The Ambulance: Toward a Labor Theory of Poverty Governance

Governing the Poor

Case and Method

Medical Response and Transport

Medical Response and Transport (MRT, pseudonym) is a large for-profit firm that provides 911 ambulance services throughout the United States. I focus on MRT’s operations in one California county where they employ roughly 350 paramedics and EMTs. The company monopolizes ambulance operations in the county through a contract with local government. ¹ MRT primarily secures revenue not from the state, but from personal health insurance policies and ambulance riders under a fee-for-service model.

Responding to well over 100,000 calls a year, MRT crews are seemingly dispatched everywhere from homeless encampments to mansions. However, as evident in Figure 1, MRT’s ambulances gravitate toward the poorest areas of its operations in the studied county. The census tract quintile with the highest concentrations of poverty has an average age-adjusted MRT response rate over four times greater than the quintile with the lowest concentrations of poverty (171.4 and 40.9 per 1,000 residents, respectively). The association between tract-level poverty and MRT response is positive, and the impoverished areas MRT ambulances frequent most include residents who are disproportionately black or Latino, jobless, renters, foreign-born non-citizens, and either uninsured or covered by public health insurance. Beyond these ecological patterns, public documents reveal that at least half of MRT’s transport invoices are billed to Medicaid or uninsured patients. MRT’s crews seem to be in perpetual contact with the county’s destitute, stigmatized, and weakly integrated populations. But these data provide no insight into how the ambulance processes these people.

OPEN IN VIEWER

Figure 1.

Mean Age-Adjusted MRT Responses per 1,000 Population, 2015 (Tract, n = 300)

Fieldwork

Building on what sociologists already know about poverty governance and the ambulance, I ask three questions. First, how does ambulance labor yield poverty regulation? I focus on the practical component of ambulance work, especially the interactions between crews and the subjects of their labor. Second, how is the ambulance horizontally positioned relative to other frontline institutions of poverty regulation? I concentrate on interactions between crews and their police and nurse counterparts. Third, how is the ambulance vertically positioned, not just above the clientele it processes, but also beneath the bureaucratic and capitalistic forces that control and coordinate its operations? I turn to MRT to answer these questions.

I accessed the firm’s operations from the top. I first secured a meeting with leading administrators at the county EMS bureaucracy who, upon learning of my broad research interests, referred me to upper management at MRT. At the firm’s local headquarters, I pitched an “exploratory field study” in paramedicine and neighborhood inequality as part of my doctoral dissertation to the medical and clinical directors. After consulting with other managers, they permitted my access to the organization. The clinical director, who claimed sociology as one of her favorite college courses, was my strongest advocate at MRT and volunteered to help with the logistics of scheduling my ride-alongs. She allowed me to request any field shift so long as it was not on a unit with an assigned intern or trainee. I selected days and nights, weekdays and weekends, and crews and supervisors. None of the eight supervisors, 25 paramedics, or 14 EMTs I asked to shadow denied my request, and several encouraged me to ask to observe their shifts again (which I often did). Through shadowing these people, I conversed with many more crews and managers as well as other parties like clients, police, and nurses.

Crews and supervisors generally, although incompletely, welcomed me into the world of paramedicine. In preparation for this study, I completed a six-week accelerated EMT training program at a small healthcare vocational school. This provided me with a superficial knowledge of ambulance work and helped me examine clinical decision-making in the field. I did not work as an EMT, but I attempted to lightly assist crews and supervisors throughout their shifts. I often carried, cleaned, and prepped equipment for crews, and I sometimes helped supervisors with simple paperwork duties. On a few occasions, I directly assisted with emergency care when events became unusually hectic (e.g., manually stabilized a broken femur, maintained pressure on a stab wound, and helped hold down a fist-swinging person). However, the rapport I built with the men and women I shadowed might have more to do with our similar social profiles. Like many of the crews and supervisors at MRT, I am male, white, and come from a working-class family far away from the neighborhoods the ambulance frequents most. ² On the other hand, my status as a third-party observer separated me from those I shadowed: some teased me for being a naïve “college boy,” some were irritated by my “politically correct” stances on 911 “system abusers,” and some were frustrated when, as a doctoral candidate, I was unable to offer smart clinical advice.

I took detailed field notes over the course of a year (February 2015 through January 2016). This began with my initial meetings with the county EMS administrators and MRT directors and concluded with my 279th observed ambulance call. When with crews, I focused my notes on their interactions with patients, supervisors, nurses, and police. When with field supervisors, I focused my notes on their interactions with crews and upper management. I jotted down many events and some conversations as they occurred, but I typically put pen to paper during downtime as I sat in hospital ambulance bays, ambulance-posting locations, and at headquarters. I also used downtime to informally interview crews and supervisors. The company forbade me from using an audio recorder, so all conversations were paraphrased in my notes. Following each shift or set of consecutive shifts, I expanded my jottings into more detailed narratives.

At the beginning of my fieldwork, I articulated general interests in the everyday operations of urban paramedicine, but I also stressed an early fascination in “trauma work” (i.e., the management of physically injured patients). I assumed I would extend Palmer’s (1983) ethnographic description of ambulance workers as “trauma junkies” who are vocationally driven to aid wounded citizens. Early into my fieldwork, crews labeled me the “trauma guy” and a few joked that I had “come for blood.” Some, however, candidly disapproved of this focus. As one paramedic-turned-supervisor noted, “You don’t want your thesis to be like that show Trauma,” referencing a canceled NBC drama he liked to mock for its inaccuracies. Indeed, it became readily apparent in the field that the high-profile trauma responses that define the ambulance in mainstream fiction, local news media, and my EMT training program were not very common. In the first month of fieldwork, I learned that ambulance crews were more likely to be responding to ill but medically stable individuals in the county’s “ghettos,” transporting unhoused and hungry bodies to meal-offering hospitals, and picking up drunk men and women off downtown sidewalks.

