Three Types of Memory in Emergency Medical Services Communication

Abstract

This article examines memory and distributed cognition involved in the writing practices of emergency medical services (EMS) professionals. Results from a 16-month study indicate that EMS professionals rely on distributed cognition and three kinds of memory: individual, collaborative, and professional. Distributed cognition and the three types of memory reduce cognitive workload during a 911 response, and they help evoke information as an EMS professional composes the legally binding patient care report. In addition to presenting results, the article details the author’s interaction with two institutional review boards, which influenced the study’s methods. The article argues that scholars should conduct more research on the collaborative and distributed nature of memory as it relates to workplace writing practices. Furthermore, the article calls for developing writing research methods that involve participant recollection.

Keywords

distributed cognition individual memory collaborative memory professional memory workplace writing medical rhetoric locations of writing institutional review boards

On a daily basis, all medical professionals communicate to care for patients. In many medical workplaces, medical care and communication occurs within one confined location: a hospital, a medical office building, or a clinic. Unlike other medical professionals, emergency medical services (EMS) professionals treat patients and communicate outside the confines of hospital or medical office walls.¹ EMS professionals communicate important information despite time constraints and rapidly changing locations in an ambulance. These constraints affect their ability to document patient information, and in turn, they must remember information until they can record it. In this article, I examine the writing and memory practices of EMS professionals to better understand how memory functions in these workplace communication practices. I present results from a 16-month study in which I examined EMS professionals’ written and verbal communication practices. I situate these results in the theoretical frameworks of memory and distributed cognition, frameworks that scholars have used to understand how we complete writing tasks (Haas, 1996; O’Hara, Taylor, Newman, & Sellen, 2002; Ong, 1986; Reynolds, 1989; Wickman, 2010) and interact with our environment (Bannon & Kuutii, 1996; Crowley, 1990; Halbwachs, 1992; Hollan, Hutchins, & Kirsh, 2000; Horner, 1988; Yates, 1966).

Results indicate that shifting locations and rapid response times force EMS professionals to rely on their external environment and three types of memory: individual, collaborative, and professional. I argue that EMS professionals’ use of memory assists written communication scholars because EMS professionals utilize two types of memory that would benefit from more examination: collaborative and professional. The three types of memory work with distributed cognition to assist EMS professionals when integrating multiple sources of information to document a patient’s care. To support these claims, I first provide background on EMS, distributed cognition, and memory. I then discuss my research methods and major findings regarding individual, collaborative, and professional memory. Last, I discuss the implications of this work.

Literature Review

EMS Communication and Documentation

To clarify the connections among time, location, and memory that I found during my study, I first review a 911 response. A response lasts, on average, 10 to 20 minutes and has six stages that involve many people (see Figure 1; Limmer & Le Baudour, 2006).

Figure 1.

The locations and people involved in the six stages of one EMS response.

In the first stage, a 911 dispatcher contacts EMS over a radio.² Dispatch tells EMS about the patient, the patient’s condition, and her location. In the second stage, EMS travels to the scene. During this stage, EMS is on the ambulance and communicates with dispatch via the radio or the computer-aided dispatch system, a dashboard-mounted laptop that gives EMS up-to-date patient and location information. The third stage begins once EMS is on scene at the patient’s location. Once on scene, EMS speaks with anyone who has information about the patient, including the patient, family members or friends, bystanders, or the police. After EMS gathers enough information, they treat the patient and load her into the ambulance; this location shift begins stage four, which occurs on the ambulance.

During the fourth stage, one EMS professional drives the ambulance and may speak with dispatch to update them on ambulance location and patient status. The other EMS professional treats the patient in the back of the ambulance; this EMS professional becomes the lead on the response. The lead speaks with the patient, if the patient is conscious, and calls the destination hospital to speak with staff about the patient’s condition. At this stage, the lead may also speak with the emergency department (ED) physician to receive medical instructions or approval for nonstandard treatments; this instruction and approval is called medical direction.

The fifth stage begins at the hospital. EMS transfers the patient’s care to the receiving hospital staff, including a physician and nurses. Once the receiving hospital staff has the information they need, EMS returns to the ambulance where three things may happen: they may complete electronic documentation about the response, they may drive back to their office (“squad”), or they may be dispatched to another patient. Figure 1 includes the term “squad” because that name best reflects a textbook response if EMS is not dispatched to another patient. During the sixth stage at the squad, the lead documents the response.

An EMS response usually ends at a squad, but the response can restart at Stage 5, the hospital. In Figure 1, I use a thin, dark arrow between Stages 5 and 6 to represent this connection. Oftentimes during my study, the EMS professionals with whom I worked were dispatched to another location while they were at the hospital. At this time, Stages 1 and 5 overlap. EMS receives the dispatcher’s call over the radio and proceeds to the patient’s location (see Figure 2). As a result, EMS may not be able to document a response right after it ends. It may be hours until an EMS professional can return to a computer to document a response. To respond to their unpredictable workplace, EMS relies on different types of memory to write the required patient care report (PCR).

Figure 2.

Connection between individual EMS responses.

The PCR is a paper-based or electronic legally binding document that an EMS professional completes at the end of a response. EMS documents all pertinent information from the response: a patient’s location, vital signs, medical treatments that EMS performs, and additional information provided by a patient’s family members, witnesses, or other emergency personnel. The PCR can have legal implications because it contains the only written account of a response (Munger, 1999, 2000). Documenting information accurately and thoroughly is vital for a patient and EMS because the PCR follows a patient throughout her medical treatment and beyond:

Hospital staff may refer to it during a patient’s hospital stay

The patient’s primary care physician may use it to continue medical care

Insurance companies may use it when billing a patient

Social services may read it to learn about the patient’s living conditions

A lawyer may consult it if a patient pursues legal action

If a patient pursues legal action, an EMS professional must refer to it while testifying

EMS documentation, then, is rhetorical. EMS professionals write with these audiences in mind. They must document as much information as possible because these audiences need specific information that depends on the audience’s unique situation. This keen rhetorical ability relies on an EMS professional’s ability to remember information throughout a response. Figure 3 outlines the types of information that communicators share and that EMS remembers during a response.

Figure 3.

Information EMS remembers or writes down at each location.

An EMS response creates and contains a large amount of information. EMS has the opportunity to be with patients throughout a response and gather pertinent information. Other health professionals rely on EMS’s information to treat a patient because these professionals are not privy to information that may impact a patient’s future care. As a result, EMS is responsible for communicating location-specific information to other health professionals. Without an EMS professional’s ability to remember information, health providers may compromise patient care. To that end, time and location dictate EMS professionals’ documentation practices and influence their use of memory in their composition process.

