Knowledge Management in Locating the Patient in an Emergency Medical Service in Italy

Knowledge Management in Locating the Patientin an Emergency Medical Service in Italy

Fabio Dovigo & Ilaria RedaelliUniversità degli Studi di Bergamo, Bergamo, Italy (E-mail: [email protected]; E-mail: [email protected])

Abstract. This study examines an Emergency Medical Service in order to analyze the compositeset of activities and instruments directed at locating the patient. The good management ofinformation about the location of the emergency is highly relevant for a reliable rescue service, butthis information depends on knowledge of the territory that is socially distributed between EMSoperators and callers. Accordingly, the decision-making process often has to go beyond theemergency service protocols, engaging the operator in undertaking an open negotiation in order totransform the caller’s role from layman to “co-worker”. The patient’s location turns out to be anemerging phenomenon, collaborative work based on knowledge management involving twocommunities—the callers and the EMS operators—that overlap partially. Drawing examples fromemergency calls, the study analyzes the practice of locating a patient as a complex and multi-layered process, highlighting the role played by new and old technologies (the information systemand the paper maps) in this activity. We argue that CSCW technologies enable the blended use ofdifferent kinds of instruments and support an original interconnection between the professionallocalization systems and the public’s way of defining a position.

Key words: control room, emergency calls, ethnography, ethnomethodology, knowledgemanagement, technology blending

1. Introduction

Coming from research undertaken in an Emergency Medical Service in Italy(named 118), this paper aims to analyze how the process of locating a patientproduces viable structures of cooperation, which constantly change in order to fitwith the communication style of the callers and improve their ability in copingwith the emergency situation.

The research has focused on EMS work practices, with special regard for the roleof technologies in managing the patient’s location and the representation of theterritory. In the emergency service, sophisticated information technology is includedin a social environment planned to meet precise organizational requirements. Theanalysis of the potential of new technologies related to the patient’s location isstrictly connected to the investigation of knowledge management in the EMS(Artman and Waern 1999; Bowers and Martin 1999; Earl 2001; Engeström andMiddleton 1996; Fitzpatrick 2003; Groth 2004; Groth and Bowers 2001; Heath andLuff 1992; Martin et al. 1997; Randall et al. 1996). Normark and Randall (2005)

Computer Supported Cooperative Work (2010) 19:457–481 © Springer 2010DOI 10.1007/s10606-010-9118-7

examine the role of “local expertise” in an EMS in order to show knowledgemanagement’s relevance to safety critical domains. As they argue, knowledgerelevance is constructed by ongoing determinations of the emergency of cases.Consequently, knowledge and expertise sharing is socially distributed both withinand between different emergency call centers, whereas the “knowledge of the localgeography” is shared out between call-takers, callers and tools. As Luff, Hindmarshand Heath stress, the new technologies may support or interfere with collaborativework practices (Luff et al. 2000). In this regard, some studies on emergency servicesshow how the use of new technology may lead to the failure of the system (Turnerand Pidgeon 1997), as in the case of the information system named LASCAD(London Ambulance Service Computer Aided Dispatch) tested in 1992 in theLondon emergency service (Beynon-Davies 1999; Fitzgerald and Russo 2005;Finkelstein and Dowell 1996). Moreover, others studies draw attention to operators’efforts to avoid the new technologies as far as work requirements are concerned(McCarthy et al. 2004).

Our study highlights that technology and operator expertise have to activelyincorporate and valorize the “lay” knowledge of the callers in order to create andmaintain reliable knowledge in contexts where the knowledge of local geographyis organizationally and geographically distributed in unpredictable ways. Throughthe telephone interview the operators have to gather information about thepatient’s location and state (in order to decide which means to dispatch) and thespecific conditions of the rescue activities, such as, for example, the roadconditions (frequently a road may be interrupted owing to an accident or roadmaintenance). We argue that locating a patient is both a cooperative and aninterpretative practice, just as the gathering of information is an activityconcerning callers and operators. All these people are involved in assessing thelocation of the patient, finding the best way to reach him. A joint effort is requiredbetween operators and callers, but often difficulties may hinder the collaborationbecause of the callers’ unfamiliarity with the institutional procedures needed toorganize a rescue intervention (Martin et al. 2007). Through our analysis, wesuggest that sometimes the caller is asked to become an operator himself, and thecall-taker has to teach him how to do this in due time.