Motivated by this early lesson from the field, I analyzed my ethnographic notes to rethink the ambulance as a mode of poverty governance. I combed through my notes seeking patterns that complemented and challenged existing scholarship, and I utilized the extended case method to make these connections and ruptures (Burawoy 2009). Beyond my extension into the everyday lives of ambulance crews and supervisors, I aimed to link the microprocesses of ambulance operations to extralocal forces, and this necessitated an extension of theory. The goal of this ethnography was neither a misguided attempt to restate common-sense folk categories (a blind obedience to empiricism) nor a pointless surrender to scholastic traditions (a blind obedience to theoreticism) (Bourdieu, Chamboredon, and Passeron [1968] 1991). Instead, I used theory to see and organize data, and I used data to stress and evolve theory.

Built from this analysis, Figure 2 simplifies a deeply complex world of urban paramedicine. Not unlike Parsons’ (1951) therapists and patients, we find a basic hierarchy with ambulance crews positioned above their clientele. Riders can demand (and often refuse) services, and some even resist paramedical authority by kicking, punching, and spitting, but crews nonetheless coax and coerce mostly obedient subjects. At the same time, riders often slide between other transient statuses like hospital patient and street criminal. This situates ambulance crews between nurses and police, whom they interact with daily. Atop the ambulance we find a proximal trinity of forces: official protocols published by the county EMS office, upper management at MRT, and the company’s field supervisors. Further up, we find a relation between bureaucracy and capital, where the former delegates operations to the latter. Instead of totally hollowing itself out, the state remains present and powerful by setting the conditions, surveilling the activities, and sanctioning the performances of capital.

OPEN IN VIEWER

Figure 2.

Positioning Paramedicine

In the next three sections, I explicate this field of relations by detailing a labor process. I begin by illustrating the practical components of ambulance work, summarizing this as a double regulation of spaces in bodies and bodies in spaces. Both regulations involve what Prottas (1979) calls “people processing,” as crews transform complex subjects into cases with simplified and standardized problems. Crews moralize this labor by expressing clear preference for the regulation of spaces in bodies over bodies in spaces. I show how this shared moralization shapes crews’ practical engagements with their subjects. From here I turn to the relational components of ambulance labor. With nurses approximating the state’s Left hand, crews engage in a process of fixing up; they pursue (quick) solutions to corporal problems and fix their subjects into one or two medical diagnoses. With police approximating the state’s Right hand, crews engage in a process of cleaning up; they momentarily clear streets and homes of deviant bodies (sick or criminal) and move them elsewhere (hospital or jail). These processes often generate tensions between street-level bureaucrats, and the primary mode of horizontal struggle is burden shuffling, where workers shuffle out of undesirable work by pinning responsibility onto their peers. This conflict helps explain how the poor slide across the transient statuses of ambulance rider, hospital patient, and street criminal, but burden shuffling and other grounded struggles are themselves shaped by the vertical circumstances of the ambulance. Field supervisors, upper management, and official protocols conspire to deploy a lean fleet that is highly flexible and minimally wasteful. This propels crews to efficiently process a mass of clientele and motivates their frequent struggles with nurses and police. It is through these practical and relational components of a labor process that the poor are governed by way of the ambulance.

Spaces in Bodies and Bodies in Spaces

On the one hand, ambulance crews regulate spaces in bodies. Much of their labor involves an assessment and transformation of people as independent structures divided into anatomical and physiological regions. Paramedics and EMTs are trained to link external symptoms to internal problems (e.g., pale diaphoretic skin and chest pain as possible indications of cardiac compromise) and internal problems to targeted treatments (e.g., administering sublingual nitroglycerin to widen a patient’s blood vessels). On the other hand, crews also regulate bodies in spaces. They move people from homes, sidewalks, bars, rehabilitation facilities, and other places to the emergency department. Sometimes they do so against the expressed will of their subjects, but most riders voluntarily summon ambulance services.

For many ambulance workers, there is a moral order to these two forms of work. Crews understand what I call the regulation of spaces in bodies to be more dignified, even if more stressful, than the regulation of bodies in spaces. The former, usually exercised by paramedics, is associated with the enduring caricature of the “ditch doctor,” whereas the latter, practiced more by EMTs, is associated with the demeaning caricature of the “ambulance taxi driver.” However, the primary moral division of these tasks is evidenced through the language of “legit” and “bullshit” calls. More ideal types on a continuum than mutually exclusive categories, legit calls are the real emergencies that involve a sophisticated regulation of spaces in bodies (e.g., chest compressions, aggressive airway management, and severe bleeding control), whereas bullshit calls are typically non-emergencies that involve little more than a simple regulation of bodies in spaces (e.g., moving non-critically ill people from their home to the hospital). ³ Only about a quarter of the calls I observed with crews could be considered legit; the rest were closer to the opposite. ⁴ Consider the following bullshit call:

On a hot California day, paramedic Adam and EMT Veronica are dispatched to a homeless man in his mid-60s having difficulty breathing. Veronica parks in front of a café cited by local journalists and bloggers as a sure sign of early gentrification in this predominantly black and legendarily poor neighborhood. We enter the building to find white baristas and customers sporting stylish boots and rolled pant legs. Neighborhood firefighters (charged with stabilizing medical 911 clients before the ambulance arrives) are already on scene and attend to a sweating man lying face-up on a bench. One of the firefighters notes this man is having difficulty breathing and walking.

Adam, a white man who resides in the county’s rural outskirts, turns toward the baristas to inquire how the only black man in the room, who later tells us he sleeps “on the street,” got there. “Did he walk in?” A woman from behind the counter responds, “Well sort of stumbled in. Said he couldn’t breathe and asked us to call 911.” Adam addresses the patient, “Hey, you gotta get up and walk out to the ambulance.” “No man, I can’t walk. I can’t breathe, man.”

Veronica, a short but firm-spoken Latina, interjects, “You’re breathing fine if you’re talking to us.” “You all are fucked up,” complains the man, “I can’t breathe, it’s hard to breathe when I walk.” Challenging the patient, Veronica asks, “Can you always speak in full sentences when you’re short of breath? It seems strange.” The man puts his hand up, as if to block the EMT’s face and voice. He says nothing. Veronica steps back and lectures the man in return, “That’s how you treat people who are trying to help you?”