Distributed Cognition

Distributed cognition offers a useful framework to understand how memory interacts with the EMS workplace. EMS professionals restructure, retain, and reorder information that they gain from their external environment. During my study, I found that my participants’ use of memory aligns with Fentress and Wickham’s (1992) definition of memory: “a process of active restructuring, in which elements may be retained, reordered, or suppressed” (p. 40). This definition relates to distributed cognition: the ways in which cognition interacts with the external environment, including the interaction with resources and artifacts used to reduce cognitive workload (Hollan et al., 2000). People use their external environment and artifacts to minimize workload, say, by using notes for a research paper. People then refer to these artifacts to restructure and remember information to complete a task, such as writing a research paper.

Learning and knowledge making are situated activities, a concept that Brown, Collins, and Duguid claimed in 1989. Drawing on activity theorists, they called for a theory of situated cognition that recognized the important influence of context on learning and cognition. Writing scholars will recognize this notion in the landmark work of Flower and Hayes (1981). Flower and Hayes identified a writing process model based on cognition, which had three main interweaving processes: planning, translating, and reviewing.

Flower (1990) extended this model, and of importance to distributed cognition, she detailed the noticing and evoking stages of the writing process. In these stages, writers notice cues from their environment, which then evoke memories. These stages connect context, memory, and the writing task and process. Writers integrate recalled knowledge that is evoked from noticing it into a piece of writing. O’Hara et al. (2002) extended Flower’s and others’ work through the distributed cognition framework. O’Hara et al. studied how writers integrate multiple sources of information during the writing process. They found that the composition process is a “hybrid task” that involves cognition distributed throughout the external environment, for example, through annotations, spatial layout of sources, and paper and electronic versions of a document. External cues, like annotations, allowed writers to fully reconstruct a document when composing.

Hutchins (1995, 2005) referred to these external cues and artifacts as material anchors. Individuals “map” concepts onto elements of the external environment, elements that are stable entities. To illustrate material anchors, Hutchins (2005) used the example of loci, or places. He traced the use of loci before Aristotle, citing the Trobriand Islands of Papua New Guinea. Villagers used geography—places—as mnemonic devices to recall myths (Harwood, 1976) and learn about the local landscape (Hutchins, 1987).

Today, we may see this use of loci as distributed cognition, given the theory’s emphasis on using the external environment to aid recall. Yates (1966) draws on Cicero, Quintilian, and Rhetorica ad Herennium to remind us that memory is tied to loci. By linking an object to a location, a rhetor’s “conscious attention” is free to attend to other matters (Haas, 1996). The rhetor—or writer—relies on memory, knowing that the object or item he recalls will be in the same “location” once he needs the information.

Types of Rhetorical Memory

Scholars in rhetoric and related fields have noted that memory is made up of three types: individual, collective, and cultural. Individual memory refers to memory instilled in a person, what classical rhetoricians call “natural memory,” humans’ innate ability to remember information. Natural memory is the opposite of what classical rhetoricians called “artificial memory,” the techniques used to improve natural memory.

Collective memory is made up of the “individual recollections” of a group of people (Halbwachs, 1992, p. 54). It is socially constructed and refers to a group’s identity. A social class, family, neighborhood—any group—creates its identity through their shared memories. Other scholars have built on this notion, saying that texts and social interaction mediate collective memory (Wertsch, 2002) and that collective memory is embodied in gestures, clothing, and performance (Connerton, 1989). Connerton’s (1989) account of collective memory, though, took the notion one step further. He examined how different groups share collective memory and pass it to future generations, moving into the third type of memory: cultural.

Cultural memory exists on a larger, social scale than collective memory. It ties the present to the past through all resources, including books, photographs, artwork, and commemorative ceremonies (Connerton, 1989; Horner, 1988). Cultural memory is open to the public domain and can serve as a culture’s memory of events, time, and space. Through cultural memory, the public comes to know a culture; culture is open to interpretation.

Collective and cultural memory are beyond this discussion of EMS professionals’ use of memory. Instead, EMS uses collaborative memory and what I call professional memory, which is comprised of textbook knowledge and protocols EMS professionals learn during training. Collaborative memory refers to the process of individuals working together on the same task, remembering pieces of information, and gathering that information together to complete an activity (Andersson, Helstrup, & Rönnberg, 2007; Rajaram & Pereira-Pasarin, 2010). Individuals rely on each other to recall information and, in the case of EMS, document. Although writing studies scholars have not yet examined collaboration and memory in this way, writing researchers have shown that collaboration positively impacts the writing process and product (Ede & Lunsford, 1990; Higgins, Flower, & Petraglia, 1992; Storch, 2005). Collaborative memory, I argue, is closely tied to goal-oriented action and distributed cognition, as I outline below.

My goal in this article is to illustrate the relationship among the three types of memory, distributed cognition, and writing practices. Communicators who work in unpredictable workplace environments rely on three types of memory and the external environment to facilitate workplace communication. EMS’s rapidly changing workplace necessarily impacts their written communication practices and their memory interaction with it, as I demonstrate next.

Method

The results I present here are from a larger research project. For this larger project, I used ethnographic research methods of interviews, surveys, and participant observation. Data collection spanned 16 months (see the appendix for a description of interview questions). Prior to this study, I was enrolled in an EMT-Basic (EMT-B) course, and I earned my EMT-B certification a few months after I began research. Once I received institutional review board (IRB) approval, a lengthy process that I detail in this section, I started using participant observation in my EMT class. I took field notes after my classes, which ran for 4 hours, two nights per week for 6 months. Following state regulations, I worked 24 hours in the ED and 24 hours on an ambulance. I treated patients under the supervision of a certified EMS professional or registered nurse. At the end of the course, I passed two state tests, one written and one practical, and became a certified EMT.

Due to the nature of the research site, my methodological approach needed to accommodate IRB and Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule regulations. I could not videotape or audio-record my fieldwork. Because I was an EMT student while conducting fieldwork, I could not make field notes while caring for patients. Instead, I recorded these notes after clinicals ended for the day and used my patient notes to help recall events. I used surveys and interviews to triangulate my field notes.

The Research Site

My research site for this study was Lochville Emergency Medical Services (Lochville).³ Lochville provides EMS care for a midsized Midwestern county, and the organization is primarily housed in one of the county’s hospitals, River View Hospital (River View). Lochville also has locations, called squads, throughout the county. These squads function in much the same way as firehouses function: They serve as a place for Lochville employees to work, eat, and sleep when they are not responding to patients during their shifts. The squads include ambulance garages where Lochville employees park and maintain the vehicles.

Participants

Participants (N = 15) included 10 Lochville EMS professionals, 1 River View ED physician, 2 River View ED nurses, and 2 River View ED technicians. I recruited participants by asking Lochville EMS professionals I had worked with during my clinicals. Lochville’s medical director also helped me by introducing me to Lochville staff during a meeting; he also forwarded recruitment emails over the Lochville listserv.

Participants reported 6 months to 31 years experience in EMS and emergency medicine. Three participants held multiple roles in emergency medicine, including working as an EMS professional and a nurse. All participants completed a survey, and 12 agreed to follow-up interviews. I interviewed participants in classrooms at the nursing school, in empty offices at the hospital, or at a squad. Participants completed surveys on their own time and returned them to me in person or by mail. Observations occurred in the EMT classroom, which also served as the staff meeting room, practice rooms, and ambulances.

