Swift Transport versus Information Gathering

Changing Technologies, Changing Roles?

Twenty years ago, providing speedy transport to the hospital was the primary way for ambulance crews in Sweden to deliver patient care. As one paramedic observed, “We used to give care with the gas pedal.” Ambulance crews, with only limited medical training and with no sophisticated medical technology at hand, sought to provide quality care primarily by driving fast and delivering patients quickly to the hospital. Studies conducted in countries outside of Sweden (e.g., Douglas 1969) have found a similar pattern.

Yet, as Hughes (1980, 122) observed in a study of the British emergency service, the process of “information gathering or information generating” has also been an important but often overlooked feature of the ambulance journey. Ambulance crews serve as the first agents in the chain of care who actually face patients at the scene of an emergency. They make assessments of the severity of the patient’s condition, using a cursory physical examination and experience-based typifications of various “normal” conditions. These assessments complement or challenge the picture delivered by the dispatch center, which is based only on oral information. In the past, ambulance crews conveyed their assessments to hospital personnel through radio-telephone conversations or through verbal descriptions and nonverbal cues in face-to-face interactions with casualty staff.

While this type of information sharing still takes place, many ambulance services complement it today with telemedicine technologies, including portable computers, smartphones, and portable electrocardiogram (ECG) units. These technologies have vastly increased the amount of information that ambulance crews can transmit from prehospital settings to the receiving hospital. The new technologies enable more advanced assessments of a patient’s status. Ambulance crews can now use ECG equipment, consisting of a handheld computer and a measuring unit, to send ECGs to the hospital, enabling them to conduct joint assessments and seek expert opinions from specialists, in, for example, cardiology. Under the supervision of the cardiologist located at the receiving hospital, crew members can start administering medications, and they can initiate preparations for an acute percutaneous coronary intervention. Communication technologies thus make advanced, prehospital emergency care possible during an ambulance assignment. Moreover, the ambulance crews can use these technologies not only to initiate advanced medical interventions in the prehospital setting, but also to gather medical information during their assignments and transmit it to the corresponding hospital. This information can improve the hospital’s preparation and ability to triage and admit patients in a safer, more effective manner (Brown and Bleetman 2006; Harrison and Cooke 1999). Thus, one could argue that the introduction of telemedicine has changed the role of the ambulance service from that of a swift transport unit—“giving care with the gas pedal” and delivering the patient safely to the casualty department—to a unit working as much with sophisticated medical information gathering and transmission.

Similar to other kinds of technologies, however, intentions and use do not always coincide. The new technologies are accompanied by organizational changes and changes in work procedures that may upset established ways of providing “good” ambulance care. In this article, we examine and discuss some of the resulting tensions. Drawing on ethnographic material derived from rides with the ambulance service in a midsized Swedish town, we portray how ambulance crews handle the demands inscribed in telemedicine technologies and attendant rules of procedure in their everyday practices. We also discuss the various strategies used by crews to deal with the tensions between applying the new technologies, which they tend to think slows them down, and their preferred work routines, which involve acting quickly to provide what they view as the best ambulance care possible.

Previous Research and Theoretical Perspectives

Scholars have conducted a number of general studies of the ambulance service (Douglas 1969; Hughes 1980; Hutchinson 1983; Mannon 1992; Metz 1981; Nelsen 1997; Palmer 1983; Palmer and Gonsoulin 1990; Reynolds 2008). Analysts have also investigated the situated use of various medical technologies (e.g., Berg 1997) and the operations of dispatch centers (McGrath 2002; Smith et al. 2008; Tjora 2000) that work closely with the ambulance service.

Studies dealing specifically with the impact of medical technologies on the ambulance service and ambulance crews typically focus on experiments or evaluations of pilot schemes concerning the potential usability and effectiveness of different types of telemedicine systems. Examples include Anantharaman and Swee Han’s (2001) study of hospital and ambulance links, Curry and Harrop’s (1998) analysis of the use of video cameras and systems for transmission of video pictures through cellular phones from emergency sites and ambulances to hospitals, and Karlsten and Sjöqvist’s (2000) portrayal of telemedicine and decision support systems in emergency ambulances. Other investigations, such as Rowlands’s (2003) study of the use of data protocols to improve ambulance reports and hospital triaging, have illustrated problems and even failures associated with the introduction of different telemedicine systems.

Most existing studies on the impact of medical technologies on the ambulance service and ambulance crews are techno-centric and rarely address the social and organizational aspects of work or the interplay between telemedicine technologies and human action. These studies thus fail to capture the complex interactions between users and objects in the situated enactment of the technologies; that is, they fail to capture how users negotiate, reframe, and localize the technologies-in-practice. We argue that a realistic appraisal of the potentialities of the new tools must take into account such situated uses as well as the compromises and negotiations they imply. Technologies do not become usable and reliable regardless of their users; instead, they acquire these characteristics through the institutionalized practices of their users. These practices also become linked to the users’ other working practices (Gherardi 2010, 502).