Interactions like this are not uncommon. Crews are often summoned to public and commercial areas to “handle” out-of-place bodies they immediately perceive to be medically stable. Crews often ask such patients with bullshit complaints to walk to the ambulance because lifting body-bearing gurneys into the rig is less convenient.

Adam and Veronica concede and load their patient into the ambulance by way of gurney. We “stay and play” rather than “load and go” (the crew continues their medical assessment before driving to the hospital). I wrap a blood pressure cuff around the patient’s arm as Veronica prepares a four-lead electrocardiogram (EKG).

“What’s your name?” Adam asks the patient. “Joe.” Joe tells Adam he has congestive heart failure and “something wrong” with his lungs but he cannot recall a specific diagnosis. ⁵ Adam uses a stethoscope to auscultate the patient’s lung sounds and then glances at the EKG monitor to see a “normal” cardiac rhythm. The monitor (which also includes an infrared finger probe for measuring blood oxygen saturation) suggests adequate respiration. “It’s all you,” Adam says to Veronica, indicating that this is a basic enough call for an EMT to “tech” (lead the administration of care). As he later describes it to me, the call is “total bullshit.” Adam jumps out the back of the ambulance and heads toward the driver’s seat.

During bullshit calls, paramedics’ and EMTs’ roles can switch. Paramedics, effectively responsible for all clinical decisions in the ambulance, can “turf” a number of calls onto EMTs. Many paramedics told me they do this because they would rather drive the ambulance to the hospital than do the paperwork for a call that involves no significant medical interventions. However, county protocols heavily limit which calls EMTs can tech, so it is still more common for paramedics to ride in the back on bullshit transports. In this case, Adam, after “objectively” determining patient stability, turfed the call to Veronica.

Following a short drive to the closest hospital, we enter a busy emergency department through the ambulance bay and wait for a nurse to triage Joe. We lean against an interior wall with three other ambulance crews ahead of us in the hospital queue (this is often called “holding the wall”). Joe lies on the gurney next to us, but we do not talk to him. Instead, we talk to the other crews. “Today’s the king of bullshit calls, man,” Adam gripes to another wall-holding paramedic, “I seriously fucking hate this city.” He continues by telling his colleagues about a woman we transported this morning for a cut finger before concluding, “We’ve been getting our asses kicked all shift” (code for being busy with calls).

After 20 minutes of holding the wall, it is finally our turn to be triaged. “What you got?” asks the nurse. Veronica responds, “SOB (shortness of breath) . . . says he can’t breathe, but he speaks in full sentences fine.” She then tells the nurse about Joe putting his hand in her face. “Got it,” says the nurse, “So he’s being obnoxious.” A minute or two later, a physician’s assistant speaks to Joe before telling us the patient can go to the waiting room, the lowest triage possible for ambulance patients.

This bullshit call can be contrasted with an ambulance response that occurred within a mile-and-half of the café where we found Joe. In the following excerpt, I am shadowing field supervisor Lisa. County protocols require that supervisors respond, along with ambulance crews, to a number of high-priority calls (e.g., cardiac arrests, gunshot wounds, and multi-casualty incidents). All the supervisors I shadowed told me this is a perk of the job, because it increases their chances of aiding crews on legit calls.

Lisa pulls our SUV under a freeway overpass and onto the periphery of an emergency scene made of fire engines, ambulances, police vehicles, and pedestrian spectators. She’s been dispatched, along with two ambulances, to an “auto vs. ped” (pedestrian) call involving an unknown number of patients. We step out of the rig to find objects everywhere. Shoes, clothing, papers, bagels, beer cans, blankets, and other items are spread across the street and sidewalk. These things are linearly smeared for a good 25 yards. They trail a small white car with a smashed windshield, a broken rear window, and a missing bumper.

We walk toward the opposite end of this trail, where ambulance crews and firefighters work. The scene is loud, but I can still hear my footsteps crunch as I step on broken glass. Lisa kicks some debris toward the curb, seemingly to clear a path for gurneys. A couple of nylon tents and sleeping bags are among the mess of objects that exploded onto the street and sidewalk.

I finally make sense of this disorder. Whoever was driving the white car drove through a small homeless encampment planted on the sidewalk. This scene instantly reminds me of tornado and hurricane disaster news coverage: a chaotic and devastating spread of personal property.

A crying man paces back and forth near the ambulance crews. He shouts into his phone with a broken and shaky tone, “That punk ass nigga ran ’em over!” I look down and see the injured: two black campers around 40 years of age, one male and one female. They are living and I am sighing with relief. An EMT elevates the gurney from the ground and starts rolling the male patient to the ambulance.

Legit calls may be less common than bullshit calls, but they are not rare, especially in the poorest corners of the county. In this five-block area, I observed my first 911 call where a young man was shot in the gut, and here I also encountered one of the first deaths I saw in the field: a crew attempted, but failed, to resuscitate a warm body found sprawled across the sidewalk. It is on these types of scenes, crews told me, that the “real work” happens.

“What you got?” Lisa asks Jacob, a paramedic treating the man on the gurney. “Open tib-fib (lower-leg compound fracture). We’re going to (the trauma center).” I can’t see the exposed bone (nor do I really want to) because the gurney is in motion and a cardboard splint conceals the wound. A pool of blood, almost perfectly round and about one-and-a-half feet in diameter, marks the spot where this man received initial treatment and probably where he waited for 911 aid.

Meanwhile, the injured woman lies face-up on the sidewalk. A firefighter holds her head and neck in place (to stabilize the cervical spine as a precautionary measure). Although an EMT has cut her clothes off, sliced fabric conceals most of her body. In one fluid motion, Lisa squats low, pulls the woman’s cut shirt down, makes a fist with one of her latex-gloved hands, and presses the pinky-side of her clenched hand firmly against the woman’s bare chest. “Do you hurt here?” asks Lisa. The woman shakes her head. Her eyes are closed and she’s biting her bottom lip. The crying bystander on the other side of the fence shouts to this woman, “I love you! I got you!” “I love you too,” she responds in a half-whisper with her eyes still shut.

The crew loads the woman into the ambulance and drives toward the trauma center code 3 (with lights and sirens) suspecting a pelvis fracture. Both crews later tell me they started intravenous lines, administered fentanyl for pain management, and were quickly awarded a bed and trauma team at the hospital.

