally.FirefightersThroughout this field research, I came into contact with fire personnel at the scene28 times. These encounters and later conversations make up the following information.According to ambulance personnel, the provincial fire departments are fundedbased on the number of calls they do. With the decrease in fires because of building codeimprovements, and sprinkler and other preventative legislation, there are less fires torespond to and their role must change to adapt to the community needs."The problem with the fire department is that they are a dyingprofession because of the improvements to building codes etc.They are trying to make a place for themselves in a society68that doesn't need them." (Dylan)One direction they have taken is to be part of the "layered response" system ofthe Emergency Health Services in British Columbia, providing initial contact at the sceneuntil the ambulance arrives. The proximity of fire personnel is usually better than that ofambulance, as there are many more fire stations than there are ambulance stations orambulances. Because of these factors, their presence is justified, their statistics aresufficient for budget support, and they can help to serve the public. Despite the numerouscalls responded to, the fire crews encountered in this research were, according to theambulance personnel, not very well trained in first aid or resuscitation skills. Ambulancemembers attributed this to,"All their training is done in-house, they don't get the real critique theyneed." (Luke)and"They (Vancouver Fire) refuse to take the First Responder course, so theyrarely do correct CPR etc." (Richard)And, at the station I commented post-call that two of the firemen's land marking for CPRwas incorrect,"Yeah, that happens all the time.^They teach each other badhabits. "(Arnold)Clues as to the ambulance perception of their relationship were evident in othercomments made, fitting into categories listed below.Ambulance personnel studied had the impression that the firemen (all were malein this study) were in their way and commented as such;"They are a fucking pain in the ass. If they did something that helped us itwould be OK, like open the door, get the elevator ready, not park theirfucking truck in front of the best access. All they do is slow us down."(Arnold)"Of course the goddamn truck has to be blocking the alley." (Arnold)"Bloody well in the way again, would be nice if we could get near theplace."(Bart)and"If this truck would get out of my way maybe we could see an address."(Luke)Firemen were also cited as not doing the appropriate rescue measure for thevictim when the ambulance arrived on scene, one overheard discussion was in referenceto the management proposal that fire personnel should get training in automaticdefibrillation because they can get there faster;"I kept track for three blocks straight. They backed us up 40 times, for tenof those they were there first on an AD (autodefib) situation, but six out ofthose ten times they had to be told to initiate CPR..."(Arnold)Other comments overheard support the above perception by ambulance personnel;"Can you re-landmark for CPR please?...No, like this." (Dylan)"If that blonde Cylon33 (fireman) gets into my ambulance one more time Iam going to speak to his captain - that's 3 times this block." (Luke)At the scene of an MVA a fireman asked me what training I had, when I told him heresponded;"Good, you take over, I don't know what I am doing."Ambulance personnel studied also felt that firemen tried to get out of helping and'slacked off at the scene. For example, on one call for a cardiac patient in an older housewith stairs that could not be negotiated with a cot the crew (ambulance) decided to do a33 'Cylons' are a robotic creature depicted in the popular science fiction movie Battlestar Galactica. Theterm was used to refer to fire fighters because of their 'mindless, robotic thoughts and actions'. This wasnot a positive light for fire fighters to be in.6970chair lift out, and verbalized as such. The room had emptied of firemen, save theCaptain. Arnold said;"Captain, could you get one of your guys back in here to help us get himout of here?"Back in the ambulance Freddie said to Arnold,"Did you see the way those CyIons slunk out of there on the cue of 'lift'?That Captain is all right, but as if he should be doing the lift!" 34At the scene of a very bad motor vehicle accident a crew member was shoutinginstructions at bystanders and crews alike. He looked directly at a threesome of firepersonnel and said,"Christ, don't all stand around at once! I need sandbags, the collar bag anda clamshell." (unknown crew member)Further, at the scene of one cardiac arrest the CPR effort was stopped for a pulse check.The fireman who had been doing the compressions stood up and moved away. Theparamedic looked around and said,"Resume CPR" (no-one returned to the chest)"RESUME CPR PLEASE!" (shouting toward the fireman) (Richard)This failure to do resuscitation efforts seemed to be widely acknowledged by ambulancepersonnel, several times in conversation they would refer to what they have coined "TheStare of Life", whereby the fire personnel are seen to be staring at the victim instead ofaiding them. This seemed to be a popular line of joking. For example, at the hospital34 This statement opens up the whole issue of the treatment of 'rookies' and the hierarchy evidenced in thefire department, as is the case with many organizations. While interesting, I have purposely avoided this asa topic because of its magnitude.71between calls a patient in an emergency bed started thrashing around hysterically, hismother called out to the group of us who were talking, "will someone help instead of juststaring!". Mark wheeled around away from her line of view and said to us,"We're giving him the 'stare of life' (doing a demonstration).""No, (Lewis interjected) it is like this (does another).""6 out of 10 times they had to be told to initiate CPR, they were doing theold 'stare of life' instead." (Arnold)At the restaurant after shift, the table of ambulance personnel stood up and gave thefireman at the other table 'The Stare of Life', with one crew member standing on the tableleading the effort.Finally, as we were boarding the airevac helicopter, I commented on the name onthe side, "Sound of Life". Dylan responded to me,"Yes, PR is everything these days, isn't it? Nothing like 'Stare of Life'I hope! (Laughs)Firemen, their activities, equipment, and work ethic were frequently made fun ofby ambulance personnel, at the station, at the hospital in between calls, and on socialoccasions after shift. This included name-calling, impersonations, and ideas of groupmis-representation.Fire fighters were often referred to as "Bucketheads" or "Squirters" for theirability to bring water to a scene, as well as "Cylons", as defined above. One commentmade as we were driving on the seawall,"The Cylons can't make it around this corner, its excellent." (Freddie)72At the restaurant after a shift there was a recently hired fireman present at another table,the ambulance group chanted,"CyIon! CyIon! Cylon!; Buckethead! Buckethead! Buckethead!"At the station stories were also told about 'CyIon mishaps',"Did you hear about the Surrey ambulance that crashed into the firetruck?" (laughter)"What about the brand new fire truck that got burned up because the fireoverwhelmed it and it was parked too close?" (laughter)"In Kelowna, a volunteer buckethead drove right into a house on fire."(laughter)At the hospital in between calls,"We're giving him the 'Stare of Life' instead."The perception that fire personnel who worked night shift did not like to be calledout, and thus were somewhat "wimpy" was also a common line of humor. This was incontrast to the ambulance members who thrived on the late night bar calls, and fast pacedaction of the streets after dark."Cylons don't like to be woken up after they have tucked into bed at10pm." (Bart)"They (fire crew) have been sleeping since 1 Opm (and therefore could notrespond to a 'public assist' call)." (Freddie)Dispatch assigned our car a call for a "walk-in man-down" at a fire hall, I asked how aman-down could be a walk-in,"Cylons get out of bed and are too disoriented to figure out how it couldbe a walk-in man-down." (Arnold)73At the scene of a suspected cardiac problem Luke joked to one of the fire personnelwhose hair was standing on end,"Did we wake you up?"Later, in the ambulance,"Did you see that CyIon hold the door open while sleeping?" (Luke)Finally, in support of ambulance liking night shifts because of the "good calls";"I like night shift better, it is never boring and you get all the goodcalls" .(Hugh)"Yeah, but once the bars are closed, you might as well go home, no goodcalls". (Arnold)While 'cruising' Robson Street, Hugh and Junior discussed the upcoming "VikingWarrior Tour"35 to Victoria (a group of ambulance personnel were going on a drinkingtrip to Victoria in between their day and night shifts) and suggested they getcommemorative T-shirts made for the occasion,"We can get shirts with a Viking on the front with a beer, and VancouverFire Department on the back!" (Junior)"Yeah, that way when you end up puking in the bathroom like last timethey will be horrified at the fire department, not ambulance." (Hugh)At the restaurant, the waitress asked if the group was a stag, Martin replied,"No, we are just a bunch of firemen out for a beer after a hard dayswork."35 Viking Warriors were a name the attendants used to refer to themselves in humor - it seemed to depictthe heroic and street oriented aspect of their working personalities.74It seems that humor at the expense of the fire department was universal amongstcrews studied, whether based on real-life examples or not. As humor was a big part oftheir day, this 'bashing' of the fire department seemed to serve a purpose in that it wasenjoyed by all crews observed.It should be noted here that in some instances the fire personnel worked hand inhand with the ambulance crews, particularly in the area of auto extrication, andstabilization of vehicles at the scene of a crash. Additionally, individuals and crews insome areas of the city were held in higher regard than the majority of 'local' crews."Burnaby is excellent, they have taken the First Responder course - theygather the information we need when we immediately get to the scene."(Richard)And, in reference to the fire department's Rescue Response Team,"They're all right. They have their IFA and are trained in auto extricationmore than the ambulance guys, and they have rappelling training, etc."(Arnold)As we pulled up to the scene of an MVA with fire already on scene,"Oh good, it's Foellmer. We'll get a history." (Hugh)Captains were also regarded with more respect that his 'boys', and were seen as a vehicleto get 'the boys' doing what they should be."Captain, could you get one of your guys back in here to help us get thisguy out of here."At the scene of a hanging the fire Captain had been upstairs with the wife of the victimtalking to her while the resuscitation effort was going on downstairs. We met him on theway out after the victim had been declared "Code 4". The paramedics commented,"Good work Captain, that was a tough one, we could hear her screamingdownstairs." (Francis)75Finally,"The Captain is all right, but as if he should be doing the lift!"As illustrated above, the behind-the-scenes regard for the fire department by theambulance workers studied was not one of respect and admiration. On the contrary, firepersonnel were implied to be lazy with respect to wanting to do calls at night, assistingwith lifts at the scene, and the like. In a sense they were also implied to be uncaring orignorant, as in the case of the 'stare of life' and neglect to begin early resuscitation efforts.While aspects of their experience were acknowledged as useful, for example autoextrication, the putting out of fires, and repelling; for the majority of calls they wereregarded as "in the way", and not adding any quality of service to the scene. Further, thisdisdain has become a standardized scapegoat, offered up in the form of humor, namecalling, and downright 'bashing'.The relationship between the ambulance workers studied and the police, however,is much better than their 'squirter' counterparts, as evidenced by overheard comments andobservations at the scene of interactions, and other references to the group.PoliceAn overview of the relationship between police and ambulance can becharacterized as appearing to be one of mutual respect on a professional level. Commentsoverheard would indicate that some ambulance workers thought that individualpersonalities of Police Constables (PC's) were questionable, but these opinions did notseem to mar their professional perception. Police/ambulance interaction was observed atotal of 30 times. This section will elaborate the nature of those interactions.Several comments overheard indicated that ambulance personnel felt PC's were"unstable". One observed situation was at the scene of a hanging, a female PC came onscene to gather the facts of the case. When told that the circumstances involved the wifeof the victim coming home to find him 'swinging' she commented,"I don't know what I would do if I came home to find my husband like that- probably join him up there!"At the hospital later that block a group of ambulance personnel were discussing thehanging, and commented about the female PC's comments being inappropriate,"There's nothing like a stable PC." (Luke)Later still,"I still can't believe what that female PC said the other day." (shakinghead)Another situation involved several ambulance workers at a station telling a story about aco-worker who had gone to his ex-wife's home, she was a PC and evidently had a newboyfriend on the force. The estranged husband went into the house and into the bedroomand beat the boyfriend with a 'billyclub', which is a restricted weapon. At the completionof the story one paramedic commented,"That's PC's for you. Always getting in trouble between the sheets."