The IRB

Before I discuss the specific methods I used to study Lochville, I must explain the complex IRB review processes that were involved in this study. My university’s IRB and River View’s IRB played formative roles in this project, and rightly so; I worked with patients, HIPAA, and patients’ protected health information (PHI).⁴ I worked closely with both IRBs to gain approval for my study. I detail my experience with these IRBs for two reasons. First, my experience with them shaped and limited the study’s scope. Second, I share this experience to illustrate the challenges and rewards of this type of research.

This study was the first of its kind that River View had encountered. The hospital IRB was used to reviewing medical research inside the hospital; no one before had been interested in communication that occurred inside and outside of ambulances. As such, the hospital’s approval process was more involved than the university’s process, which resulted in delays.

The start of the study was delayed because neither IRB would approve it before the other IRB would approve. From the university’s perspective, the hospital was more liable and held more responsibility for the study because the hospital and its associated EMS unit, Lochville, were my research sites. From the hospital’s perspective, I was working for the university and thus needed their approval before the hospital could approve the study. After 2 months of back-and-forth between the two IRBs, the university IRB approved my research plan for participant observation, surveys, interviews, and ambulance ride-alongs so that I could proceed with the hospital IRB review.⁵ I continued with the hospital’s approval only to learn that their review process was much more involved than my university’s process.

Due to the nature of my project and the number of people involved in the approval process, the hospital IRB review process resulted in two phases: Phase 1 included gaining approval for participant observation, written surveys, and audio-recorded interviews; and Phase 2 included gaining approval for the ambulance ride-alongs. During the first phase, I attended an IRB meeting during which I presented my study to the hospital IRB board. I told the board that I wanted to engage in ride-alongs with Lochville. These ride-alongs would have occurred after my EMT course ended, and I would no longer be an EMT student at the hospital. Because I would no longer be a student, I was not be covered under the hospital’s insurance. This detail raised a liability issue for the hospital, and I was instructed to talk to the hospital lawyers. Discussions with the lawyers started Phase 2 of the IRB approval process. The hospital IRB board, though, found that the other parts of my research fell within acceptable IRB guidelines, and the board approved the participant observation, survey, and interview methods. I began collecting that data.

During Phase 2, I worked closely with the hospital IRB board members, the hospital’s lawyers, and Lochville’s medical director to pursue nonclinical ride-along approval. I obtained the necessary documentation, which included a waiver of informed consent for the patients who would be on the ambulance during observations. I submitted my waiver request and did not hear back from the hospital IRB for a few weeks. I continued collecting and analyzing data from field notes, surveys, and interviews.

Despite numerous emails and discussions with hospital and IRB staff, I did not hear back from the IRB regarding nonclinical ride-alongs in time to participate in them. Six months after I submitted my waiver request, and completed and analyzed field notes, surveys, and interviews, the hospital’s IRB administrative assistant emailed me my waiver request approval letter. Apparently, the board had approved my request 3 months prior; I was told that the letter was buried under paperwork on someone’s desk. Due to this procedural delay, I was able to collect only survey and interview data and field notes from my clinical experience. I was not able to collect observational data during nonclinical ride-alongs.

The results I present here are based on participants’ audio-recorded interviews and my field notes. In interviews, participants relied on their memories to recall their written and spoken communication practices. I, too, relied on my own memory because I wrote my field notes after my clinical ambulance training. Per the hospital IRB’s guidelines and my commitment to patient care, I could not write field notes during clinicals because I was taking care of patients. I jotted down notes when I could and wrote or audio-recorded field notes after my shift ended.

Participant Observation

The initial participant observation portion of this research spanned 7 months. During this time, I learned about EMS culture before I invited EMS professionals to participate in the study. The locations in which I engaged in participant observation were classrooms, practical rooms where classmates and I practiced EMS skills, ambulances and patient locations, and the ED where I cared for patients alongside nurses and physicians. Additionally, after completing surveys and interviews, participant observation included attending Lochville’s monthly staff meetings. During these meetings, EMS administrators, educators, the medical director, and guest speakers discussed current issues in EMS and changes to protocol and documentation practices. My experiences in these locations also aided in developing surveys and interview questions, which I collected over 3 months. Participants’ responses to survey and interview questions shaped my initial observations; I came to better understand these experiences during my clinicals, which helped me better understand EMS writing practices.

Surveys

Participants worked in varying capacities within emergency medicine, and I created different surveys based on the participant’s occupation: EMS professional or hospital staff. The questions focused on their communication practices related to EMS. For example, for EMS professionals, I asked about their communication practices through a whole response. For hospital staff, I asked about their communication with EMS instead of their communication practices with physicians, radiologists, or intake specialists. I distributed surveys in person or dropped them off in a hospital mailbox for participants. Participants either completed the surveys in person and returned them directly to me, or they completed them on their own and mailed them to me in a self-addressed and stamped envelope that I gave them.

Interviews

Twelve participants agreed to audio-recorded, one-on-one, semistructured interviews, which lasted 46.2 minutes on average. Similar to the surveys, I asked participants questions based on their role in EMS and additional questions based on their responses to the prepared questions.

The first part of interviews followed the critical decision method (CDM) model. CDM was designed to study participants’ recollections of events and decision-making process in inaccessible situations, including firefighting (Hoffman, Crandall, & Shadbolt, 1998), air traffic control (Wickens, 2000), aviation (Williams, 2002), and emergency medical dispatch (Blandford & Wong, 2004). This model relates to situation awareness: how we perceive different parts of our environment, interpret them, and project how these parts might look in future situations (Endsley, 1995). Blandford and Wong (2004) used CDM to study emergency dispatchers. In interviews, dispatchers recalled a “memorable incident,” reflected on the incident, and developed a timeline for it using paper and pencil (p. 427). This recollection method is necessary when researching workplaces that prohibit observations or are protected by regulations like HIPAA. These regulations often prevent scholars from researching synchronous communication, and CDM and other recollection methods offer insight into these workplaces despite regulations.

I modified CDM to account for not being able to participate in nonclinical ride-alongs. I asked EMS participants a CDM-based question: “Think of a typical 911 call. Using this sheet of paper and pencil, develop a timeline or a sketch for the call writing down the people you speak with and what you tell them.” I adjusted the question when interviewing other emergency medical professionals. For example, I asked the ED nurse, “Think of the moment when EMS arrives at the ED to transfer patient care.” All participants drew a sketch, and I then asked, “Using this highlighter, highlight what information you document in your paperwork.” This question served two purposes: to prompt participants to situate themselves in a “typical” 911 call and to illustrate the relationship between spoken and written communication throughout a response.

In their responses to the rest of the questions, participants further reflected on their spoken and written communication practices. I asked participants how they learned to communicate and document information. Their answers, as I explain below, highlighted the vital role of memory in these practices.