In Italy each emergency service carries out the rescue service in a specificprovince (Paoletti 2009). Through the telephone interview, the operators gatherinformation about the relevant illness (or accident). Afterwards, they have toprioritize which situation requires intervention, and to choose which type of vehicleand personnel to send to the patient. The emergency service is carried out incollaboration with police, the fire brigade, the Alpine rescue team, scuba divers andassistance associations that operate in the Emergency Medical Service district. InItaly there were a lot of assistance associations (such as the Red Cross) thatprovided rescue services before the 118 institution, and which nowadays stillcooperate with the emergency service. Volunteers of those associations are trainedby the emergency operators to employ “BLS” (Basic Life Support), a specific level

458 Fabio Dovigo and Ilaria Redaelli

of pre-hospital medical care carried out in the absence of doctors and/or registerednurses. The control room personnel make decisions about which ambulances toinvolve in the rescue activities using the triage system, a process for categorizinginjured people based on the severity of their condition. The patients are classifiedadopting the “ABC” protocol (A = airway management, B = presence or absenceof breathing, and C = circulation) to which a severity color code corresponds(red: the casualty requires immediate medical attention and will not survive if notseen soon; yellow: injuries are potentially life-threatening but can wait until theimmediate casualties are stabilized and evacuated; green: the casualty requiresmedical attention when all higher priority patients have been evacuated and may notrequire stabilization or monitoring). Another precise protocol stipulates themaximum intervention time. In order to dispatch the rescue team (commonly knownas the “rescue crew”) the operators need to know not only what happened to thepatient but also, primarily, where the patient is located.

This paper discusses the importance of CSCW technologies in supporting thecollaboration between professionals and the public as a central element of a commoneffort in finding people’s location, as well as the technological blending of old (thepaper maps) and new tools (the information system) that ensures the efficiency of theintervention. The collected data will emphasize the ways the EMS operators developan artifact connecting different kinds of tools in order to organize relevant knowledgeof a patient’s location. The aim of our analysis is to show how this artifact—the“adjacency system” achieving a “technological blending”—lets the operators facethe fluid nature of locating a patient in the EMS.

1.1. The study

The data analyzed in this paper is part of a wider corpus collected during the fieldstudy conducted within the control room of an EMS for several months (Dovigo andRedaelli 2007; Dovigo 2004). The control room is a communication centre for thecoordination of the rescue service in a provincial area. The data, collected in thecontrol room of the emergency medical service in the town of Lecco, Northern Italy,refers to an ethnomethodologically informed ethnography approach (Atkinson etal. 2001; Bloor 2001; Bentley et al. 1992; Garfinkel 1967; Suchman 1997, 2007),with the support of the conversation analysis in order to clarify the role ofcommunication in the emergency coordination centre (Luff et al. 1990; Boden andZimmerman 1991; Duranti 1992; Heath and Luff 2000; Fitch and Sanders 2005;Whalen and Zimmerman 2005). The control room is equipped with radios,telephones and computer consoles as operating systems used to deal with theincoming calls (which are recorded for legal reasons). Each console is manned by anoperator who answers the phone, dispatches the means, and supports the rescuers. Inthe observed situation, the operators aren’t separated by role into call-takers anddispatchers, but each operator has to be able to handle both functions for each case.

459Knowledge Management in Locating the Patient

The data comprises field notes, transcriptions of the emergency calls, andinterviews with operators (nurses, doctors, radio and computer technicians) whowork in the control room. The analysis draws attention to the operators’difficulties in locating the patients, and to the use of the tools available in order tolocate the injured people and properly guide the ambulances, avoiding mistakesin decision-making that can arise from communication gaps or inadequateorganization of the rescue activities.

2. The analysis

2.1. How to locate a patient through the telephone interview

As stated by the operators, the first piece of information they have to obtainduring the telephone interviews is where to send the ambulances.

“It is our duty to understand exactly where the accident happened by the endof the telephone interview otherwise it is impossible to direct the vehicles.You can’t move if you don’t know where to go.”