Our study aims to address this problem. It has its theoretical base in perspectives presented by scholars interested in “technologies-in-practice” (Berner 2008; Gherardi 2010; Orlikowski 2000). Looking at technologies-in-practice involves studying the acting and knowing that people perform within a temporally delimited, emergent, and negotiated social order. It entails analyzing how people act as competent practitioners, and how they organize their action practically as methods of seeing, listening, reasoning, and responding to human and nonhuman elements; that is, what Gherardi terms studying “practice from the inside” (Gherardi 2010, 505). Thus, we see medical technologies as embedded in interactions between tools, professional knowledge, established visions, and situated demands.

Several scholars have argued that a technological device embodies the intensions of the innovators and designers as well as of those who purchase it (Akrich 1992; Berg 1997; Woolgar 1991). These actors may inscribe a vision onto the technology, in the sense that the material properties, affordances, and operating instructions of a technical device depend on hypotheses about the situations in which the device will be used. In turn, the design of a device embodies directives that inform users how they should act with it. These directives serve as a “script” (Akrich 1992).

Yet, as several researchers have shown and we will demonstrate, a discrepancy exists between (1) what innovators and designers envision and what the script prescribes and (2) how users apply the technology (Akrich 1992; Berner 2008; Orr 1998; Suchman 1987). The intentions of innovators, designers, and purchasers may not be shared by the people who will ultimately use the equipment. A mismatch may exist between what the scripts prescribe and what the users regard as their needs. Studies have highlighted the often invisible work users do to fit a technology and its features into their ongoing practices. They may resist or alter the technology or redefine the conditions of its use. In this vein, researchers focusing on medical settings have shown that the introduction of a new technology poses challenges to the involved professionals’ established work procedures and their professional identity (Greatbatch et al. 2005; Nicolini 2006; Wichowski 1994). Discussing the ambulance care setting, Douglas (1969) argues that ambulance personnel create various shortcuts when dealing with guidelines, patients, and equipment—thereby creating methods suited to their preferred mode of action. Similarly, Nelsen (1997) shows that ambulance staff use different strategies to work their way around institutional directives to accomplish what they think their work demands. Other researchers have described how ambulance crews use procedural shortcuts to eliminate and avoid unappreciated steps in a treatment protocol (Hutchinson 1983; Nelsen 1997; Palmer and Gonsoulin 1990).

In this article, we extend these discussions, which do not focus specifically on the use of technology in ambulance practices. We do so by looking at the situated uses of telemedicine technologies—how ambulance crews perceive, work around, negotiate, and even ignore them. Various researchers have given different labels to this work of adjustment, negotiations, and tinkering. These labels include “articulation work” (Corbin and Strauss 1993), “de-scription” (Akrich 1992), “domestication” (Lie and Sørensen 1996), “localization” (Berg 1997), and “taming” (Lie and Sørensen 1996; Pols and Willems 2011). We use the terms localization, taming, and nonuse in our analysis because they capture the still uncertain and negotiated character of how ambulance crews try to domesticate the new technologies. A fully “domesticated” technology is one that is widely used and has a recognizable repertoire of uses (Lie and Sørensen 1996). However, the notion of domestication does not fit in the case we analyze in this paper; instead, the ambulance crews attempt to localize technologies in various ways.

Berg (1997) uses the concept of “localization” to discuss how designers adapted the affordances of a medical tool (in Berg’s case, a computerized diagnostic system) to local needs in order to make it usable. They adapted the tool in space, that is, in accordance with local circumstances and idiosyncrasies, in scope, limiting how it could be used, and in rationale, that is for which needs and purposes. In these various ways, designers shaped the technology in relation to the relevant actors’ trajectories, that is, in relation to their previous experiences and established practices—but these adjustments also meant that the full potential of the tool was not realized.

We will use these insights to discuss the actions taken by users, rather than, as in Berg’s study, by designers, to adapt tools to local circumstances. In addition, we borrow the concept of “stance” from Corbin and Strauss (1993, 73) to highlight the role of participants’ established cultural positions toward their work; this includes their preferred “working out” practices to gain control over their work arrangements. We argue that the ambulance crews’ predominant vision of how to provide information and “good care” frames how they localize the new tools; they adapt them in space, scope, and in accordance with their local rationality, or stance.