Five months later, I shadowed Jacob, the paramedic who treated the injured man on this call. He remembered me before I remembered him, “You were on that auto-ped at the homeless camp, huh?” Together, we relived some of the details of the event. Our postponed debriefing occurred in a hospital ambulance bay, following a bullshit call that involved a young woman who complained of a headache and other flu-like symptoms. Jacob, a towering white man who must awkwardly hunch in the back of the ambulance throughout his shifts, remembered the legit call well and described it as a “good run” because he “actually did something for the poor bastard.” He continued, “Hopefully we get something good like that today.” A few hours later, we picked up a teenage boy whose hands were “blown to bits” in a fireworks accident. “Told you I get the legit ones,” he concluded at the end of the call before he started teasing me for “turning white” when I saw police picking up the boy’s dismembered fingers off a lawn.

Despite obvious differences between these two excerpts, there are some important similarities. Occurring within a mile and a half of each other, both calls involved black patients without permanent shelter. Both also entailed people processing, as crews transformed their subjects into clients with simplified and standardized problems (Prottas 1979). The nurse in the first call and the supervisor in the second call asked ambulance crews the same question, “What you got?” This is a common question and one that triggers an answer translating human misery into one or two medical “impressions” (e.g., open tib-fib). However, during bullshit calls, these answers often express frustration and suspicion. For example, in addition to stating “SOB” (shortness of breath), Veronica answered the nurse by downplaying her patient’s legitimacy (“says he can’t breathe, but he speaks in full sentences fine”). Because the ambulance is manifestly clinical, crews must classify all riders as ill or injured. In both cases, suffering was reduced to what Waitzkin (1991) calls the “physical realm,” as crews ignored, if not outright depoliticized, the larger social physics of suffering.

In processing people, ambulance crews moralize their work. But this is less a moralization of clientele (see Hasenfeld 2000) as it is a moralization of productive tasks. Both white and non-white workers used terms like “homeboy,” “esé,” and “white trash” to signal the class and racial makeup of their patients, and most used the words “hood” and “ghetto” to flag territories they understand to be morally ill (e.g., joblessness, welfare dependency, and rampant drug use). These are important cultural frames that likely structure practice, but my observations suggest a more foundational distinction rooted in a labor process. Did the first crew vilify Joe because he is black, homeless, and picked up in a so-called ghetto? Probably. And this is not insignificant. However, Joe shares this basic social profile with the campers who were crushed by a car. Yet the latter were part and parcel of something more “legit.” The primary moral separation that ambulance crews make concerns the type of work performed, be it the regulation of spaces in bodies or bodies in spaces.

Consistent with previous ethnographers of the ambulance (Mannon 1992; Palmer 1983; Tangherlini 1998), I find that crews prefer calls that involve more interventions, require more paperwork, and are generally more stressful than the usual bullshit. However, these past studies tend to emphasize the moral superiority of serious “trauma” (i.e., violent or accidental injuries). Crews today, now even further trained in the medical arts, also express preference for non-trauma calls like “codes” (cardiac arrests), diabetic emergencies, and other legit problems of spaces in bodies. Like Becker’s (1993:33) medical students, MRT crews desire patients with “real physical pathologies.” Working on such clientele enables a clear expression of one’s craft and provides crews with effectively the only path to vocational honor.

Both legit and bullshit calls concentrate in the poorer sectors of the county. The “hills,” a wealthier and whiter portion of MRT’s jurisdiction, simply has fewer runs. Geographically smaller and with homes more sparsely planted, I entered the hills only five times with crews, but two of these were for legit calls. Indeed, many crews see the hills not only as a rarely entered territory, but also as an area where legitimate work is more likely. As one paramedic told me as we drove up a steep road past large multi-storied houses, “We don’t come here [hills] much, but when we do it’s usually for something good [legit] . . . hot strokes, gnarly hip fractures . . . real overdoses, things like that.” Ghettos and hoods, in contrast, “trap” the ambulance with both legit and bullshit calls, but more the latter than the former. Across the “flats” of the county’s central city, only about a quarter of calls are legit. ⁶ Much to the frustration of crews, ambulance work in these busy areas involves a regulation of bodies in spaces more than a regulation of spaces in bodies.

Burden Shuffling

Ambulance crews do not work in a vacuum; they interact with other street-level bureaucrats, especially nurses and police. I summarize much of the work ambulance crews do with nurses as “fixing up.” With few exceptions (e.g., obvious signs of death determined on scene and 911 callers who deny transport), ambulance encounters conclude with crews transferring their clientele to nurses. Together, crews and nurses attempt to fix internally malfunctioning bodies, and in the process they categorize their subjects into one or two medical diagnoses. For legit calls, crews usually deliver nurses bodies fixed up with gauze, oxygen masks, cervical collars, narcotics, and other clinical artifacts. For bullshit calls, crews often deliver bodies fixed up only with a primary impression (i.e., a suggested diagnosis) and a set of vital signs (e.g., blood pressure, heart rate, respiration rate, and oxygen saturation).

I summarize much of the work ambulance crews do with police as “cleaning up.” From legit gunshot calls to bullshit calls for sidewalk slumberers, crews and police often converge on 911 scenes to clear seemingly out-of-place bodies (e.g., the wounded, the nuisance, and the belligerent). Police facilitate the flow of people “off the streets” and into the ambulance by (1) establishing scene security for crews in environments assumed risky and (2) summoning crews to handle subjects they deem (discretionarily or by protocol) to be more sick than criminal. For example, a common interaction between cops and crews concerns what is colloquially known as “incarceritis,” where it is assumed an arrestee feigns a medical symptom in an effort to avoid or delay jail booking.

Lateral conflicts between crews and their nurse and police counterparts are frequent. Some conflicts take the form of “finger pointing” and the “blame game.” For example, as a man found in the same neighborhood as Joe and the urban campers was pronounced dead on a nearby hospital bed, a nurse chastised a crew for not transporting the patient to a more specialized hospital. Other conflicts take the form of encroachment and jurisdictional defense. For example, a paramedic criticized a cop for “getting in the way” by asking his gunshot patient a series of investigative questions regarding the shooter’s identity.