Conversation analysis studies show that the interactional organization of callsin this setting differs from ordinary calls (Wakin and Zimmerman 1999;Zimmerman 1992a, b; Whalen and Zimmerman 1987). According to our data,the caller frequently spontaneously says where aid is needed. Conversely, if thecaller doesn’t say where the patient is, the operator’s first question is about thepatient’s location. The priorities for the emergency service are to guaranteeassistance, and to send an ambulance (it doesn’t matter which one is available) tothe patient. The first priority is to obtain the patient’s location as the call may beinterrupted due to the caller’s hysteria or problems with telephone communica-tion. The site of the accident has to be clearly located by the operators, accordingto criteria set out in a precise protocol, identifying the village, the street name,and the house number (which we call “digital landmarks”). The call-takersusually use specific speech to obtain the details of the patient’s location. Forexample, they ask the caller to specify the name on the bell if the patient is in aplace of residence, or the kilometer if the patient is along a road.

The protocol the operators have to refer to about the patients’ location isdesigned with the idea that information will be ready to be used and processed.However, locating a patient is seldom a linear or easy process. Commonly thecallers, especially those in rural areas, give out information about the locationthey live not using addresses, but describing buildings, signs, structures which aresupposedly more visible or known. The visual experience is a decisive orientationelement for them (Barthes 1970), a kind of experience related not to abstraction,but to a practical knowledge that involves sight, habit, perception of elements thatwe define “analogical landmarks”.1


The use of two different positioning systems is clearly shown in our data as incase n.15 (see Appendix). In this case a woman called 118 because her cousindidn’t feel well.

Call n. 1: O\ Operator; C\ caller1. O\ 1182. C\ I’m calling from O. [the name of the village]. My cousin A., fifty years old,

doesn’t feel very well. He is lying down on the sofa3. O\ O., what is the name of the street?4. C\ O., we are in the lower part [of the village]. Do you know the umbrella factory?5. O\ No, you have to tell me the street name6. C\ Yes, if you come to the umbrella factory. Do you know where B.’ s factory

is?

The caller immediately says the village name, but it is very hard for theoperator to obtain the name of the street. The woman, probably living in anunknown area, offers an “analogical landmark” (the umbrella factory) instead ofthe street name because, from her point of view, the factory best defines thelocation. In this situation, the operator has to repeatedly ask for the street name,instructing the caller on how to cooperate (line n.11) and justifying her insistence:the ambulances weren’t going to be leaving from Lecco so it was necessary toobtain clear references.

7. O\ No, I’m not coming to you from Lecco madam8. C\ I know9. O\ I’m sending you a local ambulance

10. C\ Yes, ok. Tell them above the courtyard. I will be there. When you take theroad to come

11. O\ Lady, listen to me. There is a name for that street name, isn’t there?12. C\ B. street!13. O\ Ok14. C\ But no-one knows it15. O\ It doesn’t matter. You have to tell me the name because16. C\ B. street17. O\ you don’t have to explain to me18. C\ Number twenty-one but call for the ambulance now, please\

The caller’s use of analogue landmarks has different effects on the rescueactivities’ organization. The landmarks may constitute the basic elements onwhich to base the patient’s localization. Sometimes the caller isn’t able todescribe the patient’s location with an address because, for example, he is astranger, he isn’t in an urban area or doesn’t know the area where the aid isneeded.


Case n.16 Call n. 1: O\ Operator; C\ caller1. O\ 118 Lecco, good morning2. C\ Good morning, there was an accident on the motorway, over the tunnel

from Lecco3. O\ Which direction?4. C\ So, going, we entered the tunnel of Lecco, we came out of it, just over the

tunnel, over the curve5. O\ Ok, listen to me: where are you going? To S. or to M.?6. C\ We are going to M.7. O\To M.8. C\ Yes9. O\ Which tunnel? The tunnel of Barro Mountain?

10. C\ Yes, exactly, exactly11. O\ Over the Barro Mountain

Case n.18 Call n. 1: O\ Operator; C\ caller1. O\ 1182. C\ Listen to me, there was a serious accident on the street between M. [village

name] and E. [village name]3. O\ Between M. and E.?4. C\ Yes, over F’s x-ray factory [a factory in which devices that emit x-rays are

produced]

In those cases the “landmarks” are the only elements on which to base thepatient’s location, so they are useful if the operators can locate the patientcombining the mentioned landmarks with an address or kilometric landmarks.The analogical landmarks may also support the patient’s localization. As “digitallandmarks”, the village name, the street name, the house number, and thekilometers enable the location of the patient on a map, but in the real world donot always allow for quick localization. Driving an ambulance, it’s easier toidentify a place if you can recognize something “special” around it “at first sight”,rather than browsing a map searching for the street name and looking for signs onthe walls.