The localization of tools includes attempts to tame the technology. This process entails manipulating tools to make them workable and relevant. But tools that have been tamed are not fully domesticated, that is, adapted to and integrated into ongoing practices (Pols and Willems 2011). A further form of localization that we discuss in this article includes the more or less overt nonuse of technologies. Scholars have discussed nonuse in relation to people’s dealing with various technologies (Oudshoorn and Pinch 2003; Satchell and Dourish 2009; Wyatt 2003). These studies tend to focus on consumer technologies, such as cars or telephones and, more recently, the Internet and computers, where consumers have a choice of refraining from or postponing the purchase or use of a tool. These studies normally do not take into account the constraints of a work setting, such as the ambulance service, where deliberate nonuse may be seen by managers as an act of subversion.

Methodology

To better understand the interactional and unforeseen processes that occur when a new technology is put to work, we chose an approach in which the researcher studies these processes “in situ.” One of us (Tobias Samuelsson) spent four weeks in the spring of 2009 riding along with the crews in five ambulances in one midsized town in Sweden. He accompanied them to emergency scenes, to the major local hospital, and to the ambulance station. (We also briefly studied another ambulance service, in a different community, which provided valuable initial insights into the work carried out.) A short-term study such as this one is hardly exhaustive, but given our focus on the use of telemedicine technologies—which comprise a small part of the everyday life within the ambulance service—we consider that four weeks gave us enough material to grasp important aspects of the crews’ relation to these technologies. If we had wanted to examine ambulance culture in general, we would have engaged in a longer period of fieldwork.

The crews used different pieces of telemedicine equipment for different kinds of assignments. The ambulance service company expects them to use telemedicine primarily in high-priority emergency cases. Over the course of a year, less than one-third of cases at this particular ambulance station are high priority; thus the crew would use telemedical devices, such as ECGs, in only about 20 percent of all assignments—those in which patients experience chest pains that might indicate an acute myocardial infarction, a heart attack. While ambulance crews normally send ECGs to the receiving hospital only when they suspect myocardial infarctions, they can still use other telemedicine equipment to transmit other kinds of information to the hospital.

The ambulance service also handles many routine assignments, such as transporting elderly patients in various retirement homes to and from the hospital for routine checkups. During these assignments, the ambulance crews do not have to use any telemedicine technologies. To avoid the latter types of transports, Samuelsson shifted between two or three different ambulances during the eight-hour days he spent observing the ambulance service, and rode for two to three hours in each ambulance every day. He also met with the other crews in between assignments, at coffee, and during lunch breaks.

During assignments, the researcher tried to stay out of the ambulance crew’s way and be a quiet bystander. Often he was asked to help out by opening and holding doors while the crew carried patients on stretchers; he was also asked to carry extra equipment or the patient’s belongings when entering or exiting the scene of an emergency. One crew member nicknamed him “chief engineer,” referring jokingly to his interest in the technologies used in the ambulance; the crew member always handed him their portable ECG computer unit to carry. Although the researcher did not provide help in the ambulance crews’ medical work, the crews appeared to see him more as a useful extra hand than as an intrusive observer. One reason for this acceptance may have been that ambulance crews had grown somewhat accustomed to bringing passengers with them during their assignments. Students training to become nurses or physicians often ride along in the ambulance to receive training in emergency medicine. The ambulance crews were thus used to having bystanders present during their day-to-day work and to demonstrating and explaining their procedures. The ambulance crew members also often explained to the patients the steps and measures they were taking while examining them. These practices helped give the researcher valuable insights and made it easier to follow the crews’ actions without intruding too much in their work.

Samuelsson cannot claim that he ever achieved an insider position in the group during his four-week stay with the ambulance service. However, his presence did not appear to hamper conversations in the ambulance or during coffee and lunch breaks. These conversations included discussions about various, nonpresent, colleagues’ missteps during assignments and their lack of competence as well as about the crew’s lack of confidence in management decisions, such as those concerning new technologies, topics that were clearly relevant to this study.

The researcher documented his observations in field notes. We did not conduct formal interviews during the study, but Samuelsson had many conversations with ambulance personnel, during and between assignments and at breaks, and he recorded these in the field notes. He normally wrote these notes between ambulance assignments in order not to disturb the crew’s work and to be able to focus on their interactions with patients and their use of various technological devices at the emergency scene. Back in the ambulance, the researcher would jot down notes on what had happened and later use these as memory aids to compose more detailed field notes. The use of a tape- or video-recorder would obviously have helped to better record the interactions that occurred during and between assignments, but for ethical reasons, to protect the patients’ privacy, we decided to use field notes as a less intrusive research methodology. Because Samuelsson took field notes only after the assignments, conversations and comments are not recorded verbatim; consequently, we use few direct quotes in this article.