However, most conflicts concern what I call burden shuffling. This occurs when, largely out of interests of convenience and a general effort to disclaim liability, a street-level bureaucrat pushes a subject onto an extra-bureaucratic counterpart. For crews, police, and nurses, the bulk of potential or actual ambulance clientele involves bullshit work to be avoided. Nurses often complain that ambulance crews “dump” bullshit on them and crews frequently say the same of police. Many of these workers reason that protocol commands such dumping (e.g., nurses know that crews must transfer anybody demanding a hospital trip, and crews know that police must request an ambulance when someone “pulls” incarceritis). However, they also know that worker discretion guides the dumping process (e.g., which specific hospital crews transport patients to and whether a police officer summons an ambulance or takes his subject to the hospital himself). As such, both playful bickering and heated arguments emerge between crews and their police and nurse peers over matters of burden shuffling.

Consider a more detailed example. The following excerpt is a case of burden shuffling between law enforcement and an ambulance crew. I shadowed Dawn and Nick as they were dispatched to transport a police-initiated involuntary psychiatric hold, a “fifty-one fifty” (the hold’s numerical reference in the California Welfare and Institutions Code). Dawn, a mid-30s black woman who has been working in ambulances for over a decade as an EMT but only recently as a paramedic, led the call and talked with one of the three officers on scene. Nick, a more senior paramedic, stood with me on the periphery. ⁷

The cop tells Dawn that his subject, who now sits in the back of a squad car with his hands cuffed behind his back, was banging on a window of a coffee shop before he stole some change and bread from a nearby convenience store.

“So, why is he on a fifty-one fifty?” asks Dawn. The cop responds matter-of-factly, “Well, we can’t take him to jail. We gotta do something with him. Nobody’s pressing charges.” “Come on, man,” moans a clearly annoyed Dawn. “He can’t go to jail,” the officer responds, now seeming to grow frustrated. Dawn is quick to counter, “But that doesn’t mean he should go to the hospital. . . . This isn’t psych.” “This isn’t psych, huh?” barks the cop, “You talk to the guy and tell me this isn’t psych.” “Whatever man,” concedes Dawn, “If we gotta take him, we gotta take him.”

The victorious officer notes in an apathetic tone, “You guys have taken them for a lot less.” Dawn responds, “Whatever, man. It’s cool. We’ll take him. But it’s inappropriate. It’s not psych.” “You talk to him and you’ll see,” reiterates the cop, “He’s totally a psych.” Dawn strikes one last time, now pounding her fist into her palm and speaking with an elevated volume to punctuate her stance, “You don’t get it. THIS – IS – NOT – A – PSYCH – CALL!” She takes a breath and says, “A fifty-one fifty is inappropriate.”

The cop shrugs and smirks as if to say, “Oh well.” Later, Dawn explains to me that she does not care whether or not the patient has chronic psychiatric problems. She simply thinks a 911 call for a disruptive and shoplifting man equates to an arrest or a release, not an involuntary psychiatric hold. At the conclusion of the call, Dawn summarizes the run to her partner and I as “bullshit” and describes the cop as “lazy.”

For the paramedics and police on this 911 call, this homeless and bipolar man was a burden. He was a workable subject to avoid. The police had the advantage because they “cut paper” that legally placed the man on a psychiatric hold, effectively medicalizing the event and shuffling the burden leftward from the squad car to the ambulance. They did this under the loose justification that the man was a significant danger to self or others, and Dawn was quick to emphasize this shaky justification in an effort to keep the subject to the right and ultimately out of the ambulance.

Arguments between crews and police do not occur on most of the calls they share, but conflicts like the one between Dawn and this police officer are by no means extraordinary. In addition to involuntary psychiatric holds, police and crews will sometimes conflict over the management of drunken subjects who may be classified as either “publically intoxicated” (a criminal problem) or “ETOH” (a medical problem and the clinical abbreviation for ethyl alcohol). Crews can often prevent the police from shuffling “drunks” into the ambulance by determining that adult subjects are “alert and oriented” and therefore capable of making their own treatment and transport decisions. If subjects can answer a few simple questions (e.g., What is your name? What year is it? What city are you in? Do you remember how you got here?), bear their own weight, and do not want to go to the emergency department, then the crew can and, according to protocol, must refuse to transport. On a couple occasions, drunken subjects capable of refusing ambulance services told crews in the back of the rig that they requested medical transport on scene because law enforcement gave them an ultimatum: jail or hospital. In one such case, the crew, furious upon learning what the police had said, released their subject onto the street a few blocks away from where police had shuffled them into the ambulance.

Hospital workers also accuse ambulance crews of burden shuffling. Nurses from the two busiest emergency departments, both of which are located in the densest and poorest areas of the county, frequently accused crews of intentionally dumping bullshit on their departments. These nurses sometimes correctly blamed paramedics and EMTs of transporting obnoxious and odorous patients to their hospitals in an effort to minimize the amount of time crews had to tolerate loud noises and nauseating smells in the ambulance. At the same time, nurses from smaller and more suburban hospitals often correctly accused crews of passing big centrally located emergency departments in an effort to receive faster triage at a less busy department. It was also common knowledge among these nurses that crews sometimes encouraged their patients with bullshit complaints to go to hospitals just outside the central city as a tactic to pull their rigs out of the busy hoods and ghettos. This was especially true toward the end of shifts, as crews often attempted to transport bullshit cases to hospitals close to their designated sign-off locations, all of which are located away from the two busiest hospitals.

For the most part, federal law prevents nurses from shuffling burdensome work onto ambulance crews. However, as one paramedic put it, “They find their ways.” Some believe that nurses prolong triage for bullshit as a deterrent strategy, a means to discourage future transport. On a few occasions, field supervisors questioned nurses about this, usually in a playful and friendly way. Nurses denied intentional delaying in all such cases, but crews noticed lower triage times in the minutes and hours following supervisor intervention. Moreover, when overwhelmed with patients, charge nurses would occasionally place their departments on a two-hour bypass status, temporarily halting the bulk of incoming ambulance traffic and extending transport times for nearby crews.