(Martin)7677This comment prompted other stories about PC's who were partners committing adulterywith one another's wife, and the finding of badges between the sheets. One marriedambulance worker shook his head saying,"Those PC's are fucking warped, man." (Arnold)Despite these comments and perceptions of Police, ambulance workers seemed toappreciate their presence at a scene, and therefore did not see the personality problems toget in the way of them doing their job. On scene, police were observed to do a variety oftasks such as traffic control, assessment of vehicles and the environment involved inMVA's, questioning of parties, arresting suspects, and the like. It would appear from theinteractions observed and conversations overheard that these tasks were considered byambulance personnel to be within the job description' of police and that they were reliedon for that aspect of the call.In contrast to the perception of fire personnel, police efforts on scene wereappreciated and approved. Consider the following comment made after a drinkingdriving MVA,"The guy was under arrest when we got there." (Arnold)The above statement in context implied; 1) acknowledgment that the PC had done his job,i.e. made an arrest; 2) appreciation of the timeliness of the action by the PC, i.e. he wasalready under arrest in the short time it took the ambulance to arrive on scene Code 3;and, 3) approval that the driver in question deserved to be arrested for drinking anddriving.More evidence of this acceptance and appreciation was obvious in situationswhere the ambulance were instructed by dispatch to "wait for 5's"36, in all cases theambulance workers waited without complaint,36 "5's" is the radio code for police, a command to 'wait for 5's' would advise the ambulance attendants towait until the police arrive before entering the scene.78"If someone wants to take bullets instead of me, I'm all for it." (Junior)"I'm for any measure that gets me home for dinner, if that includes waitingfor the 5's, I'll wait."(Dylan)The regard that the ambulance workers have for the PC's position (and their gun!) interms of their own is evident in the above circumstances. Likewise, the police rely on theambulance service to protect them with respect to injured suspects in custody. It is policeprotocol to have the ambulance see anyone in their custody that is bleeding or has anotherinjury. However, on occasion the prisoner does not comply with the ambulance worker,and the police show their respect for ambulance by discontinuing this 'right' to medicalattention. On one call, for example, Arnold was assessing a suspect's injuries out of theback of the 'paddy wagon' parked outside a local club. Freddie was chatting with theconstables. The man started getting belligerent and verbally abusive to the attendant, theattendant said very loudly,"Do you want me to treat your injury?" (Arnold)"No, fuck off!" (patient)"That's good enough for me." (Arnold)"Patient refused." (PC)"See you mates." (Arnold)In the case above, the PC and the ambulance attendant reached consensus within thelimits of their respective protocols, and both went away content with the situation.Another example of cooperation is a case where the crew was called to theSalvation Army for a person who had been caught 'fixing' (using intravenous drugs). Thepolice were called to address the law that had been broken, the ambulance to ensure thesuspect would not die of an overdose in their custody. At this call, the suspect deniedhaving 'fixed' today, claiming the last time was a few days ago. Arnold asked to see theman's arms, so the man halfheartedly pushed his sleeves up."All the way" (Arnold)79There was fresh blood and some track marks on the man's left arm, attempted to beconcealed by his tattoos. Arnold sighed, looked at the PC, then at the patient and said,"Don't jerk me around. Do you have any chest pain?""No" (patient)"So do you want an ambulance?" (Arnold)"No" (patient)(Loudly) "Those track marks are not from a few days ago. Code X folks,man refused." (Arnold)The PC nodded in agreement and led the man to the squad car.In the above case it was clear that the patient had done some sort of drug, butsince he was denying any pain and refusing an ambulance the crew was able to "Code X".Again, the constable was able to agree because his line of protocol had been met - theform had been filled out by the ambulance.The relationship between police and ambulance extends beyond the above'protocol' instances, and further illustrates the understanding and 'courtesy' that existsbetween the two groups. For example, a routine call received for a man-down turned outto be a 'Band-Aid371 only, Bart got back in the car and said,"They just wanted alcohol foam and gloves - I restocked them,we can clear."And, on the scene of an elderly man that was discovered dead in his apartment by friends(blue hands and decomposing body stench),"It would appear this man is dead" (Dylan)"Yeah, we thought he was dead, but we just wanted to make sure.Keeps it off our shoulders." (PC)Further, late at night at the scene of a reported assault in progress the ambulance pulledup to the police car to locate the victim. The PC immediately said,37 "Band-Aid" only was used to refer to a call that required nothing more than a band-aid.80"He's going to detox, then to jail. You guys see anyone elsein your survey of the area?"(PC)"No." (Freddie)"See you , then." (PC)This exchange is interesting because ambulances are not generally in the business of"surveying the area" and this occasion was no exception. However, in the name of speed,courtesy, or some unknown, Freddie was willing to back-up the PC's observation, andallow him to continue with his criminal to 'detox'.Police were also observed to be aiding ambulance personnel to the end of 'lesspaperwork', or expediting a call. One call was to a bar for an assault. The assailant hadleft and the police were taking statements from the victim and witnesses. Arnoldremarked to the PC that the injury would require stitches, the PC turned to the man'sfriend and suggested,"You can run him up to St. Paul's, can't you?"In this instance the PC was strongly suggesting that the man need not go by ambulance,and thus aiding the crew's favorite outcome, a Code X.On the street, police and ambulance were constantly interacting as they both hadthe freedom to move about the area they cover, unlike the firemen who were more tied totheir station until a call comes in. On one call to a Code 3 our car passed a paddy wagon,a patrol car, and 2 mountain bike patrol; all were waved at out the window. This was acommon occurrence. It was also common for police to stop by various stations,particularly in the downtown core, to discuss the night's happenings, have coffee, and'check in'. One nightshift, a patrol stopped by while everyone was sleeping, Arnoldcommented later,"The cops came by for a visit while you guys were sleeping, I asked themabout mace for you, Nicole. They said the best is called 'Cap Stun', andyou can buy it at 3 Vets. You just have to register that you bought it for81hiking in the alpine or whatever - no big deal - it isn't considered arestricted weapon unless you use it in an inappropriate fashion such asrobbing a jewelry store."The above 'advice' is interesting as it shows the police willingness to offer advice on suchmatters, but also how to get around the law, as it were.Further, flexibility on the part of police and ambulance can be exemplified by thefollowing two examples. After a call in the 'skids' (a highly trafficked area in thedowntown core), the crew stayed to chat with the PC's involved. Mid conversation thePC's were dispatched to a call a few blocks away."Will you guys back us up? Fight in progress." (PC)"You bet!" (Bart)Bart then leapt into the ambulance and radioed to dispatch that our car was doing the call.This is outside of 'normal' ambulance protocol; dispatch is supposed to assign calls, notthe other way around. Again, the crew were willing to go 'out on a limb' to back-up thepolice, whose work they saw as exciting and useful.A more mundane example was at the scene of an MVA, when the patientrequested to be taken to St. Paul's hospital. Sam asked me to inform the PC on scene ofthe destination, he groaned in response,"I don't want to go all the way down there, how about VGH?"I went back to the ambulance and repeated his response, Hugh said,"VGH it is."The above street interaction is another observed indicator of cooperation andappreciation. Further examples would include a case where our car was returning toquarters at the end of a shift. A patrol car came along side us to chat while in motion, thepoliceman asked what shift pattern we run, what calls we'd had during the night, and thelike. When briefed on our shift pattern he responded,"That's not a shift, it's a tour of hell! You guys should get some sleep.Have a good one!"Junior then said to Hugh,"What a great guy he is. He went to school in East Van so he knows allthe scum bags personally, and they all hate him He loves us!"The above exchange shows the camaraderie on the street, as does the excerpt below;"Do you think you guys could come up with a decent patient? Maybe givesomeone a throw-away knife or something? (Bart)"Well, I could shoot someone, but I wouldn't want to waste any bullets.There might be a bad guy to shoot at later!" (PC)Finally, at the scene of an MVA,"Hey Brad, we've been thanked twice this block for doing ourjob!" (Arnold)"Wow, they didn't want to beat you up?" (PC)"No! and...we did an excellent MVA yesterday and got to Code X."(Arnold)"Did you check out this one? So full of lust she ran a red light!" (Greta)"Such a job we have here. (PC)Crews were also observed to do what would be considered 'police work',sometimes going outside their procedure as was the case with some crew members anddomestic disputes,"You know, this force thing is really individual. What is right for me is tostay on the scene of a domestic until the police come, even if that isagainst procedure, so the woman doesn't continue getting whacked by herboyfriend. If I leave, she will.. .it would be wrong for me to leave, butthat's not to say it is right for another guy." (Luke)Another example of ambulance doing police work is in the assessment of patients at thescene of MVA's for the presence or absence of alcohol. While considered part of theirprimary assessment of a patient, ambulance crews were observed to pass this informationon the PC's quickly so as to ensure further action could be taken. For example, at the8283scene of an MVA Crew #1 came by to check on how I was doing with my patient. Icommented that the man was drunk, Jordan responded,"Make sure the RC (RCMP) knows that soon - goddamn guy should bebreathalized pronto."A final example of police work done was in the case of a man who had a cardiac arrestand could not be revived. Procedure is that the police come to the scene to do thepaperwork, wait for the body recovery service, and break the news to the family. In thissituation, the RCMP had not arrived half an hour after resuscitation efforts had ceased,and the ambulance workers deemed this "too long to keep the family waiting". Lukevolunteered to go to the home to speak to them instead of waiting any longer for thepolice.This willingness to do police work further illustrates the working relationshipbetween the two professions, especially the willingness of some ambulance crews tobreak protocol in support.There were a few exceptions to the seemingly flawless teamwork illustratedabove. The areas of the city that were covered by RCMP, as opposed to the city police,did not seem to have such a successful relationship. Attributed to less staffing per areaand the line of authority in the ranks of RCMP, several instances were observed wherethe service from the RCMP was implied as being less than desirable. RCMP were citedas being too slow to get to a call, and un-empowered to make decisions. At the scene of adomestic assault, ambulance personnel elected to stay on scene to wait for the '5's'although it was outside their line of duty,"Here we are, stuck in a call for the 5's, and there is no cable (TV). Thosegoddamn RCMP" (Luke)When the RCMP did show up 20 minutes later, Luke said to them briefly,84"Husband (points to the chair), Wife (points to the bedroom). We're out ofhere"This type of exchange is not very social nor particularly pleasant, and thus did not invitethe type of camaraderie that existed in the city core. In another case the RCMP were verylate getting to the scene of a man who had arrested and died. This necessitated theambulance attendant to go and tell the family, as they had been kept waiting "too long".After the call Richard remarked,"We missed 2 Code 3's while you were talking to the wife, what's withthese RC's?"While turning around at the end of a street because of dispatch mis-guidance an RCMPpatrol car flagged us down;"What are you guys doing?" (RCMP)"Just looking for Oxford." (Richard)Richard rolled the window back up and Luke commented,"Fuck, they are all over you when you don't need 'em."An investigation into the differences between the city police and the RCMPwould serve to enhance the understanding of why one group is regarded more positivelythan the other; with each doing essentially the same job. However, this is not the taskhere, rather, the next section will explore the observed relationship between ambulanceand hospital staff.85Ambulance interaction with hospital staffAmbulance personnel interacted with various hospital staff on a regular basisthroughout their day including admitting staff, nurses, and emergency room doctors. Thecharacter of these interactions will be elaborated below, prefaced by a discussion of thehospitals themselves.There were several hospitals patronized during the course of research, two main'city hospitals', a maternity hospital, a children's hospital, and several smaller hospitals,both public and private. Opinions varied as to which hospitals were 'good' and how thesystem worked; in fact, during the time of research there was a large controversy over aproposal to close one hospital down. Within the ambulance service there were supportersfor both sides of the debate, indicating that agreement on even a 'health care issue' thataffected them greatly was not necessarily possible. One side of the argument issummarized by the comments below,"The best thing they could do is put a nuclear device in the basement ofthat place." (Arnold)"It is ridiculous that public outcry should be able to overturn a decisionbased on fiscal facts." (Hugh)Conversely, the other side of the argument had the following statements of support,"...as it is we have to wait 10-20 minutes for a bed, I sure wouldn't want tosee Shaughnessy closed." (Luke)and"Look at this place - it is stacked to the rafters and it is the critical carecenter for Trauma, Burns and psych for the Province of B.C. Imaginewhat it would be like if they nix 350 beds from Shaughnessy..." (Dylan)Likewise, crews had opinions on which hospitals were 'good', and seemed to judge themby the staff that work there and the work they do with patients at that location. Forexample,86"It's a good hospital despite the fact that it ends up with a lot of the 'skids'.