We began our analysis during the fieldwork period, conducting it concurrently with the data collection. While typing up the field notes in the evening, Samuelsson would find certain angles that he wanted to follow up, and the next day he could take another look at them or ask informal questions about them, thus getting immediate feedback from his informants. However, we undertook the major analysis after the fieldwork had been concluded. We analyzed the collected material using a qualitative thematic analysis method (Aronson 1994; Taylor and Bogdan 1984). We summarized the material and compared field notes from different days and experiences from different ambulance missions throughout the four-week period, identifying repeated keywords and themes that emerged. Boyatzis (1998, 161) defines a theme as “a pattern found in the information that at the minimum describes and organizes the possible observations or at a maximum interprets aspects of the phenomenon.” In our search for themes, we looked for “conversation topics, vocabulary, recurring activities, meanings, feelings, or folk sayings and proverbs” (Taylor and Bogdan 1984, 131).

The themes we discovered during the analysis included the need for speed and complaints about how the crews and their superiors did not see eye to eye regarding the best use of time. Moreover, we highlighted analogies, metaphors, and sayings used by the crews—such as the English expression “load and go” and the saying “providing care with the gas pedal.” We assigned supporting episodes and quotes to the themes, and grouped and regrouped the material over and over again to review and refine the discovered themes. We organized data from different days of fieldwork into thematic groups, and these we “pieced together to form a comprehensive picture of [the ambulance crew’s] collective experience” (Aronson 1994, 1). In the analysis, we not only focused on what the crew said (the semantic content), but also on how they said things and what their words meant (the latent content). In this way, we tried to “examine the underlying ideas, assumptions and conceptualizations . . . shaping or informing the semantic content of the data” (Braun and Clarke 2006, 13). We then wrote up the analysis.

The analysis of themes, metaphors, and conceptualizations revealed a tension between the prescribed approach to ambulance care and the ambulance crews’ preferred approach, a tension we delineate in the following sections. We will discuss two major technologies—smartphones and ECG units—and how they are localized and tamed in local interactions with patients and with the hospital.

Smartphones: Moving Fast versus Standing around Typing

When an ambulance arrives at the scene of an emergency, the ambulance crew does an initial physical examination of the patient and immediately begins to treat him or her, taking symptoms and anamnesis into account. The ambulance crew must also gather information concerning the patient’s situation and transmit it to the hospital Emergency Department.

To facilitate this communication, the ambulance service company has introduced various pieces of technological equipment. For example, every ambulance is equipped with a smartphone—a small, hand-held computer. The smartphone can easily be carried in a pocket, and the ambulance service company expects crew members to take the device with them when they leave the ambulance to attend to patients. The crews can use the smartphone to transmit information from the scene of an emergency. The smartphone also has a GPS function and a translation function. This latter function can be used by the crew when communicating with patients or relatives who do not understand Swedish. Finally, the smartphone contains treatment guides and is also connected to the Swedish Medicines Information Engine, FASS. The last two functions support the ambulance crews as they determine how to proceed when treating patients. Thus, the information in the smartphone helps them recall how to interpret symptoms and instructs them on how to initiate treatments for specific symptoms. It also allows them to look up the effects of various medications. Samuelsson never saw the crew members use these treatment guides or FASS, but several mentioned that they appreciate them and see them as a great support in their work.

The managers in the ambulance service company have instructed ambulance crews to use the smartphone at the emergency site and to input information on the patient’s symptoms and the steps and measures taken for treatment. “They [the managers] think we should bring it with us and type in information in the patients’ apartments,” one paramedic mentioned disapprovingly, indicating some of the difficulties with this prescribed usage. According to the ambulance crews, management’s idea is that one of the two ambulance crew members should check the patient’s status while the other stands nearby, typing in the information as it is gathered. However, the ambulance crews that we followed in our field work did not use the smartphone in this way. The reason for this was, according to the ambulance crews, that it felt strange and inappropriate to spend time typing information into the smartphone at the scene of an emergency. As one ambulance nurse put it:

The people in charge who have decided that we should use these computers like this do not understand how we work. They think that one of us just stands around watching the other one checking the patient. While your colleague is checking the patient, you run around searching for the patient’s ID and medicine list and talking to the patient’s relatives and trying to retrieve information about what has happened and the patient’s medical history.

According to the ambulance crews, management does not understand the crews’ work and how the crew members divided up their tasks in order to speed up the process during an assignment. The suggested use of smartphones to gather and transmit information would tie the ambulance crews down and get in their way when they want to move quickly and do the job the way they think it should be done.

In the past, ambulance crews informed the Emergency Department staff of the patient’s status face-to-face, when they left the patient at the hospital. Later on, they delivered this information by radio from the ambulance to the Emergency Department during transport. Staff at the Emergency Department then processed the received information. With the smartphone, transmission of information has, in principle, been relocated to the very moment when an ambulance crew first approaches the patient at the scene of an emergency. The ambulance crews were not comfortable with having such information transmission duties added to their work. One paramedic argued, “They just throw in technical equipment in the ambulances that we are supposed to use. If we were to use all the equipment we wouldn’t have time for the patients, wouldn’t have time to provide care.”