Data Analysis

I analyzed field notes, survey responses, and interview transcripts using grounded theory (Corbin & Strauss, 2008; Creswell, 2009; Lindlof & Taylor, 2002). I used memory and distributed cognition as guiding theoretical frameworks for analysis, and they helped shape the theory that emerged—that communicators who work in unpredictable workplace environments rely on memory and the external environment to facilitate workplace communication. However, I was open to different ideas or concepts that emerged during analysis (Corbin & Strauss, 2008). As a result, I learned that Lochville EMS professionals rely on individual memory, a well-developed concept in scholarship, but they do not rely on cultural or collective memory. By remaining open to different ideas, I learned that Lochville EMS professionals rely on collaborative and professional memory as a result of their communication practices.

Coding Scheme

The coding schemes and results I present here are based on interview transcripts and field notes. I used NVivo for Mac to code data. The categories that emerged from data were individual, collaborative, and professional memory, and each of these categories contained codes (see Table 1).

Table 1.

Coding Scheme.

Category	Definition	Code	Explanation, example
Individual memory	The ways EMS professionals take in information, observe, and remember information during a response. Includes EMS’s reliance on their external environment to write and reduce cognitive workload.	Observations	Patient location, visual cues: “50% of your information comes from what you see when you walk in—at least—even though it’s only about five seconds.”
		Notes	Writing methods and purposes of making notes: “I make notes, and then I have them with me. Or I’ll write it on the back of a gauze pad or a bandage pack from the ambulance, whatever we’ve got, just so I have some notes to go by.”
		Learned experience	Decision making and intuition that EMS professionals developed over time; this experience helped them remember information and decide what information was important to document: “But you can kinda visualize in your head what’s going on, what this person on the other side is experiencing. Because you’ve seen it before, you can kinda start drawing a picture in your head.”
Collaborative memory	People who provide information to EMS professionals when they treat the patient and document the response. Includes EMS’s reliance on their external environment to write and reduce cognitive workload.	Patient	Refers to person receiving EMS care: “Typically what we’ll do is, obviously, we’ll try and talk with the patient: ‘Hey, tell us what happened.’ And that’s the best source of information, obviously: the person that’s having the problem.”
		Partner	The EMS professional with whom the participant worked: “Because maybe she’s talked to the family while I’m talking to the patient, so then I can say, ‘Hey, what did you find out?’ and she can say, ‘Well, he takes his medication,’ when he said he didn’t, or whatever.”
		Other emergency units	Emergency or medical personnel already on scene, including police, fire, volunteer EMS, or nursing home employees: “The first person that greets us is a fireman, and then he tells us what he finds, vital signs if they’ve been there for a while, and then [he] lets us know kind of what’s going on.”
		Bystanders	Individuals on the scene who were not working in an emergency or medical capacity, including family, friends, and witnesses: “Or the patient may not be able to communicate, so we may only have the caregiver. Or we may have no one to communicate with from a verbal standpoint, so we’ll communicate with the people on scene to make those decisions, and then do what we need to do, communicate with help on scene.”
		Dispatch	911 employees who received the 911 call and told the EMS squad to respond to the patient: “I think, for the call, a bit more detail, and so you also will get contact with dispatch when you say en route; they’ll give you a little bit more detail as they come in, if they’re available.”
Professional memory	Knowledge gained in a professional setting that all EMS professionals share, including textbook knowledge, protocols, and information learned in class.	Protocols, guidelines	Standardized medical protocols: “You have your protocols, which will help you, guide you through a run.”
		Format, script	Professional knowledge that may not be formally taught but learned through experience: “So there is a little bit of a script with like arriving on scene or going en route or transporting to the hospital.”
		Classroom-based knowledge	Material learned in the EMS training class. This material is standardized at a state and national level: “They’re almost kinda like . . . they’re functional, they’re part of the official structure of communication in EMS for a call, it’s stuff that is taught in our books.”

Participants mostly discussed the large amount of information that they received throughout a response. I did not code for information that participants shared with other medical professionals, like nursing staff at the hospital. To reduce data, I focused my data analysis on the information Lochville EMS received and remembered rather than gave.

Limitations

My research process was limited by not being able to collect data from nonclinical ride-alongs. As such, my results and data are based on participants’ recollections and my field notes. Ideally, I would have observed how EMS professionals write during the second phase of my study. I was, however, able to watch Lochville EMS professionals write their PCRs and use the three types of memory when I completed my clinical training, during which time I made field notes.

The results I present below are based on my work with one research site. Though some results cannot be generalized, they might apply to other EMS squads. EMS squads must meet national standards, regulations, and practices. These aspects include medical terminology and abbreviations, select protocols (e.g., American Heart Association’s CPR), and the focus on excellent patient care and documentation. Although these results may apply to EMS in general, I hedge against generalizing my results, and I focus on Lochville.

Results

I present three results that illustrate how EMS professionals use memory to distribute, communicate, and document their work. In interviews, participants acknowledged how location and time constraints limit and facilitate their writing process. To address these limitations, all participants relied on memory when writing a PCR. Based on my data analysis, as well as the scholarship in memory and distributed cognition outlined above, I organize results into three categories of memory:

Individual memory: Lochville EMS professionals’ individual remembered accounts of the 911 response and location of response events

Collaborative memory: people who provided information to EMS professionals when they treated the patient and documented the response

Professional memory: the protocols, guidelines, and unofficial scripts that Lochville EMS professionals followed during responses

Table 2 contains the number of references participants made to each category and code. Each participant referred to all three categories, though not all participants referred to each code.

Table 2.

Codes and references in interview transcripts and field notes.

Category	Number of references	Code	Number of references
Individual memory	36	Observations	10
		Notes	14
		Learned experience	7
Collaborative memory	43	Patient	11
		Partner	12
		Other emergency units	11
		Bystanders	11
		Dispatch	13
Professional memory	30	Protocols, guidelines	8
		Format, script	10
		Classroom-based knowledge	18

As Table 2 illustrates, participants referred to collaborative memory most often. For the most part, though, the references to each code were fairly evenly distributed, with the exception of professional memory; participants relied heavily on classroom-based knowledge. In this section, I detail each type of memory and how participants used each type to treat patients, communicate information, and document a response.

Individual Memory

Individual memory refers to methods that Lochville EMS used to aid recall and reduce cognitive workload. When participants referred to individual memory, they discussed the importance of observation, personal note-taking methods, and learned experience. Participants referred to individual memory 36 times.

Observations

When participants were unable to write, they relied on their ability to gather information based on their observations at specific locations. When first arriving at a patient’s location, participants observed the patient and committed that information to memory so they focused all attention on the patient. During the first stages of the response, participants tried to decrease the patient’s stress and anxiety; therefore, they focused on the patient during those first stages and not necessarily on recording information on paper.