(St. Paul's)The statement above referred to less than desirable clientele that came to the hospitalbecause of its proximity to 'skid-row'. Such patients were not well-liked by the crews inquestion (as treated in chapter 3) but in this case it was felt that there were enough otherredeeming qualities to outweigh this portion of the clientele. Conversely,"I hate that place (Burnaby General), they won't admit a patient unlessthey have a doctor there. We end up jockeying around all over the place,not to mention how the patient feels." (Luke)Above it is obvious that the crew member does not like the hospital because of theinconvenience for the crew, but also recognizes that the hospital is not very concernedwith patient service. Another example of concern over the patient is,"VGH kills people on a regular basis because of their trauma center set-up.If they lived in Denver or L.A. they wouldn't be dead." (Arnold)And,"Hospitals are not such bad places to have babies any more. They let youdo what ever you want like get up and walk around, do it without drugs,watch TV, or whatever, they are really trying hard to make it better."(Dylan)However, convenience was very important to crew members,"I really like this (Shaughnessy) hospital, I find it very comfy because ofthe close proximity of everything." (Jordan)In this statement the attendant is referring to the availability of supplies for re-stockingthe car, X-ray facilities, food services, and other 'one-stop' conveniences.The main 'city hospitals' were more than just places to take patients needingemergency care, however. Hospitals were also seen as places to exchange job-relatedinformation, to check out the 'action' coming in for the shift, to learn new skills orinformation, to obtain supplies, and to gather for the purposes of socializing.87It was routinely observed that crews would gather in the ambulance bay area or inthe hallway of the emergency ward and discuss patients they had had, problems withdispatch, union concerns, politics of the ambulance service, problematic members, andother job related information. These sessions served as learning opportunities formembers, loosely falling into the category of "what I did not learn about in ambulanceschool".The most common patient discussions were calls that did not fit the 'textbook'procedure or symptom. In these cases crews were observed to stay longer at the hospitalto see what would happen, discuss the call, or learn a new procedure. For example, Samwent looking for Hugh in the ward and found him with another crew member in thetrauma room watching as the doctors worked on a badly injured child. Sam asked,"What are you doing?""Learning and socializing at once." (Hugh)On another call I went into the ward to find our crew as it had been a very longtime since we had delivered our patient. Two crews were standing in the ward discussingthe patient."What's up?" (I asked)"Apparently our patient is dying. It is a miracle he didn't crash in theambulance." (Luke)Further, Crew #2 came outside to the ambulance where I was helping to clean up andsaid,"You need to see this Nikki, the guys' X-rays are un-believable...no one canbelieve he can move his toes or legs, or feel anything below the waist." (Luke)The above 'voluntary' examples of crews staying longer at the hospital were in contrast tosituations were they were 'roped' in to staying. A common example was when the nursesasked the crew to assist in getting the patient out of their own clothes and into a hospital88gown. On one call, after a patient had been delivered to the emergency bed assigned, anurse asked,"Could you help with her housecoat before you leave?"Sam rolled his eyes at me and Hugh then went to assist the nurse. Later, in theambulance, Sam mocked the nurse's request sarcastically and shook his head, implyingthat he did not appreciate being used in that capacity.Crews were observed to monitor the hospitals' comings and goings by radio or'drive-bys', for example, one quiet shift our ambulance stopped by the hospital to 'see whowas in'. The number of the ambulance was looked at, then Arnold went inside to seewhere they were. He returned shortly to report that they "must be in ICU (Intensive CareUnit), they're not in emerg".Crews also used the hospital as a place to gather and socialize, plan activities, andwait for calls. While in the field a 'road trip' to Victoria was being planned, and wouldoften be discussed as the hospital. Similarly, the location of the 'split night drinking fest'would be organized and passed on at such gatherings in-between calls.Finally, hospitals were places to replenish supplies, but crews were aware of thelimitations and differences between hospitals on this count,"The staff at big hospitals are too busy to wine about us taking stuff, at theoverstaffed hospitals they wine and snivel if we ever re-linen (make up thecot with their linen) or grab a hard collar, so we don't bother." (Arnold)It was not clear in the course of research if ambulance attendants were officially'supposed' to take supplies from the hospitals; it seemed to be an unwritten permittedactivity. On more than one occasion a crew member seemed to be 'sneaking' into astorage cupboard to obtain a piece of equipment, that is, looking down the hall first to seeif anyone was coming, shutting the door behind while in there, and exiting quickly to the89car with the desired item38. Other times, however, crews would openly request an itemfrom the staff, and on one occasion at least, these staff would assist in getting the item."David, we really need some triangular bandages, do you think you mightfind us a couple?" (Tom)"Oh, I don't know, I might be able to dig up one or two..."(David)Other times the item was not available, and crews were forced to go elsewhere to findone. After doing a call for a child with a broken femur we went to St. Paul's' to findanother 'sager splint' (a device used for creating traction on a broken bone). Jordan askedthe nurse if there were any lying around, she replied,"No, sorry guys, you will have to go back and get the one you left atChildren's when they are done with it."Of note was the fact that the ambulance service itself does not own any flannel sheets, yetevery car I rode in had several. Apparently the hospitals supply these on the 'Q and T'.Hospital staff and their willingness to cooperate with ambulance attendants is partof a larger topic which will be treated next. Interactions and perceptions of nursing staffwill be examined first, followed by a similar treatment of Medical Doctors.Nursing StaffThere were two distinct types of nurses encountered in this research, the first werethose working in the public hospitals, the second were those working in the privatehospitals. Generally, the ambulance personnel studied had more respect for those nursesworking in the public sector because their training, delivery of information, andevaluation of patients was regarded as more closely aligned with their own. Conversely,the private hospital and nursing home nurses were seen to be untrained, to have poorcommunication skills, and to care very little about the patients. For example on one call38 In both Mannon (1981) and Metz' (1981) studies the "Five finger discount" was well documented anduniversal. While the intention of the attendants were identical between their studies and mine, to betterhelp patients, the privatization of U.S. services makes their "borrowing" potentially more dangerous andmorally questionable. The attendants in the U.S. were, in the strict sense, stealing.90to a private hospital an elderly woman had fallen in her room. When we arrived, no oneat the front desk knew that an ambulance had been called or that there was an emergency.This was apparently a common occurrence in such establishments. After some callingaround we were told to go to the 8th floor. A nurse pointed to the door of the room thewoman was in, we found her lying on the floor with a pool of blood around her head.The nursing staff had just left her there alone. Dylan asked the nurse,"What sort of medical problems does Mrs. Trapp have?""I not know, I only be here few years." (nurse)"What about heart conditions, can I see her chart?"He looked at the chart and there was no indication as to any past or current heartproblems. Interestingly enough, the electrocardiogram (ECG) indicated that not only hadshe had a heart attack at some point, but that she was currently on medications for thatsame problem. Such mistakes and miscommunication occurred frequently according toattendants studied,"Same old thing, the nurses have all been here for five years but knownothing. It's really sick seeing all these people living here withoutadequate care." (Luke)And,"These pineapple princesses39, they're all dumb, like a sack of shit."(Junior)The observed interaction and overheard comments of ambulance attendantsregarding the public hospital nursing staff can be generally grouped into; professionalexchanges, humorous exchanges, and 'management'. Examples of these groupings willbe elaborated on below.Professional exchanges between nursing staff and ambulance were standardizedbecause of the set-up of the hospital. Firstly, crews reported to the 'triage' desk where a39 The name "Pineapple princess" was used in reference to the Philippino nurses found in privatehospitals.91patient and symptomatic description were given. Based on this information the 'triagenurse' would decide the priority of the patient and assign a bed, send them to 'treatment',or ask them to wait in the lounge. The crew would then transport the patient to theassigned location, and give the same information to the nurses there. In the case of a'Code 3' (urgent care required) patient, crews would most often call ahead to advise thehospital of the incoming patient, and the triage nurse would tell them a location as theycame through the door. For example,"This is Marion. She has fallen and hit her head on a coffee table tonight,and was unconscious for a short time. She is on anti-depressives."(Junior)"Any heart problems?" (Nurse)"None known." (Junior)"O.K....bed number 8 is open." (Nurse)Though the above interaction format is standardized, crews and nursing staff often addedsocial or humorous content to the otherwise mundane procedure. Other information wasexchanged at this time such as, niceties, complaints, changes in procedure, informationregarding a difficult patient, and the like. An example of the latter follows,"This is Mr. ^. He is a jerk and he cut his hand in a bar brawl thisafternoon. He doesn't know if he has had tetanus shots in the last 10 years,and he has a major attitude problem." (Arnold)"Right. Have him wait in the lounge." (Admitting nurse)A notification of a change in procedure at the hospital led to a rather humorous exchangeas we wheeled the patient down the hall into the emergency ward,"We have a new system for the forms around here." (Nurse)"Oh, is that right, do tell!" (Arnold)"Well, we will have a box for you guys to put your forms in." (N)"But we cannot break up our 3-part forms until they are complete - thatwon't work!" (Arnold)"Oh, I see (disappointed)." (Nurse)"Well, let's get back to this box, what kind of box is it? Will I fit into it?Is it like a coffin, does it have a door, will the light go on when you openthe door?" (Arnold)92Further, a poorly communicated call for a Code 3 heart problem turned out to be a routinetransfer for X-rays, the ALS crew member said to the nurse,"And what sort of medical problems does Mr. ^ have?" (Dylan)The nurse handed over a chart with 12 medical problems, Dylanresponded, "Oh! We have 12 diagnoses, pick any 3 folks. Step right upand take a spin." (Dylan)And, as we left another call Dylan joked to the nurse,"Oh my, (looking at a poster) when is the next carpet bowling session, ormaybe a mystery drive! I'm coming!"Finally, at the hospital Arnold and I help the nurse undress a young girl who hadoverdosed on a drug and had been throwing up and incontinent (she had feces all over herlegs as we removed her jeans),"Now, is this the new grunge fashion? Am I missing out?" (Arnold)"(laughing).. .this one is going to wake up in a diaper, I like them to wakeup that way, it's humbling for them." (Nurse)A final observation regarding nursing staff and ambulance interaction wasattempts by ambulance crews to 'manage' the nursing staff, and visa versa. Oneinteresting example was a dispatched call received at the station at 2:00 am for a transportto the home of a patient we had brought in earlier, Arnold seemed very irritated as we gotinto the ambulance and commented,"I think we need to have a chat with St. Paul's, we'll be Code X'ing thisone." (Arnold)We arrived at the hospital and he told us to wait in the car, "I won't belong." He returned shortly saying it was a Code X. I asked him how hemanaged that? He replied,"Oh we had a chat, it's a TIA.""What's a TIA?"