This statement reflects the dilemma caused by the introduction of a new technology and the procedures that management insists ambulance crews should follow when using it. In the case of the smartphone, the procedures required that the crews stop and take time to type and send information to the hospital. While this could speed up the subsequent care process at the Emergency Department, it would slow down the work of the ambulance service.

One paramedic claimed that, of course, he could understand that the people at the Emergency Department liked to get as much information as possible on the incoming patients, particularly in emergency cases. However, and especially in emergency cases, an ambulance crew would not have the time to type in a lot of information. In his view, it was better to “load and go” in such situations than to stand around in the patient’s apartment typing in information. Another paramedic told Samulsson, when discussing the smartphone, “I never use it. I don’t have the time to do that, it’s better to load and go. In this town the rides are often short so you don’t have time to type in that much.” Thus, these paramedics do not see much value in what little information they feel they would have time to actually type in during their rides.

We interpret this reluctance to use the smartphone in the following way. If the ambulance crews were to follow the script and used the smartphone as planned, it would not only impinge on their work procedures, but the technology and the procedures would get in the way of caring for the patients, delay their departure for the hospital, and thus challenge their professional self-identity as being good at delivering swift care. The ambulance crews prefer to “provide care with the gas pedal.” The additional roles of information gatherer, on the one hand, and a meticulous but passive bystander who types in and transmits information, on the other, clash with their idea of what good ambulance care is. Accordingly, the ambulance crews refrain from using the smartphone at emergency scenes.

Portable ECG Units: Flaws, Mismanagement, and Obstructive Scripts

In any situations where a patient has chest pains that may indicate acute myocardial infarction, the ambulance service guidelines require ambulance crews to bring with them a portable 12-lead ECG unit from the ambulance to the patient. Before loading the patient into the ambulance and leaving for the hospital, crew members are to record and transmit an ECG to the Coronary Care Unit, where it will be checked by staff with expertise in coronary care. Ambulance service managers have established rule-based guidelines stipulating how this should be done, to ensure standardized care in every ambulance.

However, the rules capture only part of what goes on at the scene of an emergency (cf. Greatbatch et al. 2005; Palmer and Gonsoulin 1990). During his fieldwork, Samuelsson noted on several occasions that the crews deviated from the prescribed “rule” of bringing the ECG equipment with them to the patient. When gearing up and getting ready to leave the ambulance, the crews discussed what equipment to bring with them and what to leave behind. In these discussions, they took into account their previous experiences of using the technology as well as the information they already had on the patient they would be seeing. The ambulance crews knew from experience that recording and transmitting an ECG often takes time. Moreover, they knew that connecting the ECG equipment to the Internet is sometimes difficult. Electronic devices inside a patient’s apartment, such as a lamp, radio, or an electronically adjustable bed, might disturb the connection, requiring crew members to spend valuable time walking around, trying out the ECG unit’s Internet connection in different rooms, and switching off other devices.

In addition, on several occasions, the ambulance personnel were observed having to handle computer glitches and hang-ups. The designers of the apparatus have scripted a given procedure to be used when such problems arise. They expect users to follow a prescribed sequence when they start and restart the ECG equipment, closing down step-by-step and logging out before restarting. But quite often, due to frustration at the resulting waste of time when the system did not work, the ambulance workers simply shut the system down and then turned it on again without taking the time to log out. They restarted the device “the American way,” as one ambulance nurse put it. In dealing with the recurring problems, they “tamed” the technology by ignoring the prescribed procedures for handling the system. The problems, they argued, are caused by the poor quality of the computer software. Commenting on the many computer glitches and hang-ups, one ambulance nurse stated sarcastically that “Windows appears to build in problems that make the system crash every now and then.” During the fieldwork, Samuelsson often overheard the ambulance crews complaining to their managers about problems with the equipment they use in their day-to-day work, but we have no first-hand information on whether these complaints were taken seriously and addressed.

The technology’s script also prescribes certain nonobvious ways of handling the tools. When these fail, the ambulance crews interpret these mishaps as their own failure to correctly manage the equipment; they experience the usage as something that has to be learnt the hard way. This became evident during one ambulance ride when the crew was on an emergency assignment to attend to a man who was having chest pains. On arriving at the patient’s home, the ambulance crew began rapidly collecting medical equipment to take into the apartment. When the ambulance nurse picked up the ECG unit, he noticed that it was turned off and made a remark about this to the paramedic accompanying him. The paramedic replied that he had turned the device off when they checked the car and refilled the equipment that morning before leaving the station, because he thought it was supposed to be turned off. The ambulance nurse then had to explain that the ECG unit should never be turned off, because if it were, information on the patient sent from the emergency dispatch agency would not automatically register in the unit. This nonobvious way of handling the tool was important, since a failure to comply with the assumptions in the script would mean that the crew would have to manually type in patient information, such as name, social security number, and so on—information needed to check the ECG taken on the scene against older ECGs. This would hamper the crew’s ability to provide swift care in an emergency situation.