As double regulators of spaces in bodies and bodies in spaces, ambulance crews are caught in productive but often tense interactions with nurses and police. If we accept that the hospital is generally held by the Left hand of the state and the squad car is generally held by the Right hand, then it is not unreasonable to position the ambulance between these hands. Moreover, if a neoliberal governance of poverty is halved between the welfare and penal states, then the ambulance is a place where crews do fix up work with nurses to their left and cleanup work with police to their right. These street-level bureaucrats frequently conflict over the shuffling of burdensome subjects who are overwhelmingly poor. Inundated with so much bullshit, ambulance crews routinely struggle over the management of such cases with their police and nurse counterparts. However, productive relations of poverty governance cannot be reduced to lateral interactions. Vertical forces are also at play.

The Lean Fleet

Five days a week, MRT management congregates in a large conference room for half-hour operations briefings, here called “Daily-Ops.” Usually in attendance are the chief of MRT’s local operations, the contract manager, the personnel manager, the clinical director, daytime field supervisors, and other specialized managers. ⁸ These meetings cover a number of issues, from the status of vehicle repairs to computer-aided forecasts of 911 call volumes, but they always focus on two intertwined problems: contract compliance and labor power.

In the Daily-Ops meetings I observed, the contract manager spoke the most. She regularly detailed MRT’s likelihood of “making (monthly) compliance” on several contract items, but she primarily focused on efforts to avoid monthly fines for tardy ambulances. MRT’s contract with the EMS bureaucracy specifies strict expectations for ambulance response times. ⁹ These fines can reach nearly $400,000 a month, even though over nine-tenths of MRT’s responses are “on time.” Outside of Daily-Ops, upper management told field supervisors, crews, and a nosey ethnographer that MRT has lost more than $40 million during their initial four years of operation in the studied county. Much of this loss, according to management, should be blamed on a “punitive contract” MRT accepted in order to outbid one of their few competitors.

Fines give the firm an incentive to keep areas with the greatest 911 demand supplied with the most ambulances, but these areas threaten profit in three ways. First, Medicaid, which is much more common among residents in these neighborhoods, covers only about 10 percent of the $2,000 to $3,000 transport invoices. Second, private insurance policies often evade full or partial payment by coding many bullshit transports that are common in these areas as “not medically necessary” and therefore not coverable. Third, the remaining bills that land fully or partially on ambulance riders in these areas often go unpaid, and selling debt off to collection agencies at a discounted price is not a lucrative source of revenue.

The EMS bureaucracy effectively prevents MRT from abandoning the poor, their largest and most unprofitable clientele base. As such, management must deploy other strategies to accumulate capital and alleviate financial loss. Through consultations with the EMS bureaucracy and sometimes through “higher up” proposals with the county board of supervisors, MRT has been able to adjust the fine schedule slightly and secure financial aid from the county government. The chief of MRT’s local operations also participates in statewide lobbying by private ambulance firms to increase Medicaid reimbursements for ambulance transports.

However, management’s principal strategy to increase profit is quintessentially capitalist: intensify the exploitation of wage labor. Following her summary of late calls from the past 24 hours, the contract manager always gave the Daily-Ops floor to the personnel manager. This man is responsible for ensuring ambulances are stocked with workers, a somewhat difficult task given MRT’s high employee turnover and callout rates. Indeed, a semi-permanent schedule of full-time regular employees rarely covers anticipated demand. So the personnel manager often published an auxiliary schedule every one to two days. He usually attached incentives (e.g., erased absentee penalties and double pay) to these additional shifts and to the regular shifts left vacant to “sweeten the pot” and put “butts in rigs.” By expanding the schedule and offering additional incentives to labor, the personnel manager was essentially reducing MRT’s chances of being fined by the EMS bureaucracy. He had to be careful though. While more crews on the street decreases the likelihood of late call fines, too many crews can mean “too much post-time” (i.e., the amount of paid time a crew spends parked at or near a designated street intersection waiting for a 911 call). In the Daily-Ops room, most of us would stare silently at a calendar displayed on a 50-inch monitor as the personnel manager told us which shifts were to be generated and upgraded over the next day or two.

To avoid the fines that tend to come with a thin fleet and the high labor costs that tend to come with a fat fleet, management aims to deploy a lean fleet. The point is to minimize waste and maximize flexibility. However, upper management faces two major challenges in accomplishing this goal. First, county protocols, printed in a thick pocket-sized book carried by all crews, hinder workforce flexibility. For example, as communicated through this text, the EMS bureaucracy mandates that crews process a mass of clientele net of the perceived legitimacy of their medical complaint or their ability to pay for services. Crews must do the bullshit work that threatens MRT revenue. Second, crews maintain high levels of discretion and this increases flexibility at the risk of increasing waste. Workers, often feeling overwhelmed with bullshit, seek ways to slow production or “pace the shift.”

To address these challenges, upper management deploys field supervisors. These middle managers, like Lisa, monitor and encourage an efficient flow of laboring bodies across the dozens of ambulances under their supervision. Vertically positioned above crews but below upper management, supervisors are themselves closely managed.

Supervisor Eric told me, as we ate our breakfast in his SUV, “You need to understand that upper management is micro managing us too. They’re telling us to clear hospitals and watch levels and all that stuff.” For field supervisors like Eric, “clearing hospitals” means encouraging crews to quickly return to service after completing a patient transport at an emergency department. The benefit to clearing hospitals is increasing “levels,” that is, the number of ambulances available to take a new 911 call. When levels are low or when the county is in “level shit” (i.e., level zero or close to zero), the spread of available ambulances is thin and this increases the risk of late calls. Supervisors understand that crews on a legit run may need an hour or so to complete complicated paperwork at the hospital and clean a messy ambulance for a return to 911 service (e.g., hosing blood off the gurney). However, they expect the more common bullshit calls to result in a 30-minute “drop-time” (much of this dedicated to “holding the wall” in the triage bay) with an additional 10-minute or so informal break every two or three calls.

