I Am the Dragoman: EMS Translations and Boundary Objects in National Preparedness

James Robinson

EXECUTIVE SUMMARY

I have worked in emergency medical services (EMS) for nearly thirty years; from working on an emergency ambulance, to leading an EMS agency, developing local, regional, state and national EMS policy, and applying it in the real world. I have developed a breadth and depth of experience in and knowledge of my work, and have come to believe that my experiences are knowledge. Inasmuch as I can substantiate their generalizability by analyzing them through a theoretical framework, can contribute an understanding of EMS to that stems from a critical examination of practical EMS experience. It is for these reasons that I write in the first person.

My twenty-five years of experience in the Denver Paramedic Division has engaged me in meaningful work that has transcended all levels of government. The Paramedic Division’s community of practice, “groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly,”[1] in which I am a member, and for which I am a translator, includes its own workflow and culture, and a socially constructed identity found in other organizations and healthcare settings.[2] As a community of practice, and part of the broader OHEMS community of practice, the Paramedic Division has its own, and contributes to broader perceptions of what EMS is and does as a boundary object.

The story of EMS’ evolution in America reflects the influences of its historical development, federalism, politics, financing and governmental structures. Emergency medical services systems began to develop in an organized fashion in the late 1960s. Strong federal leadership and funding under the Highway Safety Act, the National Traffic and Motor Vehicle Safety Acts, and subsequently public Law 93-154, known as “The EMS Systems Act of 1973” (EMSSA), provided policy guidance for state and local jurisdictions to develop EMS systems with the methods standardization framework of fifteen requirements, through the “carrot” of grant funding, and led to a rapid growth of EMS systems nationally.[3]

Prior to this act, ambulance services were primarily transportation services housed in hospitals, fire departments or funeral homes, with personnel who had little to no medical training, and no support or regulation, with the exception of only a few states.[4] These services reflected the efforts of local entrepreneurs and local resources and preferences, without centralized (federal) oversight or funding for building or sustaining EMS or EMS systems.[5] 

Americans in towns and cities, and along its vast road networks, expect to be able to activate EMS through the standard emergency number, 911. Even outside of populated areas, there is often an expectation that “someone” will be there to help, including in the nation’s parks and wilderness areas. What EMS means to Americans, however, differs widely across the country, and reflects their local interpretations, experiences and individual activities in the EMS “arena.”[6] These perceptual differences are consistent with the interpretive flexibility of boundary objects. [7]

Star and Griesemer introduced the concept of “boundary objects” in their study of the organizational ecology of the Berkeley Museum of Vertebrate Zoology (MVZ).[8] The museum was a case study to identify how heterogeneous people and groups were able to successfully work together across different domains and “social worlds,” without having consensus about what the museum was.[9] To each actor, who represented individual passage points of information, work processes and translations to and from their respective communities, the museum meant something different.[10] None of these perceptions about what the MVZ was had primacy over the others, facilitating cooperation and coherent collective “meaning” of the MVZ, derived from the cooperative work and translated by its entrepreneurs.[11]

EMS’ development as systems and their constituent communities of practice is an analogous tale of locally derived meaning. Thousands of local communities of practice are among the actors in collaborative EMS work at local levels that has resulted in variable meanings, performance and results within the boundary object of EMS.[12] In operations, regulation and preparedness doctrine, EMS has multiple identities, supporting the notion of interpretive flexibility across its diverse communities of practice. It is a component of healthcare, emergency services, and public health, and has stakeholders in these and many other groups, each of which translate their own meanings of EMS between and among them and to their respective constituencies.[13] At all levels of inquiry, the collaborative work from which EMS results, the interpretive flexibility it represents, and the ability for actors to “tack back-and-forth” between local and broader EMS interpretations make EMS what Star and Griesemer consider a “boundary object.”[14]

EMS provides an object for targeted cooperative work across different communities of practice and disciplines. The majority of the stakeholders in EMS are aligned in disciplines with clear organizational and disciplinary domains and venues for their respective practices. However, those practicing the discipline of out of hospital emergency medical services (OHEMS), inasmuch as one exists, suffer from the ambiguity that the term “EMS” represents. EMS nationally reflects the efforts and translations of thousands of local entrepreneurs, connected by a common term and some initially standardized methods from the EMSSA.

National preparedness policy, based on translations of the EMS object from “experts” whose knowledge is prioritized above that of local OHEMS’ situational knowledge, results in discordant scaling from locally defended perceptions of the EMS object that may not be coherent with the broader national preparedness policy perceptions.[15] This leads to policy based on cloudy expectations, false planning assumptions, and skewed actual and potential EMS capabilities.

In the realm of preparedness doctrine, multiple translations of the EMS boundary object, compounded by the absence of a lead federal agency with responsibility and authority for EMS, leave EMS in policy purgatory. In homeland security policy, EMS is a component of the nation’s emergency services sector (ESS), over which the Department of Homeland Security (DHS) has responsibility.[16] In the National Preparedness Goal, EMS is part of the “response” mission area’s “Public Health, Healthcare and Emergency Medical Services” core capability, under the leadership of Emergency Support Function 8’s (ESF-8) lead agency, HHS.[17]

The only dedicated EMS office in the federal government is in the National Highway Transportation Safety Administration (NHTSA), a vestigial office from the 1960s translation of EMS as transportation, and the federal coordination body for EMS is the Federal Interagency Committee on Emergency Medical Services (FICEMS), which has a rotating chair, no funding, and no primacy of any agency over any other.[18]

The vague federal definition and the lack of methodological standardization are problematic for EMS capability and capacity in the national preparedness sense. They leave EMS as a commoditized transportation resource, a boundary object interpretation that may or may not scale from the local to the national level.