The ambulance ride with this crew offered additional examples of the crew’s problems with taming the technology. After gearing up, the ambulance nurse and paramedic entered one patient’s apartment and began a physical examination. Given that this patient was a man with chest pains, they connected him to the ECG unit. However, although the crew had followed the prescribed procedure, the machine stated that either none of the electrodes were attached to the chest or they were malfunctioning. When the machine functions correctly it displays a picture of a human body with green lights indicating all the places where the electrodes are connected to the body; this did not occur in this case. The ambulance nurse turned to Samuelsson when this happened and said sarcastically, “Sometimes it’s like this. Technology, well, there you go.” Later, the nurse explained what had happened: “The machine had a total breakdown. It doesn’t matter how you tweak the electrodes. Sometimes you can go on for an hour tweaking the electrodes without anything happening. You have to restart the ECG unit to make it work.” To handle the situation with the patient, the nurse then logged out and restarted the unit. This time the system worked, illustrating the need to tinker with the technology in order to tame it and make it useful.

Leaving the apartment, the paramedic pulled out the cable connecting the ECG equipment’s handheld computer to the measuring unit. When the ambulance nurse noticed this, he explained to his coworker that the cable must not be removed, because then the unit stops transmitting the ECG to the Coronary Care Unit. He added, “We’ll start it up in the car again.” These assorted hang-ups of the technology and the crew’s mishandling of the technology naturally prolonged the time spent at the emergency scene.

Yet another problem is that not all the newly introduced technology is compatible with already existing technical systems in the ambulance. Emphasizing the discrepancy between what the script designates as the configured user and the actual user, the ambulance personnel argued that manufacturers tend to fill their devices with a large number of functions, only a few of which the ambulance crews feel they can actually use in their work. Some county councils (the level of government in charge of medical care in Sweden) may have ordered these features, but the same equipment is then sold by manufacturers to other county councils as well. For example, the portable twelve-lead ECG unit contains a system for keeping medical records. However, in the region studied, the ambulance service uses a different record system in the smartphone to report information. This and other superfluous functions decrease the equipment’s usability; it has, in Berg’s terms, been localized by the designers to the specific needs of some local settings—but not this particular one (cf. Berg 1997). Every time the ambulance crews used the ECG they therefore had to spend time clicking past functions they did not use, which stole time from other duties. This and other problems prompted the ambulance personnel to observe that certain tools and technical solutions must have been produced by people who do not work in the ambulance service and know nothing about it. They felt that firms and authorities wanting to try out new equipment were using the ambulance service as a kind of testing ground, something they were quite skeptical about. As one ambulance nurse said, “There is a limit to the amount of shit we can carry with us.”

Handling a Predicament: Ignore and/or Wait

As we have shown above, a mismatch often occurs between the scripts (the stipulated procedures for using the equipment, seen by the ambulance crews as demands “from the people in charge”) and the work processes preferred by the crews. To handle this predicament, the ambulance crews use various strategies to tame or ignore the technology. It was not uncommon for the ambulance crews to reject the prescribed procedures when they experienced a mismatch between the technology and their preferred working methods. They bypassed the prescribed approach and adapted the system to their work setting and their own work procedures. This meant that, at times, the crews deviated from the guidelines and left the ECG unit behind because they suspected that the description they had received from the dispatch center on the patient’s status was inaccurate. Before leaving the ambulance center as well as during the ride, the two crew members go through the received information together and discuss the case awaiting them. The received information may prescribe one type of procedure. However, if the received information is not in line with the ambulance crew’s knowledge and experience from previous encounters with patients, the crew may choose another approach.

One example of this involved an ambulance ride to an emergency assignment to attend to a teenage boy who had experienced chest pains during a visit to the local swimming hall. Before leaving the ambulance center, the crew received information on the patient, including his age and his symptoms. When they arrived at the emergency scene and geared up, the ambulance crew brought the ECG equipment with them. In the swimming hall, the boy was lying on a towel, with a friend sitting next to him to keep him company. The ambulance crew asked the boy how he was feeling now and what had happened, and they also talked to the boy’s friend. The patient did not appear to be in a lot of pain at that moment. He looked calm and composed and was able to explain in a steady voice what had happened and how he felt. The boy’s friend did not look particularly upset by the situation either, and gave the crew a concise report on what had happened. The crew checked the boy’s vital signs and prepared him for transport. During the ride to the hospital, the ambulance nurse typed in information on the patient and transferred it to the hospital. After a while, the ambulance received a message that staff from the Department of Pediatrics would come down to the Emergency Department and meet them on arrival, and thus probably vastly reduce the waiting time for the young patient. Having received this message the ambulance nurse commented “This is a good example of what it’s like when the technology and the sending of messages back and forth work. It’s not always like this.” In other words, although it doesn’t always happen this way, this time the technical system worked, all the messages got through, people on both sides of the line had time to transmit, read, and act on the information, the Pediatric staff was not occupied, and the ambulance crew could meet them on arrival at the hospital.