(me)"Trans-ischemic attack of the brain, Christine must have had one to think Iwould have fucking transported her (the patient).""What do you say in a case like that?" (me)"Christine knows that if we transported Gabby I would have been up allnight making it my personal business to bring in patients off the streets for93her to take care of We'll dig up old Roddy, he probably needs de-licing.'Let's see, you have lice, you need de-licing, come with us to the nicewarm hospital.' 'You are drunk, you need to be checked out for TIA's'.You have to do a round-up like that every 3 months to set them straight sothey lose the transport ideas."Hospital staff also tried to 'manage' ambulance workers to their advantage,"I heard that you are the head honcho around here, and I should talk to youif I want any supplies - I want some good scissors!" (David - nurse)"I'm working on it." (Roy)Later,"David, we really need some triangular bandages - do you think you couldfind us a couple?" (Tom)"Oh, I don't know, I might be able to dig up one or two.. .what's happeningwith my good scissors?" (Nurse)Further, much like ambulance staff tried to instill their way of thinking on the hospitalstaff with respect to 'transports' (above), nursing staff tried the same thing with respect topatients. For example,"This is Queenie, she is a diabetic, was unconscious and we revived herwith dextrose. She didn't want to come here today." (Luke)"Well then, why didn't you listen to her then?" (Nurse, bitterly)"Well, she's 93, and we figured she has probably made enough decisionsin her lifetime." (Luke)And,"How are you today?" (Dylan)"I would be better if you guys didn't fill up all our beds with patients!"(Nurse, bitterly)"Well, this is Mrs. ----, she is experiencing a tachycardia..." (Dylan)Overall, interactions with city hospital nursing staff were positive, with theexception of instances where the two groups goals were not aligned. Relations with theprivate hospital nurses were very strained and unproductive, and had negative effects onthe patients in terms of service, and on the ambulance service in terms of lost or wastedperson-power.94DoctorsInteractions with doctors were less frequent but still interesting. There were twotypes of doctors encountered in conversation and in the field; Emergency Room doctorsand General Practitioners (GP's). Both groups were the subject of both positive andnegative comments, however, generally the former group was held in higher esteem byambulance attendants. The basis of these observations will be clarified below.Attendants studied deemed a 'good' doctor to be one who assists them incompleting their work i.e., who gives a history of the patients medical conditions, whotreats them with respect, and who allows them to learn new procedures or skills.Conversely, a 'bad' doctor was one who made their job more difficult or lengthy by notproviding a history or condition of the patient, who was disrespectful of them or theirwork by not listening to their comments or by speaking out against or questioning theiractions, and who did not welcome them to observe for the purposes of learning. Anexample of the first instance of being a 'bad' doctor follows. One call turned out to be anolder lady simply needing to be taken in for an X-ray. Junior commented,"Doctors don't think twice about calling an ambulance for anything, hewas just here! He didn't even hang around to tell us what the history of thepatient was, it would have taken him 2 minutes. The $10 000 question(how we could reduce expenses of the ambulance service drastically)."Alternatively, 'good' doctors were those who passed on vital information resulting in anexpedited call, and appreciative ambulance workers. For example, on one call we arrivedat emergency with a patient and reported to the triage desk. The admitting nurse said,"Go right in to bed 11, his doctor called ahead with the information.""Wow, I'm impressed! Who was the doctor?" (Hugh)"Judy Kent." (Nurse)"Wow! I'm impressed." (Hugh)Doctors who seemed disrespectful in some way were also not popular withattendants studied. For example, on a difficult call that should have been assigned to the95Infant Transport Team, our crew brought in a child that had been seizing. The doctorbarely listened to Luke's history, and made comments such as,"Re-do those IV's." (Doctor)The above statement implied that Luke had done substandard work with respect toputting some IV's into the child's arm. He had in fact done an excellent job, as wasacknowledged by the nurse in his defense, "The IV is great!". A few minutes later thedoctor looked around, sighed loudly and said,"Can we get the room cleared!"Such a request denied the crew the opportunity to learn, and therefore pushed that doctorfurther into the realm of being 'bad'. Another example was a call with a 93 year olddiabetic woman. The Crew had revived her in her home where she was found to be semi-conscious and non-verbal. Upon arrival at the hospital the emergency doctor on duty saidthat she wasn't diabetic at all, she was . Luke commented,"There's a conspiracy - I know it.. .that stupid doctor what's-his-name saidshe wasn't diabetic, yet she came around after getting dextrose - youexplain that!" (Luke)Later that shift,"I hope that jerk doctor is not on shift still." (Luke)Finally, at the scene of a man who had hanged himself and was in cardiac arrest,the ALS crew member controlling the rescue effort called in to the emergency doctor onduty to request that the effort be stopped. The doctor on the phone asked what had beendone for the patient, Dylan responded "protocol". She then asked what drugs had beengiven, Dylan seemed very irritated, frowning and told her. She agreed to stop theresuscitation effort, and Dylan thanked her, hung up the phone, shaking his head and stillfrowning. "Protocol' is a standard procedure involving standardized drugs - from the96members' point of view the doctor should not have needed to ask, and that paramedicfound the question insulting.In contrast were doctors that were appreciative of the crews' efforts,complementing them on the work they did, getting them to continue assisting once in theemergency ward, and the like. Such interactions were learning opportunities and positivere-enforcement for the crews, who get very little of the latter. An example was on a callfor a 20 year old with a broken back, Luke had prepared blood samples, filled out theentire form, got two IV's in, and done two sets of vital signs. The doctor commented,"Excellent work! This helps us a lot. Do you want to help us get ready forX-ray?"Further, when our crew brought in a transfer of a young girl from a MVA Dylan and Istayed in the Trauma Room and watched the rescue efforts. Periodically the doctorwould ask Dylan questions about how the patient was found, and verbalize what he wasdoing. Whether this verbalization was intended as a learning opportunity for observers orto talk himself through the protocol, it was much appreciated and put the doctor in thecategory of 'good'.A final example of what crews considered to be a 'good' doctor was in the case ofagreement on the 'moral evaluation' of a patient. One story that was often told but that Idid not observe directly was of a doctor that everyone liked at St. Vincent's Hospital. Heapparently agreed with the attendants' view of MVA victims and their 'pseudo' neckinjuries, he would routinely tell the patients to "get up, you are fine!". This story was metwith great respect and approval whenever told.The next section will deal with the peers of those studied, that is, other ambulanceattendants. Treatment will include those with greater or lesser training or experience,those colleagues who were 'devalued' in some way, and general comments about theirinteractions.97Other ambulance attendantsGenerally speaking, as with many other organizations, there were individuals thatgot along really well, others that didn't, and some that were just neutral. While thesecategories cannot be explicitly made with respect to criteria for each, it is useful toexamine the conditions as they were presented by attendants and observed by theresearcher.Some attendants were friends, either through working together in the service, orfrom outside activities or interests. These people were entertaining to work with as theyoften joked back and forth more than others, making the mood very light. They alsoseemed to have a great deal of respect for one another, there weren't any comments madebehind each other's back about quality of work, decisions made, or the like.There were several reasons for attendants not liking another member gleaned fromthe scene. The first came about as a result of the way they conducted themselves at work.This category included members who were seen to have poor or dangerous skills, to bementally unstable in some way, or to overstep their responsibilities. Examples ofoverheard comments regarding an individual's skills or abilities are as follows,"Watch out for 44 Bravo, I don't trust their driving." (Jordan)and"Which of Lance and Tim are better trained?" (Me)"It's a toss up if either of them are, I wouldn't want to be one of theirpatients." (Luke)"Goddamn it Freddie, you know to bloody well get the Form ready with apatient like this - get out of my face next time!" (Dean)"I hate working with 44 Bravo, those guys are just too intense at a scene."(Luke)Another specific condition under which members were regarded as less thandesirable to work with was the case of EMA's from the interior coming down toVancouver to 'get calls'. These circumstances arose when an EMA II trainee had toandand,98experience certain types of patients before he or she could proceed to the next block. Itwas felt by 'local' members that these individuals did not have the call volume experience,therefore making them less capable. Such individuals were also cited as 'taking too long'at the scene to 'get a history', load them into the ambulance, or other related features.Examples of comments about patients who were thought to be 'unstable' in someway would include the following,"Freddie's an MO, the patients would be better off if you attend."(to me)and,"Yeah, the car's a mess because this MO native guy that they can't get ridof was working last night. When I next see him we will have to have alittle chat to see if I can get through to the remaining brain cells that youdon't leave an ambulance in this condition." (Arnold)and,"I refuse to work with her. She is an MO and has pulled a big scam byclaiming sexual harassment by a member. Just avoid her like the plague."(Tom)An example of overstepping ones' responsibilities at the scene is,"Did you see the way that little jerk argued with my oxygen request? Andthen he ran the IV all the way through! I think next time I see him we'llhave to have the hands off and shut-up chat." (Luke)The researcher directly observed members making errors in the field, both withpatients and while driving. For example, "Freddie" was observed at least three times togo through a red light without doing the 'red light protocol'. Such errors can be highlydangerous obviously, both to the crew and to other motorists. Another example waswhen Sam repeated a 'primary and secondary survey' on a patient when his partner hadalready completed one and documented it. The error in this case was pointed out to himby a senior member. Another example with the same attendant was when he wasattending a diabetic lady—he did not do a 'chemstrip' test for determining blood sugarlevel until his partner pulled the vial out of the jump kit and put it near the form he wasfilling out (this test would be a primary item to determine what was wrong with that typeof patient). A final example was when he tried to put an oral airway into a conscious99patient. The patient was conscious but not talking, so Sam tried to insert an airway in herthroat to make sure she was breathing (This would be very uncomfortable to a consciouspatient).The partners or co-workers on the same shift of the members in the situationsabove would sometimes make comments about the errors to me or to other attendants atthe hospital or station. Other times they would just roll their eyes, make suggestions, orintervene completely. Behavior was never observed to be discussed or corrected in theabove instances, they just went by.Attendants also judged members by their non-work related actions. Overheardcomments included,"The guy beat up his ex-wife's boyfriend with a restricted weapon, hedefinitely shouldn't be working." (Tracey)and"Freddie is like 'Son of Sam'. He did a call with Steve and got into Karatestance after to go at him over some minor issue. The guy's a MO."