Observations played a key role in individual memory. A paramedic, Marie, commented that she wishes she had realized earlier in her career just “how much attention you need to pay to detail to give a truly accurate picture.” Another participant, Sam, an EMT-B, gave a more quantified response to how much information he observes at the start of a response: “50% of your information comes from what you see when you walk in—at least—even though it’s only about five seconds.” The information Sam referred to includes the patient’s age, sex, and weight; medical conditions, including medical jewelry, medication, or hospital beds; current conditions, such as an unkempt house or a car accident scene; and signs of events that contributed to the condition, such as evidence of physical abuse or the smell of alcohol. Participants remembered these observations while they treated, transported, and transferred a patient’s care to hospital staff.

Observations allowed participants to alert other health care providers of health concerns. For example, participants noted a patient’s current situation, like a patient’s living conditions. Participants had insight into potential contributions to a medical condition because they were the only medical professionals who entered a patient’s original location. One ED nurse, Larry, stated that these observations are especially important when a patient is in a car accident:

[If] you’ll just take a listen to the paramedics, you’ll get a good idea of the mechanism and what forces that patient went through. And there have been times I’ve had paramedics look at me and say . . . “[Larry], the car looked like this.” . . . And then right away I’m starting to think, “Okay, there’s probably underlying processes under the skin that we really need to be on top of and watch this patient more closely.”

This response illustrates that both EMS professionals and other medical professionals relied on EMS professionals’ observations of a scene. A patient’s treatment depended on it.

Similarly, if a patient’s living conditions suggested that a patient needed extra support, for example, from a home nurse, participants observed the patient’s living conditions, remembered it throughout a response, and documented that information in the PCR, as Joe related:

I’ll put additional information that doesn’t pertain at all for the treatment modality that the nurse needs to go through. . . . “Hasn’t checked his blood sugar in six months” or “Hasn’t done his laundry in six months” or “Kitchen was overflowing with dishes, and there’s dirt and trash on the floor,” or whatever.

Joe, then, might tell the doctor the patient has not taken his blood sugar recently, and the doctor might also document that observation to alert social services that this patient might need a home nurse. These observations, when written down or shared, helped continue a patient’s care long after participants transferred patient care to hospital staff.

When committed to memory, these observations allowed participants to provide crucial information to other people responsible for a patient’s care. The act of observation is a critical EMS skill. In urgent situations like a car accident, I learned that participants did not have time to take detailed notes of an environment. Rather, they remembered this information in their individual memory. However, for information that they needed to recall exactly, like medication dosage amounts, participants took notes. Due to limited time and circumstances, they improvised writing surfaces and methods.

Notes

To remember specific, time-sensitive information, participants took notes. Participants were not always able to document information after a response ended. At times, they were dispatched to another patient (see Figure 2). During those times, notes played a vital role in documentation practices and individual memory. Without these notes, participants risked forgetting information that was crucial for other medical professionals who may treat the patient, such as medication dosage amounts.

Notes helped solidify knowledge gained throughout a response. To accommodate time and location limitations, note-taking methods were creative, fast, and informal and minimally interrupted the task that participants completed. Participants did not have access to computers in the ambulances or when they met a patient, so they made notes on any available surface. Kevin, a paramedic with decades of experience, illustrated how his note-taking process has evolved:

I used to write on the gloves—or on my hand. . . . When we went to gloves, pens don’t write on that, so I put a piece of two-inch tape on my leg, and I’ll just jot notes so that I can remember. . . . I make notes, and then I have them with me. Or I’ll write it on the back of a gauze pad or a bandage pack from the ambulance, whatever we’ve got, just so I have some notes to go by.

Notes then became external representations of individual memory. They decreased cognitive workload. In turn, notes increased the amount of attention participants gave to other tasks, like patient care. It also helped bridge time; often participants could not complete documentation at the end of responses. Notes helped evoke memories of events when participants wrote the PCR. Another participant, Chris, summarized various note-taking practices of Lochville EMS professionals in general:

Yeah, you’ll see things written on gloves. . . . Pillowcases, sheets. . . . My arm will be full of information. Like I’ll write vital signs on my arm or things like that . . . because gloves can smear, depending on the pen. Or you throw it away and go. . . . Everybody has got their own way of doing it.

In certain situations, time, location, and patient status required Lochville EMS professionals to write on nontraditional writing surfaces, like a patient. During his interview, Joe took me through his writing strategies in a particularly dire situation:

I usually carry Sharpies with me and stuff because so many things go on sometimes, especially if we’re following vital sign trends or something like that, I start writing on the sheet that the patient is lying on. Cardiac arrest and stuff like that, sometimes I’ve been known to write on the patient. That way I know exactly when I’ve given each dose of medication and so on, and that way if we get called out right away and the doc wants to know, “Hey, how many doses of epi did he get?” chances are . . . it’s on his arm or it’s on his chest because I’ll write on my patients all the time. So that’s just kind of the routine that I go through, and that way, you know, it’s consistent.

When participants wrote on permanent surfaces, like a patient’s body, the information traveled with the patient throughout his stay at the hospital. If a doctor or nurse had a question about when a medication was given, she or he could look at the patient for this information. The patient’s body, then, served as long-term memory and a memory aid for the medical providers who cared for the patient.

Other writing surfaces were short-term, temporary, and disposable: Participants threw gloves away after each patient contact and washed pillowcases and sheets after each patient. Hands and arms offered only so much room before participants needed to clean them to make room for more information. These methods, then, served as short-term memory only for participants. Another medical professional would not have seen these notes; they served as a personal memory-aid method. What made these methods more personal was that participants had their own note-taking style.

In addition to recording patient information, participants made notes of what patients said, which played a pivotal role for insurance companies or lawyers. In his interview, Ryan detailed the specific kinds of information he noted for those audiences:

If they [patients] make some kind of statement that would have implications in like a court case or in like an insurance payout, then yeah, we will make a note: “Well, this witness said that the patient made this comment to them” or “The patient commented. . . .” So if it’s something that we think is important, we will quote them as best as we can remember.

What is important to note here from Ryan’s response is “as best we can remember.” Ryan’s response pointed to an awareness that individual memory is fallible and can become full. To avoid overloading their memory, participants enhanced their ability with memory aids, like notes. Participants indicated that they learned these aids over time, often through learned experience.

Learned Experience

Experience aided participants when deciding which information to commit to memory or write down. In discussing observations and experience in his interview, David, a paramedic, commented that they work together: “It’s just a matter of . . . gleaning that information from [people on the scene]. . . . A lot of that comes from experience . . . knowing what to ask from what kind of a situation.” Through experience, participants learned what questions to ask, observe, note, and remember. Despite best individual efforts, however, an individual’s memory is fallible. To that end, participants relied on each other and other individuals involved in a response to help remember and communicate information.

Collaborative Memory

Collaborative memory refers to information that a group of individuals share and remember. Based on results, collaborative memory at Lochville included information that was shared by the patient, an EMS partner, other emergency units, bystanders, and dispatch. Participants relied on other individuals’ recalled information to treat a patient and document a response. In interviews and field notes, participants mentioned collaborative memory the most, with 43 references.