It is notable here that the ambulance crew had not acted as prescribed in the guidelines at the scene of the emergency. They should have checked the boy’s ECG while at the swimming hall, but they waited until they were back in the ambulance. Samuelsson asked them afterward why they had chosen to deviate from the guidelines in this way. They replied that it did not feel right to initiate an ECG process in front of the teenager’s friends; this would have worried them. According to the guidelines, the user should not take such local social conditions into account. But the ambulance crew let human considerations overrule the script. In addition, the ambulance crew argued that they did not really think this was an emergency case. Based on their experience, and given the patient’s symptoms and his age, they concluded that this did not seem to be a case of heart problems. Making decisions like this, the crew members thus took into account both the situation at large and the received information on the patient’s status. They also took into consideration their preferred approach to ambulance care. If neither the patient’s profile nor his or her symptoms strike the ambulance crew as indicating a myocardial infarction, they may decide to overlook the directives. Therefore, they do not use the ECG equipment, a decision that allows them to make less of a fuss and to move faster. These kinds of situated considerations are normally not taken into account by those designing the script for and configuring the correct use of the technology in question.

From a strictly medical point of view, one could claim that the additional time spent checking and sending an ECG while at the scene of the emergency is worthwhile in every case. Several researchers have shown that identifying symptoms and initiating treatment at an early stage can significantly improve the patient’s survival chances (Anantharaman and Swee Han 2001; Karlsten and Sjöqvist 2000). In cases of acute myocardial infarction, time is often of the essence, as has been shown in previous research (e.g., Björklund et al. 2006). If the ambulance crew would send a heart patient’s ECG to the Coronary Care Unit, where it is checked by coronary disease experts, and, if there is an acute problem, then transporting the patient straight to the Coronary Care Unit rather than to the Emergency Department can shorten the patient’s time to treatment by approximately three hours. In other words, the extra ten to twenty minutes that the crew would spend checking a patient’s heart with the ECG at the scene of the emergency may be minutes well spent.

The ambulance crews are, of course, aware that time is of the essence. The crews’ deviations from the guidelines are precisely an effect of their ideas about how best to save time. Using technology to communicate information on the patient’s status to the hospital while still at the scene of the emergency can improve the hospital staff’s triaging and shorten the patient’s passage through subsequent steps in the care chain, as was the case with the young boy from the swimming hall. This saves time for the hospital staff and may shorten the patient’s time in medical care. This time savings, however, may prolong the time spent during the ambulance assignment. Given the ambulance crews’ preference for “providing care with the gas pedal,” the meticulous transmission of information conflicts with their preferred working methods. As a compromise solution, trying to both shorten the time spent at the emergency scene and live up to the demands placed on them by “the people in charge,” the ambulance crews typed and transmitted some information from the ambulance and used the cell phone to provide information to the Emergency Department while on the way to the hospital. In this way, the ambulance crew managed to get away with deviating from the stipulated guidelines and at the same time reduce the risk of managerial repercussions.

Discussion

In this article, we have highlighted tensions in the ambulance service caused by the introduction of new telemedicine technologies. Health services around the world have set a transformative process in motion that may change the role of the ambulance service, integrating it more closely into the larger chain of care. The use of telemedicine technologies demands closer cooperation between the ambulance service and other medical units and implies a strengthened role for the ambulance crews as information gatherers. This may not correspond well with ambulance crews’ ideas of what ambulance care is all about, that is, getting the patient to the hospital as swiftly and safely as possible.

The introduction of new technological systems and new work procedures often meets with resistance. Scholars such as Douglas (1969) and Nelsen (1997) have shown the negotiated order of work processes; they have also, to some extent, addressed problems that arise when new guidelines and equipment are introduced into work processes. These researchers highlight ambulance crews’ actions but give little consideration to the role of the material artifacts in their discussions. While social relations are important in these processes, to understand how a technology functions and how useful it is in practice, we need to pay closer attention to materiality, to scripts built into the technology, their constraints and possibilities, and how these are handled by various actors. Thus, we need to consider the extent to which the technology is compatible with users’ perceptions, experience, knowledge, and traditions, and what the users do to localize and tame the technology based on their local needs and practices. We have tried to extend the results from previous research by focusing not only on social relations and the interplay among human actors, but also by taking material artifacts, rules, and regulations into consideration when scrutinizing social interactions.