(Sparky)and"Bruce always wears a bullet proof vest. That really says something abouta guy, you know - it says they are looking for trouble. I'll tell you, anysigns of violence and I'm out of there. If Bruce is my partner we'll have tohave a chat about limitations of responsibility." (Lewis)A side note to this category was my experience of getting warned several times bydifferent attendants not to let 'Sam' get near me as he was a problem around women,"The women's committee has so many complaints against him, it's noteven funny." (Luke).and"Stay away from that guy Nicole, he's a real asshole." (Dylan)A final feature of 'devalued colleagues' is to do with 'part timers'. Part-timers inthemselves are not devalued because of skill, attitude, or 'rookieness' necessarily, rather,it is the fact that they are filling in. The members that replace the regular attendants arereferred to as "Geek of the Week".100DispatchDispatch for the B.C. Ambulance Service is centralized on the West side. Moststaff working the switchboards are EMA's (Emergency Medical Attendant) and haveworked 'on car' (on the street in an ambulance) in the past. Some dispatchers are full-timeambulance attendants who are able to work overtime shifts in dispatch when need be. Alldispatch are trained in Emergency Telephone Instruction (ETI), which is used to instructbystanders at the scene to initiate rescue attempts until the ambulance arrives. During thecourse of field research it became evident that some dispatch were liked more than others,based on a number of criteria. This theme of 'good' and 'bad' dispatch will be elaboratedupon below, based on observations and overheard comments.Dispatch in the Ambulance Service did not escape being the brunt of jokes,stories, and to serve as general release or 'bashing', as in the case of the firemen. In somecases the joking was not critical of the dispatchers' ability to dispatch, rather, theirpersonal lives, personalities, and the like. In other cases it was a direct result of someaspect of their work, for example ambulance personnel were often heard telling storiesabout being 'burned by dispatch' so that other crew members would be wary.One example of a frequently told story about a dispatch involving his personal lifewas the following. One dispatch was continually referred to as the "Mary Kay man" afterthe line of cosmetics. Evidently he was a homosexual who liked to wear make-up;"That's why they put him there (dispatch), so he can dress however hewants and not horrify the public." (Hugh)Conversely, some stories involved things they did on the job, but were not seen asdetrimental to their abilities necessarily;"This guy is hilarious. He is always telling us which way to go to a call,or asking specifically where we are. One time he said "hey, are you atMcDonalds?", so we had to make fun of him - we said "we're in the southlane, facing the sun, I am in the passenger's seat, Science world can beseen, there is a blue car in front of us." (Sparky)and101"I once got a call from the guy (dispatch) for a "routine for a bleedingasshole". He doesn't give a shit, he's hilarious on air." (Arnold)and"Yeah, I once got a call from him to go to Packard Street in Coquitlam.He said "that's Packard, like the car, of course you are too fucking wetbehind the ears to know that", he's hilarious." (Junior)Other stories had to do with some aspect of their work performance, for exampletwo crews met at Burnaby General, one was coming in with a patient and remarked,"Routine for a short of breath!?" (rolled eyes at us) (Dana)"Yeah, we heard that when we were lost".40 (Richard)Another example was a story told at the station about a peer who had beeninvolved in an MVA because of a Myocardial Infarction (MI - heart attack) at the wheelin the interior on a highway. Dispatch had refused to send an ALS car because there werealready two BLS cars on scene,"They are going to hunt down that dispatcher - now the guys in ICU(intensive care unit) -couldn't have been a Vancouver dispatch. It sure is adrag when it is one of our own" .(Luke)A final example is a call received for a 'routine OD',"I've been burned too many times by this dispatch - you go there for apublic assist routine, and its a full arrest and you have to whistle (driveCode 3) them into the hospital yelling at your partner down the stairs, "Getthe defib!" (Hugh)Dispatch was also overheard joking with crews on air or by telephone, sometimes at theexpense of the crews. For example, one nightshift our crew wanted to go to the jail tovisit a PC friend who was working. Hugh asked permission,"How do you feel about us going down to the jail to see someone?""A relative?" (dispatch)"Ha, ha. No, a PC friend." (Hugh)40 A short of breath call should be a Code 3 in all cases, and would require ALS back-up. To send a car"routine" to such a call would be unheard of.102Also, on day shift the power went out in the station one day, Hugh called dispatch to letthem know what was happening. Dispatch replied,"Go to A."(VGH, standby)"OK." (Hugh)"Just kidding." (dispatch)"Oh." (Hugh)Many statements by attendants on the job yielded clues as to which dispatch were'good' and which were not. Generally, 'good' dispatch were those individuals who notonly did was what was expected of them, i.e. ensured the safety of the crew, spokeclearly, made informed decisions, but also those who were humorous, dispatched 'good'calls to the crew in question, respected the crews' need to do other things i.e. eat, take'mental health breaks', and go out of their area. Such individuals became well liked,indeed the crews often judged how their night will go depending on who was dispatching,"Oh no, we're going to get it tonight!" (Jordan)Crews appreciated those dispatchers who 'took care of them.' On one call to an assault wewere instructed to 'wait for 5's' (police). Junior reported to dispatch that they were not onscene when we arrived, and said we would wait. The police then showed up and weproceeded inside to do the call without notifying dispatch again. A few minutes later thedispatch radioed on the portable to find out if we were all right;"That's the best dispatch, he always keeps track of his crews." (Junior)The above is in contrast to dispatchers that do not pay such close attention,"41 Alpha 10-7 quarters." (Hugh announces we are at the station)Pause"41 Alpha 10-7 quarters." (Hugh repeats)Pause"That's the third time tonight he hasn't answered a quarters cal141!" (Hugh)41 A 'quarters call' is the transmission made to dispatch by the crew when they arrive back at the station.Dispatch is supposed to asknowledge that they received the transmission.Further, some dispatch were well liked because of their humor on air;"Routine for a bleeding asshole. He doesn't give a shit, he's hilarious.""Meeting at the Bel Air tonight." 42(dispatch)"Ha! On air! this should be a good one." (Hugh)"Code 3 to UBC for a collapse." (dispatch)"52 Alpha cancel, Viking warriors retreat!"43 (dispatch)"You village maiden." (Arnold)The above examples are interesting as it is against radio protocol to use the system foranything other than work. Well-liked dispatchers often slipped a little something extrainto their calls, as above. Further,"42 Alpha 10-7?" (dispatch)"42 Alpha Robson and Thurlow" (Dylan)"How's the Buck's?" (dispatch)"Yukon's very good today" (Dylan)Arnold then remarked to Dylan,"If Tommy's on today hopefully Bravo can do all the transfers and we willdo all the good calls."Transfers were generally the most boring of calls and crews hoped to avoid themthroughout their day. One advantage to having dispatch who also worked 'on car' wasthat they understood this factor of the job, and it seemed they favored those ambulanceattendants who they knew or liked with the 'good calls', as implied above. This was incontrast to 'bad' dispatch,"Oh no, we'll be doing transfers all night and standing by all over theplace." (Junior)"Yeah, he once had us stand by at Broadway and Cambie (about 4 blocksfrom their station), so we went 10-7 quarters on portable. It was hilarious,what an idiot." (Hugh)42 The Be! Air Cafe is a restaurant near the downtown stations popular among attendants.43 The inside joke of Viking Warriors was carried throughout shifts in reference to power relationships.For example, "You small and weak junkie, me powerful drug lord", or "You village maiden, me VikingWarrior. It seemed to be a morale booster.103andand104Another characteristic of a good dispatcher seemed to be one who recognized when amistake was made,"41 Alpha, sorry about that call - that was the one with the languagebarrier - we didn't know what was going on."."No problem." (Dylan)In contrast were situations were mistakes were made but not reconciled,"44 Alpha routine to East 41st, collapse." (Dispatch)"44 Alpha cancel, take instead Code 3 to West 44th." (Dispatch)"44 Alpha cancel, take instead Code 3, East 41st." (Dispatch)"Fuck! Make up your mind, we're running out of gas!" (Jordan)and"46 Alpha Code 3 for a cardiac $%#* Oxford.""46 Alpha, say again? (Richard)"46 Alpha 44*4 Oxford." (dispatch)"46 Alpha, say again? (Richard)"46 Alpha 4404 Oxford." (dispatch)Our car drove around looking for the address for approximately eight minutes then Crew#1 said,"Fuck, I can't find it!""46 Alpha, address please?" (Luke)"46 Alpha 2604 Oxford." (dispatch)"We're 4000!" (Luke)"Christ, I couldn't understand a thing from this guy." (Richard)Dispatch who enabled the crews to 'get things done' i.e. get food, finish what theyare doing, and the like were also popular, particularly when the call was 'routine' or thecar was serving as back-up to another. For example,"41 Alpha 10-7." (dispatch)"41 Alpha Burrard and York." (Sam)"41 Alpha, routine when you are ready." (dispatch)In the above instance the location given was the intersection closest to a popular deli andcoffee shop. Dispatch knew where the crew was and what they were doing, and thusallowed them to proceed at their leisure. This is in contrast to the 'less considerate' ones,"If it was just a transfer, they should have told us and we could havegotten lunch first." (Sam)and"44 Alpha/ 41 Bravo, Code 3 for a collapse." (dispatch)"Doesn't that just frost you." (unknown crew)Dispatch were also noted as unpopular for sending a crew other than the closest one to thecall,"Bravo is at least 25 blocks closer, what a jerk."(Junior)And for questioning a crews' judgment at the scene,"42 Alpha, man-down found in respiratory arrest, request ALS back-upand re-assignment of previous call." (Arnold)"42 Alpha confirm respiratory arrest." (Dispatch)"42 Alpha, I said he was (gruffly)." (Arnold)And for dispatching the nature of the call tunclearly',"The way they dispatched that one I thought I was going to be looking at afetus in a toilet bowl, damn it, she made me spill my coffee!"(Luke)and"A routine 'for a something' - are we supposed to guess?" (Jordan)"Yeah, great (sarcastically)." (Dylan)A final note related to dispatch is the crews' ability to 'manage' some dispatch, andtheir shift more generally. For example at the station on a quiet night Arnold wasmonitoring the portable radio to hear any action. Dispatch was heard to assigning a code3 to another crew. Arnold quickly called in,"42 Alpha, we're 10-7 quarters if you need us.""Yes (pause), I was looking for you. Code 3 to the Salvation Army for anOD." (dispatch)"Excellent!" (Arnold)105Another example is when the crew does not 'clear' (say they are free from the lastcall) until a 'bad' call has been firmly assigned to someone else. For example the crew106laughed when another crew was assigned a 'routine abdominal pain' at a nursing lodge onKerr. The driver slowed the ambulance down to crawling speed, Richard laughed andsaid,"I'm with you, I hate that place. It's where they send Chinese people todie. You can smell it in the halls."Similarly,"41 Alpha routine for a lower GI (gastrointestinal) problem." (dispatch)"Let's back pedal on this one, maybe we can catch a Code 3 on the way sowe can get out of this call." (Junior) (the ambulance slowed downdramatically)Further, in between calls at the hospital another crew member came outside and said,"Dispatch is looking for you.""So, we're busy. Jordan, find out what the call is and we will make adecision as to how quickly we want to get this cleaned up." (Dylan)Finally, when driving outside of our area one night to see the hookers, dispatch asked ourlocation (10-20), Junior said to Hugh,"Where should I say we are?""I don't know, Pacific and Cambie?" (Hugh)"Sounds good."The relationship between dispatch and ambulance workers on car was dependenton the above criteria set by the workers themselves. Humor, the assignment of 'good'calls and not of transfers, and leaving some leeway was important to the attendants.As illustrated in the above chapter, the quality of relationships betweenemergency service personnel differed greatly, dependent on a number of factors. Roles atthe scene, hierarchies, personal convictions, and peer pressure could all be seen ascontributing factors to the resulting relationships.107CONCLUDING REMARKS"How much longer do you think you are going to be in this business?""No more than 5 years, then I'll go back to school to re-train.""What will you do, Medical School?""I haven't decided yet, but I'm thinking I might want to stay completelyaway from working with the sick and injured, 12 years is long enough."This study has been based on a participant observational study of a group ofEmergency Medical Assistants in Vancouver. It began with discussion of the history ofthe scene, that is, the history of the British Columbia Ambulance Service, as well as adiscussion of the methodology in terms of technique and problems encountered in thefield. Other topics examined include characteristics of a typical shift, crew preferencesfor types of calls and patients, informal transfer of 'working knowledge' to attendantsthrough apprenticeship, and the relationship between attendants and other emergencyservices personnel.As with most studies, there are always topics left un-treated or un-exposed. Thisstudy is no different. With a lengthier stay in the field I could have addressed types ofpatients more thoroughly and confidently, I could have spoken to the acquisition of 'streetsmarts' on a first hand basis through the process of 'becoming an ambulance attendant'myself, and could have experienced any 'rookie treatment'. I could have gone to ruralstations and experienced what it would be like to get one call every two shifts, and thedifferences in crew culture in such a situation. Given enough time, I may also have hadthe experience with treating a member of the public who was also my friend, ascommonly occurs in smaller towns. Further, I could have taken the formal training ofEMA's with an eye to the differences in what is taught at the Justice Institute, and what isput into practice on the street. Finally, I could have tried to look at the things that plagueEMA's such as stress, problems with management and scheduling, qualifications of Unit108Chiefs, the issue of "de-pairing ALS", inadequate "recruitment"44, the absence ofevaluation techniques, and the like. Perhaps I could have uncovered some interesting andhelpful insights with an eye to improving their situation. Perhaps not.This study is the first of its kind in Canada. Other examinations of this group ofworkers in this country have been from other academic points of view, and haveprimarily used survey techniques and personality profiles rather than going close-up as Ihave. Further research on EMA's in Canada will serve to increase understanding of theworkers, their concerns, and ultimately have an influence on care of the sick and injuredfor future generations.44 There really is no recruitment technique in the service in the formal sense of other emergency services.There are no real interviews, there is no emphasis on education or work experience outside the field--it isall "who you know".109BIBLIOGRAPHYAdler, P.A., P. Adler. 