A vertical struggle between crews and supervisors ensues on the grounds of hospital ambulance bays. Supervisors, via their in-rig computers, can always see where crews are. When crews are at hospitals, a supervisor can see how long they have been there and whether they have completed their paperwork. Supervisors will often arrive at ambulance bays unannounced to question crews about clearing when levels are low, when a single crew has been at the hospital for over 50 minutes (i.e., about 10 minutes past the informal turnover and break time expectation for bullshit calls), or when more than four crews are at the same hospital.

Crews also carefully direct their time in the bays. While there, workers often ask their partners, “How long we been here?” An overwhelming majority of crews push their hospital drop time to around 45 or 50 minutes, which typically includes 10 to 15 minutes to eat, use the restroom, and otherwise relax. ¹⁰ Thus, they remain at the hospital to the point just before a supervisor will question them. Supervisors can see crews’ locations on a global positioning system, but workers cannot see supervisors on their computers. When a supervisor would drive into an ambulance bay it was not uncommon to hear crews suddenly clear from the hospital over the radio. “They scatter like cockroaches,” supervisor Grant told me as a couple of units cleared when we pulled into a busy ambulance bay. But from the standpoint of crews, many of whom are forced to work past their 12-hour shifts and are frequently denied meal breaks, they are simply carving out breaks in a busy 911 system stacked with bullshit calls. As one paramedic put it, “What’s the fucking point (of clearing the hospital early)? We’d just be rushing to more bullshit down the street.”

This nexus of bureaucratic and capitalistic forces from atop the ambulance helps explain why crews regulate bodies in spaces over spaces in bodies. Official protocols encourage MRT to deploy ambulances into areas with the greatest demand and generally provide services to anyone who requests and requires them. This promotes treatment and transport for those with legit emergencies, like the homeless campers crushed by a car, but also for those with more bullshit complaints, like the man who seemingly faked or exaggerated the severity of his breathing difficulties. With crews disproportionately sent to populations experiencing intense social suffering and tattered safety nets, it is perhaps not surprising that ambulance riders seek a broad spectrum of assistance from one of the few institutions the state more or less promises them. But while protocol explains why crews have to work bullshit, the motives and practices of MRT management better explain why any one crew works so much of it. The EMS bureaucracy forces MRT to send ambulances into largely unprofitable areas and, in an effort to lessen the economic pain of this mandate, company management attempts to deploy the leanest fleet possible.

These vertical forces also help contextualize burden shuffling. Crews, disgruntled by the amount of bullshit they have to run, seek strategies to lighten their workloads. In addition to slowing production by extending their hospital drop times, crews often attempt to unload undesirable work onto others, and they frequently try to prevent such work from landing in their rigs. Crews attempt to block the clientele police try to shove into the ambulance, and they dump stable patients onto nurses at emergency departments that will make their shifts easier (e.g., away from so-called ghettos and hoods). Crews are propelled into lateral conflicts over burden shuffling at least in part because an intermingling of bureaucratic and capitalistic forces overwhelms them with bullshit. Moreover, a sense of vocation may galvanize crews to work calls involving a deep and technical regulation of spaces in bodies, but no comparable moral drive motivates them to regulate bodies in spaces. Overwhelmed and “run to the ground” by the circumstances of lean production, crews seek to minimize their workload, and this often puts them in conflict with other street-level bureaucrats.

Conclusion: The Labor Theory of Poverty Governance

The ambulance is a unique but revealing case of poverty governance in U.S. cities. Its crews regulate spaces in bodies and bodies in spaces. Such labor positions the ambulance between the Left-handed hospital and the Right-handed squad car. This is a positioning defined in large part by tension and conflict. Horizontal struggles between ambulance crews and their nurse and police counterparts are frequent, and when they occur they typically involve clashes over burden shuffling. A combination of bureaucratic and capitalistic forces also generates the conditions for a lean fleet. This establishes a vertical struggle between crews and those who control and coordinate their labor, and it fuels conflicts between crews and other governance workers. It is through these circumstances that the ambulance processes a mostly poor clientele.

This article contributes to existing scholarship in multiple ways. By spotlighting an overlooked institution, this study adds the ambulance to a long list of poverty-regulating institutions. Beyond reconceptualizing the ambulance, this study also locates this institution, clarifying a larger field of forces in the process. Building on Wacquant’s (2009) articulation of Bourdieu’s (1998) ambidextrous state, this study positions the ambulance between the protective Left hand and the punitive Right hand of poverty governance. However, by focusing on how poverty regulation is made daily, this study reveals common struggles neglected by Wacquant: struggles over the distribution and efficiency of governance labor. In several respects, this article extends Lipsky’s (1980) vision of street-level bureaucracy: vertically organized institutions where semi-agentic workers process indigent populations and connect them to a scarce supply of state goods and services. But, where the bulk of street-level bureaucracy research links labor to state authority, my ethnography contributes to a smaller but growing literature that links street-level governance to interactions between bureaucracy and capital (Sears 1999; Soss et al. 2011). Unlike Lipsky but like Lara-Millán (2014), this study accounts for horizontal relations between workers of different street-level bureaucracies. Differing from the latter, however, this study also examines germane vertical relations between workers and the actors who control and coordinate their labor. In short, this study is novel in that it examines three dimensions of poverty governance—its labor, its horizontality, and its verticality—simultaneously and in intersection.

My analysis establishes a versatile set of concepts and motivates what I call the labor theory of poverty governance. As stated earlier, this model offers three general claims. First, the poor are governed across these dimensions: the labor of governance, the horizontality of governance, and the verticality of governance. Put another way, poverty governance includes both a practical and a relational component. Second, these dimensions are intersectional and interdependent. Throughout this case study, I have insisted that no single dimension of governance should be understood without reference to the other two. This is why, for example, ambulance crews’ horizontal struggles with police (e.g., burden shuffling) only make sense relative to the productive projects these workers share (e.g., the regulation of bodies in spaces) and the vertical circumstances under which crews labor (e.g., the lean fleet). Third, it is through these intersections that the poor’s life chances are extended or severed. This is perhaps most obvious as labor, doubly caught in hierarchical and lateral struggles, funnels people from the streets to hospitals or jails.