To achieve successful patient care, participants relied on the successful, collaborative interaction of people at each location throughout a response. Participants always worked in teams. They relied on each other’s memory of the response and on information provided by dispatch to document, for example, time stamps and address information. When participants arrived on scene to the patient, they often spoke with witnesses, bystanders, or family members. These people provided participants with key information about the patient, especially if a patient was unable to communicate or suffered from a disease that compromised reliable memory (e.g., Alzheimer’s).

Patient

The patient played a key role in collaborative memory. Ryan noted, “Typically what we’ll do is . . . try and talk with the patient. . . . And that’s the best source of information, obviously: the person that’s having the problem.” If the patient was conscious, responsive, and able to speak, participants relied on the patient to provide much of the information that they needed to provide treatment.

The patient might have also told participants information that was not directly related to treatment but may have impacted the patient’s well-being. For example, a patient may have referred to domestic abuse or another concern that may be important enough for a participant to remember and document in the PCR. Ryan noted that Lochville EMS professionals paid particular attention to any information “that would have implications in a like a court case of in like an insurance payout.” Ryan went on to comment that they would “quote them [the patient] as best as we can remember” in the PCR, especially if he was not able to write it down immediately.

Kevin recounted his typical patient interaction during a response in his interview:

I go in, introduce myself to the patient and confirm what’s going on with them. Usually [my] partner gets vital signs and I ask questions about what’s going on . . . so we can determine kind of our treatment plan from there. And then, based on what the patient tells me, we develop a treatment plan.

Kevin’s response indicates that patient-provided information offered participants key information about how to move forward. The collaborative pronoun “we” here, too, referred to the participant’s EMS partner—treatment planning was a collaborative effort that could begin only once information was shared. Ideally, the patient provided this information, but patients were not always able to share information or did not relate reliable information. If the patient had an altered mental status (e.g., dementia or intoxication), participants could not depend on only the patient for accurate information. Additionally, if the patient was unconscious or unable to speak, participants could not ask a patient for information. In these situations, participants turned to other external sources and collaborated for information gathering, often with their partner.

Partner

Participants always worked with another Lochville EMS professional. A participant, David, stated that “[d]ispatch and your partner are really the two people that you talk to,” indicating that dispatch and EMS partners were the two most important components of information gathering and recall. Participants depended on each other to treat patients and remember information. A paramedic, Tyler, demonstrated how he relied on his partner: “Because maybe she’s talked to the family while I’m talking to the patient, so then I can say, ‘Hey, what did you find out?’ and she can say, ‘Well, he takes his medication,’ when he said he didn’t.” As Tyler’s quote reveals, participants needed each other to gather pertinent information. One participant stated that he needed to be aware of what the patient and his partner were doing “to get all the details possible.” Tyler’s partner was like a second set of eyes or pair of hands during a response.

Participants’ partners helped recall information when documenting. Participants reviewed a response with their partners to be sure they did not miss anything that needed to go in the PCR, particularly during a critical response, as Joe discussed in his interview:

If it’s been a challenging run, like if we were actually doing CPR or something like that, we had a lot of different things, we’ll be like, “Hey, did we get everything done? You know, okay, we did this, we did this, we did this,” because we’ll need it for report purposes and things like that. . . . Or [I’ll ask my partner] “What did you think?” just kind of a quick review so I can get my ducks in a row to write my report.

Despite their crucial role, participants’ partners were not the only other trained rescue professional who assisted during a response.

Other Emergency Units

Other emergency units were usually at the scene when Lochville EMS arrived. These units included police, fire, volunteer rescue, or nursing home staff if Lochville responded to a nursing home. Participants noted that they relied on these units to remember and share pertinent information with them. These emergency units helped Lochville EMS professionals verify information gathered from other sources. In his interview, Joe said that information could change when they gathered it. For example, a patient could correct a firefighter when the firefighter talks to EMS: “We’ll get there and talk to the LFD [Lochville Fire Department] guys, and they’re like, ‘He said the pain started an hour ago,’ and the patient is like, ‘No, that’s not what I said. The pain started two hours ago.’”

During these potentially confusing moments, participants collected more information from the fire department or other bystanders. At times, this information helped other readers of the PCR make sense of a patient’s condition and the response. For example, a patient’s primary care physician would need certain information if the patient could not recall information consistently, like the duration of pain or pain location. If participants documented these details, the primary care physician would be alerted to a patient’s decreased cognitive ability. By remembering these pieces of information and recording them in writing, participants demonstrated keen rhetorical awareness for their audience and their patient’s future potential needs.

Bystanders

Bystanders included other individuals on scene who were not affiliated with medical or rescue units: family, friends, or witnesses who saw the events that led to the 911 call. Participants interviewed bystanders if they were available because they provided important supplemental information. Their role became even more important when a patient was unconscious or unable to talk. Ryan stated that during these times, Lochville EMS professionals tried to talk to “the person who made the call or who found [the patient].”

Bystander information was so critical at times that participants documented it, like in the case of a cardiac arrest or resistant patient. In these situations, participants wrote, “Bystander stated something to the effect of. . . .” Joe referred to specific instances where he has quoted bystanders in his PCR: “[W]e get a lot of calls where, you know, ‘Dad’s gonna be mad because we called 911. He didn’t want us to.’ So I’ll put, ‘Family stated. . . .’ That way the doctor and the staff know exactly who that information [came from].” This type of information offered PCR readers more context. In the case of geriatric patients, as this participant’s response pointed to, these “he-said-she-said” details provided insight into family dynamics at home. A social worker could turn to this patient’s PCR to see that the patient may not be taking care of his medical needs and may require more assistance.

Dispatch

The dispatcher was the first person with whom participants communicated. Dispatch was in control of the response during the first stages; they had all the information that participants needed to help them prepare and to drive to the patient. This information included patient location, the reason for the call (chest pain, car accident), and any other pertinent details (e.g., “Caller says to use the back door once you get to the patient’s house.”). Dispatch shared this information either over the radio or computer-aided dispatch system.

Participants remained in contact with dispatch throughout the response. They gathered more information from dispatch, and they shared information with dispatch as needed. As Sam said, dispatch would “give you . . . more details as they come in, if they’re available.” For example, participants contacted dispatch once they were en route to the hospital. Dispatch and a partner were the only two people who stayed with Lochville EMS throughout the duration of the response; the partner was physically with the professional, and dispatch was always available via radio.

As I learned during my clinical experience, dispatch provided participants with important numbers that they needed to document in a PCR, such as the address of the patient’s location. This information was stored in and easily retrieved from the computer-aided dispatch system in the ambulance. By inputting this information and having it saved in the computer-aided dispatch system, participants did not have to spend cognitive energy remembering the information or writing it down. Instead, they retrieved the information after a response when they had time to do so. Participants, then, relied on dispatch to remember and document these pieces of information so that they could access it when they were able to.