1987. Membership Roles in Field Research. Sage UniversityPaper series on Qualitative Research Methods (Vol. 6). Newbury Park, CA:Sage.Allison, E.J.; T.W. Whitley; D.A. Revicki; S.S. Landis. 1987. "Specific OccupationalSatisfaction and Stresses that Differentiate Paid and Volunteer EMT's" Annals ofEmergency Medicine. 16(6), pp. 676-679.Becker, H.S. 1951. Role and career problems of the Chicago public school teacher.Ph.D. diss., University of Chicago.Becker, H. S. 1963. Outsiders. New York: Free Press.Becker, H.S., B. Geer, E. 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New Jersey: Prentice-Hall.James, Alma. 1988. "Perceptions of stress in British Ambulance Personnel" Work andStress. 2(4), pp. 319-326.Jeffery, Roger. 1979. "Rubbish: Deviant Patients in Casualty Departments" Sociologyof Health and Illness. 1(1), pp. 90-107.Leiderman, Deborah B., Jean-Anne Grisso. 1985. "The Gomer Phenomenon" Journalof Health and Social Behavior. 26, pp. 222-231.Leiter, Michael. 1991. "Coping Patterns as Predictors of Burnout: The Function ofControl and Escapist Coping Patterns" Journal of Organizational Behavior.12(2), pp. 123-144.Lofland, John. 1972. "Editorial Introduction" Urban Life and Culture. 1(1), pp. 3-5.1976. Doing Social Life: The Qualitative Study of Human Interaction inNatural Settings. New York: John Wiley.Madsen, David. 1983. "Preparing the Research Proposal". Successful Dissertations andTheses. San Francisco: Jossey-Bass.111Malinowski, B. (1922) 1961. Argonauts of the Western Pacific. New York: E.P.Dutton.Manning, P.K. and J. Van Maanen. (eds.) 1978. 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"Ogre, Bandit, and Operating Employee: The Problems andAdaptations of the Metropolitan Bus Driver" Urban Life. 1(4), pp. 339-362.Stoddart, Kenneth. 1974. "Facts of Life About Dope" Urban Life and Culture. 3(2), pp.179-204.^ 1981. "As Long as I Can't See You Do It: A Case Study of Drug-RelatedActivities in Public Places" Canadian Journal of Criminology. 23(4), pp. 391-406.1982. "The Enforcement of Narcotics Violations in a Canadian City:Heroin Users' Perspectives on the Production of Official Statistics" CanadianJournal of Criminology. 24(4), pp. 425-428.1986. "The Presentation of Self in Everyday Life: Some TextualStrategies for 'Adequate Ethnography' Urban Life. 15, pp. 103-121.1990. "Writing Sociologically: A Note on Teaching the Construction ofa Qualitative Report." Teaching Sociology.1993. Personal Communication.Sudnow, David. 1965. "Normal Crimes: Sociological Features of the Penal Code in aPublic Defender Office" Social Problems. 12(3), pp. 255-264, 269-270.^ 1967. Passing On. New Jersey: Prentice-Hall.Van Maanen, John. 1988. Tales of the Field. Chicago: University of Chicago Press.Vincent, C.L. 1979. Policemen. Toronto: Gage.Visano, Livy. 1987. This Idle Trade. Ontario: Vitasana Books.Webber, Max. 1958 (1904-1905). The Protestant Ethic and the Spirit of Capitalism.Trans. Talcott Parsons. New York: Charles Scribner's Sons.Whyte, William Foote. 1943. Street Corner Society. Chicago: University of Chicago.Zimmerman, D.H. 1966. Paper Work and People Work: A Study of a Public AssistanceAgency. Ann Arbor, Michigan: University Microfilms.113APPENDIX ONE:Confessional TaleI grew up in various suburbs of a Vancouver as part of a small middle classfamily; my mother worked part-time when I was in grade school, and my father workedfull time as a general manager of a middle-sized building supply firm. Since I canremember, they worked very hard at passing on to me a solid work ethic that they held tobe central in any child's development. Work was regarded as a means to the end ofindependence, responsibility, experience, and later, university attendance. From thisearly talk of work and the occupations that people do I became interested in the topic, visa vis a self-centered question of, "What will I be when I grow up?". I would quite oftenthrow out ideas to my parents of vocations that seemed logical to me in terms of the skillsI possessed. Each time one of them would very carefully take the time to explain some ofthe pros and cons of that vocation, usually coupled with illustrative situations. I soonbecame able to create these scenarios myself, and used the technique to enlighten myfriends.As a teen I obtained part-time work as a lifeguard and swimming instructor at anearby country club, partially influenced by my father who had grown up with lifesavingin Australia, and partially because of my love for the water. This vocation provided aslightly older crowd of co-workers to interact with, as well as the financial independencethat was much coveted by my peers. While lifeguards come from many facets of life,there are some similarities among staff groups generally. There always seems to be oneor two 'technogeeks' at each facility I have worked at (over 20); and I use this term inonly the most positive sense. These individuals are interested in such things ascommunications equipment (walkie talkies, VHF, pagers, cellular phones, etc.), rescueequipment which is 'gagetty' (motorized boats, oxygen tanks, spinal immobilizationunits), and personal rescue or first aid items that are interesting (pocket masks, fanny114packs to hold supplies, super scissors, etc.). Additionally, these individuals like beinginvolved in situations where they get to use this equipment and their skills, particularly ifit is out of the ordinary or 'news worthy'. Understandably it is these same individuals thatoften make their careers in the 'helping professions' as nurses, police, firefighters,ambulance attendants, and doctors. For this reason I came to be interested in the topic ofambulance work in particular, as many of my past co-workers chose it as a career path.The stories of 'calls' done, training undergone, and efforts to make light of what seemedto be difficult situations intrigued me, not in the sense that I wanted it as my own career,rather that it would be interesting for others to understand the job and the experiencesthose in it go through.As an undergraduate I took a field methods course which inspired me to go on insociology, and to put in to practice some of the methods and theory I had been told storiesabout.. Participant observation research seemed a bit like undercover detective work tome, regardless of whether the members of the domain knew the full purposes of theresearcher being there. I always felt that few people really understood what the disciplineof sociology was about, and that toting it as 'the study of patterns in society' cleverlydisguised the more interesting aspect of its inquiry - the members of that society. In thissense, the 'cover' of field research seemed to me to be a unique opportunity to study workoccupations. Job descriptions and first hand explanations never seemed to shed enoughlight on a vocation - I wanted to know what it would feel like to be in the job. Tocarefully investigate a dark alley on the hunt for a 'bad guy', to deliver a lecture to a groupof 200 students, to defend a suspect of murder in a court of law, or to arrive at the sceneof a bad car accident as a paramedic.Once in graduate school I had an instructor who had the foresight to 'force' all thefirst year graduate students to write an M.A. thesis proposal as part of his courserequirements. With my involvement in aquatics at the time and the ever-present'technogeeks' turning to the ambulance service, I decided to focus on the latter. Like115many students my first attempt at such a project was naive and unrealistic, and while itmet the course requirements it would not survive in the 'real world' of sociology. I wenton to complete my graduate course work but continued to have trouble etching out asuitable research proposal. After several topic changes and a leave of absence, I produceda version of the original proposal that was approved for research 3 years later.The accepted version of the proposal involved less fieldwork than I had originallyenvisioned, and seemed to me to be less 'honorable' than I had wanted. I really felt forthese people who worked night and day under what I thought were strenuous conditions,dealing with sick and injured people exclusively - I really wanted to do a project that insome way would 'help them'. As I struggled with the literature around stress and theworkplace and such topics, I realized that any centering on that topic would lead me outof sociological field research and into another area. In the end I decided that the bottomline was that the project had to get going, and that it was going to be as worthwhile as Imade it. If nothing else it would involve a number of attendants and perhaps have themlearn something about themselves or the job they do by looking at things differently.With this new perspective on my previous naiveté in mind, I approached variousmembers of the ambulance service that were friends and enlisted their help in etching outa plan of which stations to study, with whom, and the like. They also guided me to theright administrators to get permission to do the project. However, my first attempt toimplement this new plan and list of requests was met with little support or hope. I calledthe scheduler of thirds, and was told that they were not letting anyone ride third as theywere getting too many requests. He said the only way to go about it was to write a letterto the Superintendent of the ambulance service, outlining what I wanted to do and forwhat reason. As I drafted this letter I had a sinking feeling that the bureaucracy wasgoing to tie up the project, and it may not ever get approved. I was aware that with my'connections' in the service I could ride third 'under the table' for a few shifts here andthere, but did not feel this would meet the requirements of etlmography. I then got an116ironically lucky break - my printer at home broke as I was trying to print the polishedcopy of the letter. I went to use a girlfriend's her office downtown, but her software was adifferent version than mine and therefore would not read the disk I had brought. Shecalled down the hall to a co-worker to see if he would try the disc. His efforts to printfrom the disc were met with failure as well. As he peered at the screen to try anddecipher the problem he suddenly exclaimed, the Superintendent of the AmbulanceService, I know him, why don't I just call him for you?". I looked at him in dubiousdisbelief and asked if he would mind. He said it was no problem, he knew him from aresearch project he had done on personality profiles of paramedics through the JusticeInstitute.He called as we stood there in the office, and got the Superintendent's secretary,who said he was away at his cabin. The man was about to call the his residence inSechelt when I interjected and said it could wait until Monday when he was back. Heassured me that I had nothing to worry about in terms of approval for the project, hewould see to it and let me know what the next step is. I left the office and thanked himand my friend, and went home. As I unlocked the front door the phone was ringing - Idashed in and answered it - the man was calling to say that he had contacted the ChiefSuperintendent instead, the project had been approved and he would send a memo to thateffect to the scheduler, who I should call Monday to arrange the exact dates. I thankedhim profusely and hung up. I just couldn't believe what a break I had received.First thing Monday morning I called the scheduler back, he was away so I left mynumber and name. A day later he called back and left a message for me to call him backat the office or at home, and left both numbers. I returned his call and he said he hadreceived a memo from the Chief Superintendent requesting that I be granted my requestto ride third. He began to tell me which days he thought would be best to ride to 'seesome action', and said that I would have to go home at midnight because sleepingaccommodations in the stations were inadequate. I quickly explained that in order to117carry out my research it was necessary to observe for full blocks, and I was not concernedabout sleeping arrangements. I also explained that I had spoken to members at thelocations recommended to be the busiest, and they were happy to have me ride. Weworked out the dates and times, he warned me that tardiness was not tolerated, that I wasnot to be involved in the treating of patients, told me what to wear, and wished me 'goodluck'. He also said that he would fax me copies of the memos sent to the Unit Chiefs toshow to my advisor. The latter arrived a few days later with the statement "please extendher all courtesies" on each. I was quite relieved and amazed that this had all cometogether when it seemed to be doomed.As the time drew nearer I selected suitable clothes - dark pants, white shirt,obtained a small notebook to write in while on shift, and thought about what I knew aboutthe service already. I also talked to members I knew as to what to expect, how the shiftsworked, etc. One interesting thing I found out was that they all did 'early relief, that is,they came in for their shift half and hour early so that the earlier crew would not get a callin their last half hour. The scheduler had not known this and told me to arrive at theregular time, I was glad I had found out!The first day I set out to find the station early, but could not find it. As the stationwas brand new that week, I was not given the exact address, only the cross streets. Isearched the hundred block on both sides, and looked for a vehicle I recognized. As Iwas searching I was thinking to myself that being late was not going to make a very goodimpression. What if they get a call