While these concerns have been addressed in various science and technology studies already, in our view the cultural logic, which informs how the work is done, has not been given enough attention. We have tried to address this gap by showing the importance of an established and well-tried cultural stance toward work; in this case it colors whether and how ambulance crews use various technical tools in their everyday work practices.

The decision-focused logic inscribed in the technologies conceptualizes the work of ambulance crews as a cognitive information-gathering practice. This overlooks the interactive, cooperative, and heterogeneous nature of ambulance work. As we have discussed, ambulance crews take into account the social circumstances of each patient’s situation, the material conditions of the places encountered, and the emotional reactions of patients and bystanders. Getting the work done involves their continuous negotiation with the various elements of ambulance practice, such as patients, car wrecks, beds, staircases, bystanders, regulations, and more or less appropriate technologies.

We have presented examples of how the crews—given these circumstances and their preferred stance toward giving good care—try to actively tame the technologies and their prescribed uses. They do this by bypassing the step-by-step procedures built into the technologies, using, for example, proactive nonprescribed logout methods. They tinker with the technologies in order to handle various glitches and redundant features that slow down their work. Interestingly, we found no examples of what researchers have noted as an “interpretative flexibility” of the technology (Pinch and Bijker 1987); the taming that we noticed did not include changing the scripts of the tools, neither their material form nor the prescriptions for their use. But we do not know if feedback from the users may have led to subsequent changes in the scripts by the ambulance service company.

A prominent form of localization that we found was the crews’ deliberate nonuse of the technology, either as outright rejection or as postponement of its use, and often in opposition to prescribed rules. Depending on local circumstances and in line with their stance toward how to provide good ambulance care, the crews actively decided when to use the technologies and when this was not feasible or useful. Thus, we argue, localization not only entails decisions about of how a device is to be used (cf. Berg 1997), but it also involves decisions about timing (when) and place (where) to use it, how much (scope) and for what purpose (rationale) it should be used.

This nonuse or delayed use of a tool is something the crews do without much ado; it is an invisible practice. Had they voiced a more active, open protest or made obvious alterations of the technology, this may have been noted by the crews’ superiors and perhaps led to reprimands. The crews’ silent resistance is hard to detect; it also presents a challenge to researchers trying to understand the complexities of technology use in situations of change. Delayed use and intermittent, strategic nonuse is probably a very common strategy adopted by workers to localize a technology and subordinate it to their established practices and desires; it deserves more attention and an appropriate research methodology. As suggested by Ehn and Löfgren (2010, 4), cultural researchers tend to be focused on and “preoccupied with the explicit, eventful, and dramatic.” Explicit rejections are often noted by the researcher, whereas less expressive actions, such as ignoring or refraining from using a technology, are not as easily noticed. As we show here, the use of participant observation has made it possible to detect, study, and highlight the importance of such subtle and often overlooked activities.

Scholars in the STS tradition have given nonuse of technology a certain amount of attention, but mostly in relation to consumer technologies. However, as underlined by Oudshoorn in a recent study, a focus on nonusers of telecare technologies seems especially urgent, since a decision to resist using such technologies could affect health in ways that rejection of other types of technologies (e.g., those related to leisure or other forms of consumption) would not (Oudshoorn 2012, 126).

In line with this, one could argue that the ambulance crews misuse the technology or keep the technology from fully delivering as promised. However, this would entail fitting the situation into a success or failure matrix, which we reject. Rather, we claim that the introduction of new tools, to be workable, should be seen as an ongoing process, characterized by negotiation and compromise between workers, situations, rules, and technologies. It cannot be framed as an isolated, technology-focused experiment nor understood only in terms of evaluations from above. In addition, the situation is seldom static. While the ambulance crews in various ways resist the transformation of their work inscribed in the new tools and regulations, their preferred modus operandi, their stance, is not unaffected in the process. The ambulance crews appreciate that, with the new technologies, patients can receive care more promptly upon arrival at the hospital. They appreciate that patients with suspected acute myocardial infarctions can go straight to the Coronary Care Unit. They are in the business of saving lives and are focused on improving patients’ chances of survival and recovery. Given this, they often do use the technology, albeit with some delay and according to their experience-based assessments of the situation. Thus, they increasingly combine practices based on their earlier role of “providing care with the gas pedal” with a new stance oriented toward a role as technologically sophisticated information gatherers. Further studies of how workers, and others, localize new technologies should take into account such hybrid, but workable, cultural stances that people adopt in their interactions with technologies-in-use.