Professional Memory

Professional memory includes the knowledge and skills that participants learned throughout their training. This training included memorizing protocols and guidelines, learning formats and scripts, and gaining classroom-based knowledge. Participants referred to professional memory 30 times. Professional memory structures an EMS response, and this structure aided in recall when participants documented a response. This structure was “in the back of [a participant’s] mind” throughout a response because it helped with other aspects of individual and collaborative memory (participant interview). The structure helped participants and other medical professionals involved in the response know what to observe, note, and share; professional memory involved genres that drove communication forward. Sam described this essential structure: “Without that organization, the whole thing breaks down.”

Protocols and Guidelines

Protocols and guidelines referred to official standardized treatment plans. Each patient condition had its own protocol: cardiac arrest, respiratory arrest, sprained ankle. They outlined the appropriate, legal medical care that participants provided for a patient who fell into the protocol criteria. Participants memorized protocols and guidelines and drew on this memorized, professional knowledge to treat patients.

Furthermore, protocols served an important function when documenting a call. Because protocols provided a standard course of treatment, participants did not have to rewrite every treatment they performed during a response. Instead, as Joe stated in an interview, they could write, “followed ACLS [advanced cardiovascular life support] guidelines” for a patient who had advanced life support care. Protocols allowed participants to reduce cognitive workload and focus on the patient. Readers of the PCR understood protocol references because these readers also memorized the protocols.

Format, Script

Formats and scripts referred to spoken communication guidelines that EMS professionals learned outside of the classroom. They were unofficial because they were not regulated like protocols and guidelines, and they did not refer strictly to medical treatment. Formats and script allowed professionals involved in the response to share information because they all understood the formats and scripts. Larry, an ED nurse, took me through the script involved when Lochville EMS arrives at the hospital:

So I’m going to say to the paramedic something very simple like, “What’s going on?” and the expectation is they’re going to tell me the history of present illness, which is going to include their chief complaint, what’s going on with them, what happened to them; their pertinent past medical history; and what they’ve done so far for the patient.

These expectations set the rules for these unofficial genres, and these expectations, much like protocols, facilitated communication. Like protocols, formats and scripts structured a response. Like other aspects of memory and recall, participants learned these formats and scripts through experience. Participants memorized them over time, which, in turn, allowed them to interact with other medical professionals more effectively.

Classroom-Based Knowledge

In addition to protocols, formats, and scripts, participants consistently referred to the knowledge and skills they learned in EMS training. This information included mnemonic devices and basic medical information, like the normal range of vital signs. Participants referred to this knowledge as doing things “by the book,” and they noted that if they followed everything “by the book,” “it’s really nothing hard to remember” when working with a patient.

When Sam answered the first question, he color-coded his sketch. He wrote down certain items in red and others in blue. When I asked him what the red color indicated, he replied,

What I have in the red here is dispatch initial, ambulance dispatch, detail en route, arrival announcement, medical direction, incoming report, and admin/hand over documentation, as well as end of call. All of those things are things . . . need to be present in every call . . . they’re functional, they’re part of the official structure of communication in EMS for a call, it’s stuff that is taught in our books.

Sam explained how classroom-based knowledge transferred to workplace EMS communication. This knowledge created the structure for a response; Sam called them “sign posts.” Participants filled in the structure with specific information from the patient, bystanders, or other individuals involved in a response.

Sam also verbalized the organization of a typical response and referred to specific information that Lochville EMS professionals learned in class:

[A]fter the visual contact and all the information that that brings, you go and start talking to your patient, and you do things that we do in class, like SAMPLE history, which stands for Signs and symptoms, Allergies, Medications, Past pertinent medical history, Last oral intake, and Events leading up to the accident. . . .

SAMPLE is one mnemonic device that Lochville EMS professionals learned. Participants referred to other mnemonic devices that they learned, like AVPU (Alert, Verbal stimulation, Painful stimulation, Unresponsive), which helped them determine a patient’s level of consciousness. These devices guided participants to ask patients appropriate questions and gather pertinent information needed for treatment and documentation. Like protocols, formats, and scripts, classroom-based knowledge facilitated recall and retention and reduced cognitive workload for Lochville EMS professionals.

Discussion and Implications

These results provide insight into how memory and distributed cognition works in, and is formed by, fast-paced, high-stress environments. Specifically, this research highlights two points: how the external environment facilitates memory in an unpredictable workplace, and how collaborative, professional, and individual memory work together. Specifically, they work together to help Lochville EMS professionals integrate sources of information into the PCR.

The External Environment Facilitates Memory

Lochville EMS professionals use their external environment to facilitate memory and communicate with other medical professionals. How they use their environment, though, demonstrates sharp audience and rhetorical awareness, and an awareness of memory’s temporal nature.

Lochville EMS professionals distribute individual memory onto the external environment, as shown from their use of taking notes on any available surface. The surface they choose to write on depends on where the patient is going next and the information that needs to be communicated at that location. This rhetorical choice is evident with the paramedic who writes on patients with Sharpies. This paramedic only writes information on the patient—dosages and times of medication administration—that other medical professionals would need to know immediately in order to continue patient care. By taking notes on this permanent surface with a permanent marker, the paramedic demonstrates a sharp rhetorical awareness of his audience and their information needs.

He also shows his awareness that individual memory can fail and that collaborative memory makes up for this failure. By writing on a patient in marker, this paramedic ensures that he will share critical information with the appropriate people even if he does not have the opportunity to share it verbally—or if the receiving hospital staff forget the information. In a sense, this note-taking serves as a form of external long-term memory for other medical professionals who care for the patient. Therefore, individual memory merges into collaborative memory. By taking notes on a patient, a form of individual memory, the paramedic shares information with other medical professionals, a form of collaborative memory. Cognition becomes external and distributed; these observations are written on the patient, which other medical professionals view and remember.

When recording less pressing information or information that they need to evoke individual memory, participants write on less permanent surfaces—gloves, bed sheets, medical tape, and paper. Participants discard this information after they document the response, and as such, these surfaces become external short-term memory for them. This information may include a patient’s weight and height, vital signs, or details that the patient or a bystander shared on scene. Most of the time, other medical professionals do not immediately need this information to treat the patient, or they could get the information themselves (e.g., they could weigh the patient). EMS professionals also are able to take these writing surfaces with them when they leave the ED; they do not leave these temporary writing surfaces with hospital staff like they do when they leave a patient with hospital staff. The writing material an EMS professional chooses, therefore, demonstrates his rhetorical awareness of the kind of information, who will need it most immediately, and for what purpose.

This short-term memory device helps participants complete the PCR. By writing on artifacts in the external environment, Lochville EMS professionals link their cognition throughout and across the different contexts involved in a response (ambulance, patient location, hospital, etc.). Individual and collaborative memory offer Lochville EMS professionals external cues for reducing cognitive workload; they use more than notes to notice cues and evoke memories (Flower, 1990). They use other individuals’ memories and their professional knowledge to notice and evoke information, which ultimately allows them to achieve two goals: to care for a patient and to communicate.