and leave me behind? I finally noticed some newlypainted garage doors and peered inside the papered window-found it. I went around backand parked, very conscious about the possibility of the existence of a parking system ofsome sort, one that I have just thrown a major loop into. I tried the door, it was lockedwith a code-lock system. As I did not know the combination I had to knock. The stationchief, Roy, answered and let me in, so I introduced myself and explained that I wassupposed to be riding with Arnold for the block. He informed me that Arnold was118transferred late the night before to an ALS (Advanced Life Support) car, and would notbe in that day. He then went back into his office. I went into the living area and satdown, thinking back to my methods courses trying to decide if it would be better to stayat one station and observe or to stick to one person. I choose the later, and then thoughtabout a delicate way of approaching the Unit Chief with my problem, thinking - What anuisance I am being and it is only 7:45 am! I approached Roy and he said he would calldispatch, find out where Arnold was, and get him to call in to the station. Shortlythereafter, the phone rang and Roy said that the other crew would come and pick me up,then bring me back at the end of the day. Perfect.The ALS car that arrived with Arnold was interesting to be a third riding out of.The third seat was in the back, raised up about a foot and a half such that a person sittingthere could not see out the front windshield without crouching over. This was a veryunsettling way to travel, looking at a white wall or a strip of street going by, especiallywhen traveling at Code 3 speed. The first Code 3 call we received I was rather takenaback at the sensation of not being able to see where we were going, especially since thesmall glimpse I had of the road was the yellow line going straight through the car! Irealized at that point how much trust one had to have in one's partner. As we turnedcorners I felt the distinct possibility of a crash, particularly with the style of driving thatseemed to be necessary to get people off the road so the ambulance could pass by.Later in my field research on calls this concern doubled when the weather waswet, and on one occasion our car slid 3 lanes of traffic to the right as we banked a corneroff of the Burrard Street bridge. Another time the car was going Code 3 through anintersection and narrowly missed another ambulance crossing the opposite way! (Suchmishaps were considered to be the fault of dispatch). The attendants seemed relativelyun-fazed on such occasions, save side-long glances at partners and a few white knuckleson the door handles. I was, however, quite fazed, and repeatedly asked the question tomyself, "Why am I doing this! I could be doing document analysis!". I did get used to119the sensation and the driving as time went on, and felt a little silly at my initial reactions.After all, these people had taken driving courses and they did do it for a living.Another fearful experience in the field was that of going to do Airevacs. I hateflying at the best of times, being one of those not appeased by statistics of 'planes aresafer than cars', and the like. The thought of going in a small plane initially washorrifying, and later, a helicopter, seemed impossible. My naiveté pulled through for methough, I managed to convince myself that helicopters were much safer than planes(despite my later acquired knowledge that they have far more moving parts to go wrong),because they were more maneuverable. I did not get air sick, which I saw as a positivesign, but I did spend most take-offs and landings wondering 'why am I doing this? Icould be on land!'. In the end I quite enjoyed the helicopter trips, and hope I can go inone again. My major rationalization through the ordeal was to keep thinking "These guysdo this all the time, the pilots don't look suicidal either". I made it.A situation arose while on car in my first block that was terribly embarrassing. Ihave a medical condition known as 'exercise induced asthma', which as of yet has neverbeen produced by exercise. Nonetheless, on the first night shift I decided that I was notgoing to make it through the night without some sort of caffeine stimulant, and not beinga coffee drinker the Starbucks runs were out of the question. I decided to brave an 'icedmocha' though, the chocolate content sounding very appealing. Half way through thisconcoction I began to wheeze, and thought I was coming down with a cold suddenly.This condition worsened until I felt it was recognizable as asthma. I, of course, did nothave my inhaler with me as I rarely get the symptom, and decided to quietly suffer.Arnold eventually noticed me wheezing and asked me if I was OK. I said I was fine,being quite embarrassed about the whole thing. I really couldn't figure out what hadbrought this on.Later in the evening as I felt worse Arnold insisted that I take a 'ventilin neb'which is a medication one breathes in with medical oxygen to relieve the symptoms of120asthma. I began to take this treatment sitting in the back of the ambulance, and we got acall. There I was, sitting in the back of an ambulance breathing into an oxygen mask,going Code 3 to a cardiac call thinking, "How embarrassing. Patient No. 1, could youplease pass that 02 to the other patient?". The call ended quickly, thank goodness, andwe went back to the station to sleep for a while. At some point Arnold asked me if I wasitchy anywhere, I suddenly realized my collarbone and neck area were very itchy, and Ihad been scratching the area for the last hour. I looked at the area and discovered a bunchof hive-like bumps were there. Wow, I thought, what a joke I am, I couldn't even spot anallergic reaction on myself, how could I possibly think I was 'qualified' to be observingambulance from this 'inside perspective'?Arnold then gave me an antihistamine, I went to sleep for a while, and felt muchbetter earlier in the morning What an experience. Somehow I would prefer next time tobe the anonymous patient rather than being surrounded by friends and co-workers. I alsoremember thinking about all the 'wanking' and 'wining' patients there were out there. Isure didn't want to join that category, I don't think I would ever call an ambulance formyself, I would sooner crawl to the hospital.Another set of embarrassing memories of the time spent in the field is the feelingof being unsure as to what to do at the scene, and what not to do. As some of themembers were familiar with my first aid skills, they tended to let me do things, or tell meto do things at the scene. There was no problem with the tasks given, but I often was notfamiliar with the terminology for equipment or the exact location of items within theambulance. After I had trouble finding a simple item such as tape, I made sure that Ispent some time at the beginning of each shift figuring out where the basics were in theambulance (all were set up differently), and asking questions about items I could notidentify. One time at the scene of a car accident an attendant yelled out to me "Nikki,measure up for a hard collar". This is a simple procedure for a person who had beentrained in the administration of hard collars, but I was not licensed through Industrial121First Aid to do so. My strategy was to guess, and luckily for the patient, I guessed right.I suppose the attendant would have sent be back for a different one if I had been wrong,but I felt a bit guilty and embarrassed about that after, as if I shouldn't have been there torely on if I could not perform for them.On another call I was sent off the get the stretcher out of another ambulance. Thestretcher was an 'old style' one, with more requirement for the attendant to lift, and I wasnot familiar with it. I had trouble getting it unlatched from the ambulance floor andremember having it seem like days had gone by from when I was asked to get it and whenI returned. I had the impression that by the time I got the thing out of there the patientwould be long gone to the hospital or something. The mind plays tricks.A similar situation but not nearly as worrisome was one nightshift at 41, we hadjust come in. There were two other crews 'in' when we came on duty, and everyone wassitting around watching the news. A call came in and being the case that the 'first crew inwas the first crew out', I didn't pay much attention to it. Suddenly I hear my name beingcalled from the downstairs garage as the door was sliding up. Oops! You cannot takeanything for granted around there. If an attendant feels like doing a call, I guess they goto it!Another struggle I had in the field was wondering what to say and what not to sayin conversation with attendants and hospital staff. I sensed a certain amount ofdefensiveness with some attendants encountered with respect to going to university, so Itried to avoid the topic. When people asked me what I was doing there I often just said'riding third to see what ambulance work is like'. I didn't feel that was too deceptive as itwas true, I just didn't announce that I was writing a paper on it. The crews I worked withdirectly were all eventually aware of my reason for being there, but I really only hadtrouble with one attendantThis man was the most despicable creature I had ever encountered; he was aracist, a chauvinist, a homophobic, was confrontational and unjustifiably opinionated - I122hated to be near him. I really did not know what to do around him as anything anyonedid or said was immediately jumped on with a 'devil's advocate' position. The otherattendants said nothing around him, so I took the cue to do the same. He was the onlyone in the course of my research that ever directly confronted me with his charmingopinion about universities being a waste of time and the like. I tried to avoid getting in toany conversations with him after that, but really did not feel as though I had succeeded inwinning him over. Despite these displays of hostility he commended me for my help atthe scene a couple of times, and seemed to accept me on the level of an observer.Perhaps he just liked to have an ear to bend.On the subject of embarrassing moments in the field were a couple of instances inwhich my gender seemed to come in to play. At the second station I visited I foundmyself chatting with one of the other crew members, he had gone to school in a similararea as I had, and we had mutual acquaintances. Later on in the day his partner had to goflying on an airevac so I asked what Lance would do while he was gone, wondering ifthey did a four hour call in to compensate. The answer I got took me by surprise and Ireally did not know what to say as it was in front of a few people,"What does Dave do while John was on the Airevac?""He's doing it. Studying, sleeping, and chatting you up. Not necessarilyin that order."At the time I decided it was best to ignore the comment and continue the line ofquestioning on the subject of calling another partner in. Unfortunately this tactic did notwork as the same sort of comment was made later at the bar to a larger group ofattendants, I still didn't know what to do except adamantly deny that there was anyinterest there.Another situation at the bar 'on the split' was embarrassing as well. A well-known'womanizer', Tom, was getting friendly with me and I decided it best to put him in hisplace once and for all to stop his advances. This decision was met with grand approval of123all the attendants present, but created a problem in that they felt I 'was on their side' withrespect to 'getting Tom'. At one point I was offered $5 if I would put my tongue in Tom'sear while he was chatting up another young woman, I declined which then put me back inthe dubious position of perhaps being on Tom's side, or worse, being after him.Generally speaking, the above instances of less than perfect situations in the fielddid not total disaster, but may be of use to future students who wish to undertake a similarexcursion into the field. There are always, I believe, a number of other situations that onecould include in such a confession, but perhaps seem too personal or may in some wayjeopardize an informant. I, as many students have or will, had to struggle to achieve abalance that I (and my informants) could live with.124APPENDIX TWOGlossary of Terms and CodesTermsAirevac^The transport of a patient, usually in critical condition, by air. Bothhelicopters and small planes are used for these missions.ALS^Advanced Life Support.BLS^Basic Life Support.Bag and Mask A device used to manually provide oxygen to a patient who requires it.Bagging^The verb used to describe the action of using the bag and mask device.Bay^The indoor garage space that the ambulance is kept between calls.Block^Referring to the grouping of shifts which make up a full-time attendant'swork week.Buckethead A term used to describe fire fighters because of their use of buckets,supposedly to carry water.'Buck's'^A shortened version of the word 'Starbucks', used in reference to coffeeitself or the establishment Starbucks.Chemstrip^A litmus-type paper used to determine blood sugar level in patientsuspected to have Diabetic problems.CPR^Abbreviated form of Cardio Pulmonary Resuscitation, a manual techniqueused to maintain life (circulation of oxygenated blood) in a pulselesspatient.Cylon^A robotic life form encountered by the crew of the Battlestar Galactica,used to refer to fire fighters because of their apparent inability to think (asa robot cannot).Defib^Short form of 'defibrillation,' referring to the electrical stimulation of aheart which is no longer beating on its own.Detox^Short form of detoxification, referring to the sobering up of patients whoare inebriated from alcohol.Dextrose^Sugar, used to revive diabetics.125EMA^Emergency Medical Assistant.Emerg.