Although EMS personnel will be the first to respond in disasters with the other partners in the ESS, they are the least prepared component of community response teams, receiving the least training, funding, and inclusion in preparedness policy creation.[19] As of the date of publication for this thesis, there is no national policy requiring the delivery of EMS services, leaving states to this mandate, which only have four have done.[20]

A designated lead agency for the discipline of OHEMS, which disregards the delivery model, will support the development of reliable capabilities that correspond with the actual needs and capabilities of the OHEMS community of practice, rather than “abstract expectations.”[21] This will result in more coherent preparedness policy, benefitting from the incorporation of OHEMS’ situated knowledge. The nation needs a national dialog about emergency medical services in and among America’s communities, rather than in narrow expert policy spaces. A dialog with policy makers and the other actors in the EMS to ensure “the public gains a sense of ownership over government decision making,” revealing insights into appropriate levels of services, aligning expectations and providing opportunities for stakeholders to create new shared meanings and their translations into new EMS objects.[22]

[1] Etienne Wenger, “Communities of Practice: Learning as a Social System,” The Systems Thinker, January 21, 2016, https://thesystemsthinker.com/​communities-of-practice-learning-as-a-social-system/.

[2] Jean Lave and Etienne Wenger, Situated Learning: Legitimate Peripheral Participation (Cambridge: Cambridge University Press, 2001). Lave and Wenger introduced the concept of communities of practice, which has inspired a large body of literature subsequently.

[3] Emergency Medical Services Systems Act, Public Law 93-154, U.S. Statutes at Large 87 (1973): 594–604; Institute of Medicine Committee on the Future of Emergency Care in the United States Health System.

[4] Manish N. Shah, “The Formation of the Emergency Medical Services System,” American Journal of Public Health 96, no. 3 (March 2006), 416.

[5] Shah.

[6] Adele E. Clarke and Susan Leigh Star, “The Social Worlds Framework: A Theory/​Methods Package,” The Handbook of Science and Technology Studies 3 (2008): 113-137.

[7] Susan Leigh Star and James R. Griesemer, “Institutional Ecology, `Translations’ and Boundary Objects: Amateurs and Professionals in Berkeley’s Museum of Vertebrate Zoology, 1907-39,” Social Studies of Science 19, no. 3 (August 1, 1989): 393, https://doi.org/​10.1177/​030631289019003001.

[8] Star and Griesemer, 387–420.

[9] Star and Griesemer, 388-90. Clarke and Star provide a much more detailed framework for interacting social worlds in their 2008 publication: “The Social Worlds Framework: A Theory/​Methods Package.”

[10] Star and Griesemer, “Institutional Ecology, `Translations’ and Boundary Objects,” 390.

[11] Star and Griesemer, 389.

[12] Institute of Medicine, Emergency Medical Services: At the Crossroads (Washington, DC: The National Academies Press, 2007), 3.

[13] Star and Griesemer, “Institutional Ecology, ‘Translations’ and Boundary Objects,” 390-91; “What Is EMS?” EMS, accessed August 7, 2018. https://www.ems.gov/​whatisems.html.

[14] Susan Leigh Star, “This Is Not a Boundary Object: Reflections on the Origin of a Concept,” Science, Technology, & Human Values 35, no. 5 (2010), 605; Star and Griesemer, “Institutional Ecology, ‘Translations’ and Boundary Objects,” 392.

[15] Paul R. Carlile, “A Pragmatic View of Knowledge and Boundaries: Boundary Objects in New Product Development,” Organization Science 13, no. 4 (August 1, 2002): 445.

[16] “Emergency Services Sector,” Department of Homeland Security. Accessed July 8, 2015. http://www.dhs.gov/​emergency-services-sector.

[17] “Core Capabilities,” FEMA. Accessed August 23, 2018. https://www.fema.gov/​core-capabilities.

[18] See EMS.gov for information on NHTSA’s office, and “Federal Interagency Committee on EMS,” EMS, Accessed May 31, 2015. http://www.ems.gov/​FICEMS.htm, for information on FICEMS. See also Frank J. Cilluffo, Daniel J. Kaniewski, and Paul M. Maniscalco, “Back to the Future: An Agenda for Federal Leadership,” Washington, DC: George Washington University, 2005, 12.

[19] Institute of Medicine, Emergency Medical Services, 4.

[20] M. Van Milligan et al., An Analysis of Prehospital Emergency Medical Services as an Essential Service and as a Public Good in Economic Theory, Report No. DOT HS 811 999a (Washington, DC: National Highway Traffic Safety Administration, 2014), 11.

[21] John Seely Brown and Paul Duguid, “Organizational Learning and Communities of Practice: Toward a Unified View of Working, Learning, and Innovation,” in Knowledge and Communities, 106, Science Direct, 2000, https://doi.org/​10.1016/​B978-0-7506-7293-1.50010-X.

[22] Cliff Oswick et al., “Codesigning as a Discursive Practice in Emergency Health Services: The Architecture of Deliberation,” The Journal of Applied Behavioral Science 46, no. 1 (March 1, 2010), 75-76.

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