Corman, M.K.Paramedics On and Off the Streets: Emergency Medical Services in the Age of Technological Governance. Toronto: University of Toronto Press. 2017. 219pp £20.99 (pbk) 978‐1442629875

Corman's ethnography of Emergency Medical Services (EMS) in Calgary, Canada, begins with an exploration of his own conflicting views of paramedics. He informs us how he saw paramedics as both lifesavers and passive healthcare workers who drive patients to hospital. He highlights EMS as a relatively neglected area within healthcare research, his own interest in this field of study having being piqued by a personal encounter with paramedics following a road traffic accident. Corman's work is situated in what could be described as a second transition in EMS, where new technologies are increasingly being brought in to govern working practices. The first transition in EMS occurred in the 1970–1980s, when EMS was a relatively new profession. It is from this era that the majority of previous work originates, often focusing on the psychological functioning of paramedics as ‘trauma junkies’ who become reliant on the psychological high of a ‘good’ call (p. 9). Whilst Corman returns to these concepts of ‘good’ and ‘bad’ calls, his work provides a more in-depth picture of the work of EMS, uncovering how the organisation of EMS, and other healthcare professionals with whom their work interfaces, influences what is considered a good or bad call. Corman's findings are drawn from a comprehensive ethnography of over 200 hours of observations and around 150 interviews. The book is divided into two sections and provides insights not only into the work of paramedics on the streets, but also the dispatch centre workers who organise the workload, and the doctors and nurses with whom the work of EMS interfaces. In the first section (chapters 2 to 5), Corman introduces us to some of the paramedics themselves, the setup of the ambulance, and some of the equipment such as the ‘Lifepak’ (a multi-purpose medical device capable of measuring blood pressure, oxygen levels, conducting ECGs, and delivering defibrillations) and the electronic patient care record (ePCR), a system introduced around 2008 to replace paper records. This section of the book uncovers some of the often unseen and unacknowledged work of the paramedics, such as learning to correctly lift patients and how the setup of the ambulance itself both constrains and enables their working practices. We are also provided with accounts of how paramedics attempt to play the system in order to maximise their time out on the streets and minimise the time spent waiting with patients in the hospital. For example, intravenous drips may be used to ‘sell’ the patient to the triage nurse as being more unwell, facilitating them being admitted to the hospital more quickly (pp. 67–71). Whilst it is easy to appreciate the paramedics’ desire to be out on the streets, where they feel they can be of most use, Corman highlights how these practices can impact negatively on their working relationships with the triage nurses, creating an atmosphere of tension and mistrust. The second section of the book (chapters 6 to 8) focuses primarily on the coordination and governance of EMS, or ‘the brains of the EMS’ (p. 117). Within this, we are introduced to the work of the ‘call takers’ and ‘dispatchers’ (p. 118). Recently, there have been moves towards standardising the work of the call takers, with the introduction of Emergency Medical Dispatch Protocols which guide the questions call takers ask people who contact them. However, not all calls made to EMS fit within the confines of these standardised protocols, and call takers are often required to ‘freelance’ (p. 123). Whilst this freelancing is often required to elicit the necessary information from callers, deviations from the standardised protocols will lose the call handler points when their work is assessed. Chapter 6 introduces us to the Regional Emerging Patient Access and Coordination System (REPAC) which is used to relay emergency department capacity to the paramedics. The intention of this system is to ensure that demand is spread evenly throughout the city. Yet the paramedics in Corman's enthography express cynicism about its efficacy, suggesting units are often all directed to the same site. Questions are also raised about how such a system benefits the patient, as the hospital with the most capacity may be the furthest away from the patient's home. Chapter 7 focuses on how new forms of managerial control have been introduced to tame the work of EMS. In this chapter, the reader is given greater insight into the ePCR and its secondary function, as a tool to monitor the paramedics’ labour, and how the paramedics themselves learn to use the forms as an insurance policy to cover their backs from potential trouble. He concludes his chapter by mapping the various institutional and social processes involved in organising, monitoring, and accounting for the work of EMS. The majority of these knowledge production processes rely on codified or quantifiable data which, Corman suggests, may fail to account for the breadth of work performed by frontline EMS. Throughout the book, Corman explores the increasing standardisation and surveillance within EMS through a critical lens, asking questions about whether these new technologies and protocols are really making the system more efficient, and whether improvements in efficiency necessarily benefit patients or, indeed, the paramedics. The book is an interesting and engaging read. However, I feel that the richness of the ethnography would have benefited from the inclusion of a greater variety of paramedic voices. Although, Corman conducted observations with 24 paramedics, the majority of data originates from just two individuals. Nonetheless, overall, his book offers a significant insight into the working practices of EMS. I hope it prompts greater interest and study of this aspect of healthcare.

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