Memory Allows Communicators to Integrate Sources of Information

Coding revealed two types of memory that are yet to be addressed fully in writing scholarship: professional memory and collaborative memory. Professional memory has to structure a response, but it needs to be flexible enough to account for all types of unpredicted situations. In short, protocols need to prepare Lochville EMS professionals to care for a patient but allow them freedom to adapt the protocol according to the patient’s needs. The professional genres prompt a Lochville EMS professional to begin a course of treatment and remember details later in the response. Professional memory provides an outline for an EMS response, and EMS professionals rely on individual and collaborative memory to fill in that outline with pertinent, patient-specific information.

The interaction of individual, collaborative, and professional memory culminates at the end of a response when an EMS professional writes the PCR. The document is the result of individual, collaborative, and professional memory at work, and it is only as effective and accurate as its author: an EMS professional.

The three types of memory allow EMS professionals to integrate multiple sources of information together. In interviews, participants referred to collaborative and individual memory when discussing professional memory. I have labeled each reference in brackets. David noted,

[W]hat Dispatch tells you [collaborative] may not be the same, and the information that they observed [individual] when they initially got on scene, or that they’ve observed from a nurse’s standpoint [collaborative] since the patient has been in their office, that can be very beneficial to the health and care of that patient. It’s just a matter of, I guess, gleaning that information from those people, getting the information that you need [collaborative]. A lot of that comes from experience [individual], you know, knowing what to ask from what kind of a situation [professional, individual].

The three types of memory are recursive and interdependent. Lochville EMS professionals do not necessarily draw on them in any particular order, but they draw on all three when recounting a response.

Individual, collaborative, and professional memory facilitate information retrieval during a response, allowing a Lochville EMS professional to complete required documentation. Figure 4 is an example of documentation that Lochville EMT students complete as they help treat patients and practice their documentation skills. This form is similar to the structure of a PCR that Lochville EMS professionals complete.

Figure 4.

Classroom form that structures memorized content.

The form in Figure 4 is an example of professional memory. It contains mnemonic devices (“AVPU”), textbook knowledge (“140/84”), and protocol information (“O₂ NC”). An EMT student fills in this form by recalling information from the response. The professional memory cues on the form facilitate recall. Additionally, the information documented is the result of individual, collaborative, and professional memory. The student relies on her own observations, notes, experiences, input from other EMS professionals, and protocols and classroom-based knowledge to create this artifact. The Lochville EMT student completes this brief form, and the Lochville EMS professional who oversees the student may use this form to complete her PCR for the same response. They then collaborate to complete the PCR, integrating the three types of memory to successfully document patient care.

Implications

This research highlights memory and distributed cognition’s crucial roles in workplace documentation processes. While this research has implications for the EMS workplace, I focus here on written communication theory and research.

If a workplace document is incomplete or inaccurate, we often turn to the writer and ask, “Did you forget something?” We are quick to ask the writer to see what she or he forgot, but, as the EMS workplace shows, the writer is not the only one involved in the documentation and recall process. External forces that make up professional and collaborative memory play a role in recall. It may prove useful, then, to investigate how professional and collaborative memory function in other workplaces. Writing scholars should pay particular attention to how distributed cognition functions in these spaces, given that researchers have already noted the crucial roles memory and cognition play in writing.

Following along those lines, scholars who study distributed cognition have noted how cognition differs in print and electronic contexts (Haas, 1989; O’Hara et al., 2002). Health care records, including electronic health care records (EHRs), are often the sole source of a patient’s medical history. The writing that occurs in chaotic circumstances related to medicine provides the foundation for the information kept on file. As such, the location- and memory-based writing that medical professionals perform is often overlooked when it should be a focus of future research. To compare this case to writing studies, examining EHRs is like studying only final submitted drafts of student papers, ignoring the invention or drafting stages. If writing scholars want to learn how medical information is shared and how distributed cognition functions in this high-stakes writing process, scholars should further examine EHR communication practices through a distributed cognition or memory framework.

Lastly, this research project points to the challenges involved in studying highly regulated yet unpredictable workplaces like EMS. My research methods shifted in response to institutional requests and delays. To that end, I relied on participants’ recollections of accounts. Researchers entering these kinds of contexts should be prepared to adjust research methods accordingly and perhaps develop methods to account for these situations. Farkas and Haas’s (2012) and Teston’s (2009) modified grounded theory approaches provide strong starting points for conducting research on situated literacy practices and in highly regulated institutions. However, writing scholars need methods for studying places that institutions and IRBs may not permit researchers or audio-recording devices, like a patient’s home or other confined, confidential spaces. When writing scholars study these spaces and the participants who work in them, we rely on the participants’ memory of their work. This recall can be challenging to study especially when we are interested in observing writing practices, practices that workplace communicators may not be fully cognizant of. The modified CDM that I present in the methods section offers one way to investigate these spaces, but writing researchers should continue pursuing alternate methods that allow scholars to study workplace writing practices in retrospect.

Conclusion

I end with an example from my fieldwork that highlights the importance of this memory and workplace writing research, and the implications of memory faults and writing. During a Lochville staff meeting, the medical director reviewed a recently completed PCR with the staff to discuss areas of improvement. A lack of solid communication and recall contributed to confusion with a recent patient’s treatment. The medical director brought up a PCR on the overhead projector and verbalized the information written on it. He said, “Based on this patient’s status, he should have been given two IV lines and not one. The PCR states that he had one IV line, which could have caused many complications for the patient. This treatment doesn’t follow protocol.” A paramedic sitting across from me raised his hand: “That was my patient. I started two IV lines following protocol.” The medical director responded, “Well, you didn’t write it down, so you didn’t do it. We have to get better a documenting our work, folks. Patients’ lives depend on it.”

In this piece, I have shown how workplace memory practices help workplace communicators complete a goal. This piece offers written communication scholars a different perspective on how memory works in nonstationary workplaces, which could include home visits for social workers or field work for engineers. Workplace limitations force certain workplace professionals to memorize information and utilize their environment to facilitate communication. By researching how memory works in these contexts, we can better understand the writing process involved in these workplaces.

Footnotes

Appendix

Acknowledgements

I would like to thank Richard Johnson-Sheehan, Linda Bergmann, Patricia Sullivan, Stephen Bernhardt, and Anis Bawarshi for their feedback on earlier versions of this work. Christina Haas, Allen Brizee, and three anonymous reviewers helped shape this piece, and I am grateful for their time and advice. Thank you to Ben Camston (pseudonym) for his permission to use the form in . Finally, I thank the Purdue University Research Foundation and Towson University’s Faculty Development and Research Committee for their financial support of this study.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Purdue University Research Foundation and Towson University’s Faculty Development and Research Committee provided financial support.

Notes

Author Biography

Elizabeth L. Angeli is an Assistant Professor of English at Towson University in Towson, Maryland. At Towson, she teaches undergraduate courses in professional writing and the rhetoric of science, as well as graduate courses in the Master of Science Professional Writing Program. Her research interests include medical rhetoric, technical communication, and research methodologies. She holds an Emergency Medical Technician-Basic certification.

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