^Short for 'Emergency', referring to the emergency ward of a hospital.Epi^Short for Epinephrine, a drug used on a patient who is having an allergicreaction to something (severe).ETI^Emergency Telephone Instruction (certified), those who work in dispatchare currently required to be trained to this level.Extrication^Removal of a patient, either from an automobile, 'autoex', or a steepembankment, 'over embankment ex'.Fanny pack A small pouch with a belt that goes around the wearers' waist to holdpersonal effects. Popularized in the early 1990's as both a fashion andfunction item.FAST^"Full Arrest Survival Trial", a research project throughout the Serviceintended to assess the need for Fire Fighters to be trained in AED,Automatic External Defibrillator.Fixing^A verb used to refer to a person who is in the process of utilizingintravenous drugs.Form 2^The form used to record the crew's report of a patient when sent on a call.The form is a triplicate format with space to record each detail of the call.GI^Abbreviation for gastro-intestinal tract.Grunge^A current form of fashion started by Neil Young and popularized in thenearby city of Seattle by several 'grunge rock bands'. The style isessentially unclean looking, with oversized clothes in many layers. Plaidsand denim garments are among the popular choices.ICU^Short form of 'Intensive Care Unit'.IFA^Industrial First Aid, a course endorsed by the Worker's CompensationBoard of British Columbia for use on industrial work sites. The course isapproximately 80 hours long with both written and practical exams at theend.Incontinent When a patient has lost control of his or her body waste functions.Intubation^The insertion of a tube into a patients tracheal tube and down into theirlungs in order to facilitate eased breathing. Used for non-breathing orpulseless patients as well as conscious patients who require less strain ontheir bodies due to heart attack, stoke, etc.126IV^Short form for 'intravenous'.Landmarking The process of locating the correct place on the sternum of the chest to docompressions in Cardio Pulmonary Resuscitation.MI^Short form of 'Myocardial Infarction', referring to a total lack of oxygen toa central part of the heart, causing irreversible damage. Severe MI's canstop the heart from beating on its own.MO^The short form or slang of "mental outpatient". Used in the technicalsense as well as a colloquial one, for example, "Freddie is an MO."Generally a 'crazy' or 'unstable' person.MVA^Motor Vehicle Accident.OD^Short form for 'overdose', usually referring to a patient in respiratory arrestor cardiac arrest from taking too much of an illegal or prescribed (abused)narcotic.On car^Working in the ambulance.02^Scientific form for oxygen.Oral Airway A plastic device used to maintain an 'adequate' airway in an unconsciouspatient.Outstation^An ambulance station that is not located in the central lower mainland.Generally a place where new attendants begin their careers.Paddy wagon A vehicle operated by the police department for mass arrests and drunks.Generally takes occupants to detox and/or jail.PC^Short form for "Police Constable".Pineapple Princess Referring to the immigrant nurses that where working in privatecare hospitals.Platoon^Referring to the shift pattern an individual or group of individuals workon. For example, John works on 'B' platoon.Psych^Slang for a psychiatric patient.Quarters^The ambulance station the car is assigned to.ratbag^a derogatory term used to describe someone who is underhanded or 'slimy'in their personality, dealings, etc.127Recert^Short form of 'recertification', meaning to renew an award or level ofcertification.Rappelling^A vertical descent with rope aids. A rescue technique used to go downcliffs, buildings, etc.Sager Splint A device used to temporarily immobilize a fracture in a long bone such asa femur.scrote^A derogatory term used to describe 'bums' that live on the street.Scumbag^A derogatory term used to describe a person that is unclean or morallyquestionable.SED^SAFECO Extrication Device. A device used to remove patients fromwrecked cars.Squirter^A term used to describe fire fighters because of their work activity of'squirting water' on a fire.Swinging^A common term used to refer to a person who has committed suicide viahanging.Super scissors Special sharp scissors designed to cut clothing, screen, thin metal, etc.Used at accident scenes.Tachycardia Rapid heart rate.TIA^Trans-ischemic Attack. (of the brain) Used to refer to a person who hasmade a bad decision.Triage^The prioritizing of patients in a multiple victim scenario.Wank^A noun used to describe a person who is not behaving in the way theattendant feels they should.Whistle^Referring to a Code 3 call where the car has to 'whistle' (go fast with lightsand siren) into the hospital.CODESCode X^don't have to transportCode 1^family member on board (unauthorized listener)Code 2^routine mode of travel, no lights or sirens, obey all laws.Code 3^emergency, lights and sirens while travelingCode 4^reference to deathCode 5^police requiredCode 6^fire memberCode 7^reference to dispatchCode 9^reference to AIDSCode 30^Crew is in danger, need police ASAP10- Codes10-4^understand, clear.10-7^off the air or on the scene of ^10-8^on the air.10-20^what is your location?Hospital CodesA^VGHC^St. Paul'sQ^GraceS^Royal ColumbianL^ShaughnessyY^Surrey Memorial128H Burnaby GeneralM^St. Joseph'sK St. Vincent'sU U.B.C.W^Lions GateO St. Mary's129APPENDIX THREE130Official FormsrITIVIrlVe UT^.^., .-^..forndsMeninioisrstry HLTH 2402'irt41^British Columbia Responsible^CREW REPORT^REV. 8705...",EMERGENCY HEALTH SERVICES COMMISSION COMMISSION COPY32. REG'N. STATION SHIFT1^I^I^I33. DATE OF SERVICEDD^MM^NI,I^131 I34. VEHICLE /1. PATIENTS SURNAME TIME^Km20. CALL RECEIVED/^-,35. SPECIAL CODE0 0 0 0®^00^®I36. PROV. RESPONSE 1p_37. RESPONSE #2. PATIENTS GIVEN NAME^ INITIAL38. AMBULANCE RESPONDED TO^PATIENTSADDRESS039. HOSP. CODE3. POSTAL ADDRESS 21. STARTI 40 PATIENT CARRIED TO 41. HOSP. CODE4. CITY 5. PROVINCE 6. POSTAL CODE22. CODE^0 07. PATIENTS PHONE # 8. BIRTHDATEDO^MM^YvI^I9. AGE 10. SEXQM OF23-^CODE^0 0 42. DRIVER # NAME24. AT SCENEI43. ATTENDANT # NAME11. M.S.P. I.D. 12. S.I.N. #25. TO DESTINATION%/,44. ESCORT NAME13. PATIENTS PHYSICIAN45 UNIT QUALIFICATION0 EMA^1:21 EMA 1.V.^0 ALS I^0 ITT0 EMAII^C) EMA-D^0 ALS II14. BILL TO: (NAME IF NOT ALREADY INDICATED) 26.^CODE^0 027'^CODE^C) 015. POSTAL ADDRESS28. AT DESTINATIONI46. LAYERED RESPONSE0 EMAI/H^(^ALS^ALS not available0 EMA-DDI0 F. Dept. Initials:^1016. CITY 17. PROVINCE 18. POSTAL CODE29 CLEAR://19. BILL TO / IDENTIFICATION^0 Sheriff^ID. Other(:) Patient^(2) Standby^0 . A.G., B.C. 0 M.H.A. Trans.(3 M.H.R. 0 Parent 0 Home Care^Gits • Cont. Call0 W.C.B.^(2) D.I.A.^0 Police^a Cancelled0 I.C.B.C. 0 D.N.D. (2) I.H.T./T.R.^0 Pt. refused0 Nonresident^0 A.G. Canada^0 M.H.A. (D. A.N.U.0 Employer (2) Coroner^0 R.C.M.P.47. HOSPITAL CONTACTED30. BASEI48. PHYSICIAN ORDERING31. AMBULANCE IN PAST 24 HRS.Y^N^Unknown0^0^049. POLICE DEPT. / CONSTABLE # 50. VEH. LIC # IFM.V.A.51.CHIEF COMPLAINT^ 56. VITALTIMESIGNSSYS.B.P.DIA.PULSE RESP,RATERESP.EFFORT0 @Olt°CAPREFILL®57.ECOMAVSCOREM TOTAL64. DISPATCHED^AS^DIAGNOSISAirway Obstruction^10^0^(0Arrhythmia^©^0^0Bums 0^0^0Cardiac Arrest^@^0^@Chest Pain-MI^0^0^0Chest Pain - Other^0^13^0Chronic Disorder^13^0^0Collapse/Found Dn. 0^0^0Coma^0^0^0Congestive Failure^(3)^CI^pD.O.A.^0^0^0Diabetes 0^@^®Drowning^0^0^0Drug/Alcohol OD^0^10^@)Fracture^0^0^©GI/Abdom. Pain^13^13^®Head Injury^®^0^0Hemorrhage^0^0^@Infectious Disease^0^@I^0Intetpers. violence^Ciii^0^03M.V.A.^0^@^ftlNeuro/C.V.A.^0^0^@:)Obs./Maternity^@^®^0Psych/Behaviour^0^@^@Respiratory/SOB^(g)^@^0Seizure^®^®^®Spinal Trauma^®^0^@TRANSFER I@^0^@Trauma - Major^0^0^0Trauma Minor/Cuts^@^10^@Other (specify)^0^@^652.MECHANISM OF INJURY / HISTORY OF ILLNESS.^._^.^.. 0 0 0II,0 ®58. EXAMState of consciousness ^H & N60.TS 161.TS 262. PUPILSEqual ®,....7,React^V.)Dilat.^0Const.^0Rt. Lg.^0Lt. Lg.^0Other^0ChestC.V.S.53. RELEVANT PAST HISTORY.^ AbdBackI-Z Extu.i ).-^ 2ixC.N.S.0 ,nu)0 (/)^Blood Loss63. SKINNormal^0Cyanotic^0Pale^0Flushed^0Diaph.^02^ cn4 59. DIAGNOSTIC AND ADDITIONAL COMMENTS54. MEDICATIONS_--55. ALLERGIES-__65. AIRWAY CONTROL0 Cleared10 Positionedi- (D SuctionedZ^,..-,-,u..i kv Ventilated66. OXYGEN0 Cannula0 Mask0 Venturi0, at^%67. CARE GIVEN10 Control Bleed0 Dress wound0 Splint0 Traction(2) Back Board68. I.V.ATTEND.®ATS.000SUCC.^DRIVER^ATTS. SUCC,^TIME^SIZE SOLUTION0 D5W0 D1OW0 NS0 FI/L0 OtherTOTALVOLirn1.1BLOODDRAWN069.PROTOCOL CODES000°0 070.PATIENT FOUND000®71.PATIENT POSMONEDi. 10 Oral Airway #4u.i ,CC kb) Intubated 1 ^i- 02 at^10m.0 Neck Immobil.0 Transport only72.PATIENT TRANSPORT73. HOSPITAL SELECTEDin 74. TIME775. MEDICATIONS AND PROCEDURES 76. RESP.RATE 77. PULSE 78.^B.P.SYS. DIA. 79. CARDIAC RHYTHM 80. RESULT INMAL CODE4u.iCc4081 ADDITIONAL REPORTS^I 82. 1.I.0 - LMC INITIAL I 83. DRIVERS SIGNATURE ^ ATTENDANT'SSICINATI IP=^Rd M n I cc OC,LIS/16., euve,1 LrePTOMINCO ofBOOM ColumbiaMinistry ofHealthEMERGENCY HEALTH SERVICES COMMISSIONPROPERTY LOSS REPORT 132THIS FORM IS TO BE USED IN ALL INSTANCES WHERE PROPERTY IS LOANED BY AN OPERATOR.DATE: ^STATION:OPER. #: RESPONSE #:PROV. RESPONSE #:UNIT #:PATIENT TRANSFERRED TO: ^AIRVAC F--]^HOSPITAL Ti^OTHER AMBULANCE nOTHER r--1 , EXPLAIN: ^EQUIPMENT DETAILS:^QUANTITY^ ITEMDISPOSITION OF PROPERTY/EQUIPMENT:DETAILS OF 151 LOAN/BORROWER;^LOANED TO: OP.# ^  LOANED BY: OP.#NAME: NAME:EMP. #  ^EMP. # ^AT: ^  NOTE: PERSON RECEIVING EQUIPMENT WILLDATE:  ^BE FULLY RESPONSIBLE FOR ITSPFTHPN 771 TWP (IDTnTMAI ADCDATADSHORT TITLE FORM (for the spine of the thesis)Please put your surname and a suitable short title for your thesis in 50 characters or less below. Leave two spaces after the author and asingle space between words in the title. Do not use chemical or mathematical formulas. Please print very carefully or type theinformation.Example:MACKENZIE^MYTH & RITUAL IN THE WINTER FESTIVALYours:Lioos-LL^KE-r) A-Aio vi.,411-6- ARE- kL.WA'ISFor Office Use Only:Bind Everything^Class A^No Trim / Trim Little^DatePocket Oversewn / Double Fan Glued Colour:Folded Material^C.1 or C.2No Tape^Tang.CR-11(3/93)133PROVINCE OF BRITISH COLUMBIAMINISTRY OF HEALTHEMERGENCY HEALTH SERVICES COMMISSIONRELEASE AND INDEMNITYIN consideration of HER MAJESTY THE QUEEN in Right of the Province ofBritish Columbia, as represented by the EMERGENCY HEALTH SERVICES COMMISSION,permitting me to travel in a vehicle used by it for the purpose of observingthe operation therein, I, the undersigned, hereby release HER MAJESTYTHE QUEEN in Right of the Province of British Columbia, the EMERGENCY HEALTHSERVICES COMMISSION, their servants, employees and agents, from all claims,actions, suits or demands whatsoever that I, my next-of-kin, heirs,administrators, executors or assigns may now or hereafter have, own, orpossess arising out of or in any way related to my being a passenger in thesaid vehicle and whether caused by the negligence of HER MAJESTY THE QUEENin Right of the Province of British Columbia, the EMERGENCY HEALTH SERVICESCOMMISSION, their servants, employees, or agents or otherwise.AND further, I hereby agree to indemnify and save harmless HER MAJESTYTHE QUEEN in Right of the Province of British Columbia, the EMERGENCY HEALTHSERVICES COMMISSION, their servants, employees and agents, from all claims,suits, actions or demands whatsoever made against any or all of them andarising out of or in any way related to my being a passenger in the said vehicle.AND further, I do declare that prior to seeking publication of any articleor other material containing information of which I may become possessedthrough my observing the operations of the EMERGENCY HEALTH SERVICES COMMISSION,I will submit same for review by the Executive Director of the EMERGENCY HEALTHSERVICES COMMISSION or his designate.AND further, I do declare that I will not disclose to anyone outside theEMERGENCY HEALTH SERVICES COMMISSION, any information of which I may becomepossessed through my observation of the operations of the EMERGENCY HEALTHSERVICES COMMISSION without authorization from the Executive Director of theEMERGENCY HEALTH SERVICES COMMISSION.DATED at^ , British Columbia, this^ day, 19(SEAL; SignatureNameAddressOccupationHLTH 1042 - 02/81(k-RADVANCED LIFE SUPPORT - CARE RECORDEMERGENCY HEALTH SERVICESProvince of^RESUSCITATION FROM PRE-HOSPITALBritish Columbia CARDIAC ARRESTMinistry Of Health andMinistry Responsible for SeniorsOFFICE USE ONLYCOORD. REVIEW1343. RESPONESE No.2. STATIONRegion80.1.DATEDDM MY Y6. SURNAMEADDRESS OF CALL^Same as7. GIVEN NAMEHOME ADDRESSome address or:8. SEXEMDF9.DATEDDMMYOFBIRTHFAMILY DOCTOR OR SPECIAUST10. LOCATION OF CALLEl OWN HOME 0 OTHER HOME54. RELEVANT RECENT MEDICAL HISTORYEl STREET 0 NURSING HOME El DOCTOR'S OFFICE El OTHER:MEDICATIONSPUBLIC PLACE D WORK PLACE55. PAST MEDICAL HISTORY Na. OFPREVIOUSMrsTIME 73-74. MED. OR PROCEDURE ROUTE RESULT RHYTHM 75. PALP PULSE OR BP56. PRESUMED CAUSE OF ARREST['Cardiac U OD 0 Trauma0 Other (specify):57.FOUND IN ARRESTEl WitnessedUnwitnessedEl ARRESTED during EMA3attendance (Refer to SPC form)61. INITIAL ARRHYTHMIAEl Coarse VF0 Fine VF^RATEV tachycardiaEl 3rd degree block ^IdioventricularEl EMD^El Asystole58. CPR prior to arrival by:0 Bystander^U EMA 20 Fire dept.^0 Other:El No CPR prior to arrival 59. Est. time In arrest priorto any CPR^60. Est. duration CPR priorto EMA 3 arrival^PROCEDURES PERFORMEDIIV E 05W^Cathetersize ^E Saline62.No. of attempts to start ^63. 17:  successfulunablej later went interstitial64. Total vol. Infused^..COMMUNICATION66. Name of Hospital contactedCONTACTED BY ^MESSAGE Ttelephone ER staff0 radio^ El MDEl dispatcher65. VENTILATIONNo assist requiredArnbubag ventilation0 ET intubation attemptsuccessfulunable to intubateTube_sizeCode0:^RADIO ORDERS:0 Not required0 Rec'd. from ERRec'd. from MD at scene67. Name of arrival hospital Code^TimeDr. ordering68. CONDITION ON ARRIVAL AT HOSP TAL5 DOA Li Admitted to ER5 CPR being done on admissionVITAL SIGNS69. Rhythm ^70. Rate   71. BP 72. SPONTANEOUS RESPIRATIONS5 None Li Weak, needs assistance5 Spontaneous respirations 00M.D.ADDITIONAL COMMENTS (RHYTHM STRIPS ON REVERSE)with ET tubewithout ET tubeLIC. NO.76. ALS ATTENDANT 77. ALS ASSISTANT^ LIC. NO. RECEIVING PHYSICIANM.D.ILTH EHSC -2429 Rev. 92/01


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