Of course, significant variations in the subjects of governance, institutional autonomy, and other conditions limit the applicability of this model. This is especially true for the specific concepts presented through this case study and their suggested correspondences. For example, the regulation of spaces in bodies may not always be as Left-handed as suggested from the back of an ambulance (e.g., compulsory sterilization in the past and bureaucratically reinforced barriers to abortion in the present). Likewise, the regulation of bodies in spaces may not always be so Right-handed (e.g., Housing First programming as a nonpunitive response to chronic homelessness). However, the general insistence that the poor are governed through labor processes embedded in horizontal and vertical relations may advance our understanding of a wide variety of cases. And, through empirically and theoretically informed revisions, the three analytic constructs proposed through this examination of the ambulance (i.e., spaces in bodies and bodies in spaces, burden shuffling, and the lean fleet) may be transferable to a variety of sites. Consider the relevance this study might have for two massive institutions of poverty governance in the United States: the welfare office and the prison.

More folk term than official title, the welfare office is typically realized as a branch of a local human services bureaucracy. In addition to connecting their clientele to forces that broker a regulation of spaces in bodies (e.g., Medicaid, detox services, nutritional assistance), caseworkers directly perform this regulation through their efforts to inspire responsible, entrepreneurial, and self-governing subjectivities among their clientele (Korteweg 2003; see also Pulkingham, Fuller, and Kershaw 2010). Caseworkers also regulate bodies in spaces (e.g., workfare programming as an effort to bind able parents to the sites of low-wage labor). The theory assembled here suggests that lateral relations between overwhelmed street-level bureaucrats account for a crucial dimension of poverty governance. Caseworkers, for example, may engage in a struggle like burden shuffling with the Left-handed agencies they refer clientele to and with the Right-handed agencies with whom they share jurisdiction (e.g., for subjects who receive public assistance but are also under parole supervision). When applied to the welfare office, the labor theory of poverty governance also calls for an examination of bureaucratic authority (e.g., the use of strict performance standards for caseworker labor) and capitalistic influence (e.g., delegating specific operations like Medicaid administration to capital and the absorption of market principles into bureaucratic operations through strategies akin to lean production).

A labor theory of poverty governance may also demystify the prison. Despite claims that the U.S. penitentiary is like a “warehouse,” prison laborers do more than a cold maintenance of bodies in spaces. Indeed, correctional officers work to keep inmates in cells, rotating them daily through the spaces of the cafeteria and the yard and punishing them for incompliance (Lombardo 1989; see also Crawley 2013; Liebling, Price, and Shefer 2010). However, the prison is also a place for regulating spaces in bodies. Nurses (Weiskopf 2005), counselors (Fry 1990), and life skills instructors focused on transforming prisoner mindsets (Seim 2016) compose a consequential, albeit understudied, part of the correctional labor force. The theory proposed in this article suggests that we cannot understand the practical component of carceral labor without also analyzing the horizontal and vertical relations through which penal governance occurs. In addition to importing subjects from courts and jails and later exporting the bulk of these people into parole offices, the penitentiary is likely internally structured by the intramural relations between correctional officers, in-house drug counselors, educators, nurses, and other laborers who make and maintain prison operations. The labor theory of poverty governance also specifies a vertical dimension of the penitentiary. And while the hierarchical relations between inmates and staff that sociologists have long focused on are important (Clemmer 1940; Sykes 1958), the theory proposed here is equally concerned with relations between staff and the actors who control and coordinate their labor.

Whatever its capacity to inform other cases, it is important to distinguish the labor theory of poverty governance from some of its parental frameworks: street-level bureaucracy and a theory of (bureaucratic) fields. Consistent with Lipsky (1980), this theory claims that governance is made by semi-discretionary agents who act in reference to forces above and below them. However, the labor theory of poverty governance deepens the analysis of production by deconstructing the subjects of labor, revealing a more complicated network of production in the process. The proposed theory extends the once innovative claim that policy is made from the ground, but it focuses more deliberately on what is actually transformed by frontline workers (e.g., spaces in bodies and bodies in spaces). This suggests a horizontal vision of governance where street-level bureaucrats struggle over productive tasks across locations and professions. Since the beginning, street-level bureaucracy scholars have claimed that multiple frontlines are managing the poor, but only a few studies highlight the sideways interactions between workers of distinct vocations (Hupe and Hill 2007; Lara-Millán 2014). In examining the everyday productions of a splintered and ostensibly hollow state, the labor theory of poverty governance assumes its people-processing sites are variably porous. This theory insists that lateral struggles between workers affect the life chances of the poor in ways inexplicable to models narrowly focused on the vertical conditions of governance labor.

This theory also works with and against a specific vision of the bureaucratic field and a more general vision of social fields adopted throughout sociology. The labor theory of poverty governance thinks in terms of multidimensional relations and assumes state power is embedded in, and exercised through, vertical and horizontal struggles. It generally accepts a hierarchical separation in higher and lower state nobility and a lateral distinction between the protective Left hand and repressive Right hand of the state (Bourdieu 1998, 1999; Wacquant 2009). However, this theory concentrates on the practical and relational components of a labor process. Unlike field theory á la Bourdieu and its various iterations across organizational, economic, and political sociology (see Kluttz and Fligstein 2016), the definitive social relation for the labor theory of poverty governance is not an endless struggle over relative position. The labor theory of poverty governance does not examine actors or sets of actors competing for the material and symbolic capitals that supposedly structure a field from top to bottom and side to side. This theory holds that the poor are regulated not just by people vying over different forms of capital, but also (and perhaps more so) by people caught in vertical and horizontal struggles over the labor of governance. This motivates the construction of analytic maps that are both familiar and foreign to field theory (e.g., Figure 2).

Returning to the ambulance, we find a significant institution for governing the poor. Its sirens echo in the poorest sectors of the metropolis more than anywhere else. The ambulance does not process the poor in isolation, but rather through its interactions with other institutions across the welfare and penal states. Moreover, interactions between bureaucracy and capital significantly steer this street-level bureaucracy on wheels. To make sense of this institution, I have focused on the practical and relational components of what makes and re-makes it daily: a labor process. The labor theory of poverty governance proves to be a useful tool for analyzing the ambulance specifically, and it seems to be a promising model for explaining how the poor are governed generally.