Case n. 20 Call n. 1: O\ Operator; C\ caller (from line n. 20)1. C\ Ok, I’m going along the street, however it’s 20 [the house number]. Tell

them that it’s 20, it is a small street. You find 20 after 26 [usually the evennumbers are on the same side of the road and n.20 is followed by n.22 ]

2. O\ After 263. C\ Yes because it is an inside track, after the railway, do you understand?4. O\ After 26, inside track5. C\ Yes, there is a track, a path that comes down towards the railway


The caller’s exclusive use of analogical landmarks slows down the telephoneinterview, wasting time because the citizen’s expectation about the amount ofinformation to provide when calling for assistance differs from the operator’s.Tracy (1997) describes this interactional trouble as “caller’s resistance” caused bya problem in framing: the operators assume a “public service” frame, whereas thecallers’ is a “customer service” frame. The emergency service operators expectcitizens to provide information that will help the organization accomplish its goalin specific ways (the correct address, the street name and number ... ). Therefore,they make an assessment of the legitimacy of the information given by the caller(public service frame). Conversely, the callers assume that what matters is theirdesire for the aid to arrive (customer service frame), not giving weight to theparticular way—analogical or digital—they give information (see case n. 15).

However, the “analogical landmarks” may also be considered a resource by thestaff. Despite the regulations they have to take into account, the operatorsrecognize the importance of this kind of information, which they usually refer tothe rescue team, as shown in case n. 15. The operator passes on to the rescueteam not only the village and street names, but the caller’s landmarks too. Thisway the rescue team was able to locate the patient rapidly.

Call n. 2: V\Volunteer; O\ Operator1. V\ C.? [The volunteer responded by saying the village name of the assistance

association headquarters]2. O\ Hello, please go to O. The caller told me that the street name is B.3. V\ B. street4. O\ She told me that it is an unknown street. In O., in the southern part, where

B.’s umbrella factory is, something like that5. V\ Yes, at the end... I’ve understood

In this case the caller said that she would wait for the ambulance on the road (calln.1, line n. 20). This offer was accepted by the operator, because a “sentinel”—aperson waiting for the ambulance in a visible place in order to guide the emergencyunits to the right place—can significantly reduce intervention time.

In conclusion, the “analogical landmarks” and the request for a person to wait toguide the aid (the “sentinel”) are important elements in the process of locating apatient, even if protocol doesn’t require them. The operator usually mixes informaland formal procedures in order to improve the service, actually increasing thepatient’s survival chances and/or reducing injuries.

2.2. Sharing knowledge

The service’s organizational structure provides for a precise distribution ofcompetences in the control room. To guarantee the rescue activities, theemergency service requires that different kinds of skilled operators cooperate


effectively: doctors, registered nurses, but also radio, telephone and computertechnicians, specifically trained in order to manage the emergency call. The service’sorganizational structure is based on the territorial knowledge provided by several tools(maps, street indexes, computers) that are supposed to be consistent with the locationactivities. As we noted, the maps are certainly useful, but little help in makingdecisions when conditions change, for example due to road maintenance. As thecontrol room staff widely recognizes, the maps are abstract representations, farremoved from concrete circumstances, and the rescue activities depend to a highdegree on the personnel’s knowledge of the territory in order to reduce the rescue time.

“The call management doesn’t change, but I feel secure if I know the zone.In some villages, for example, there are small streets that require the use ofspecial ambulances whose dimensions let them reach the patient. So, if youhave some knowledge you ask the caller: ‘Can the ambulance go beyondthat street? No? I will warn the team to use the small ambulance’”.

“When you have to send a helicopter it is important to know where the parkingarea for the landing is; if the patient is in the mountains and you know the areayou can advise the team on which side of the mountain there is a landing area”.

The personnel’s territorial knowledge, which develops due to professional andnon-professional activities, is distributed through control room and rescue teampersonnel in an interesting and dynamic way. Similarly to Normark and Randall(2005), we also recognized the contingent nature of knowledge about locationthat isn’t provided in any hierarchical form. Nevertheless, in the EMS describedby Normark and Randall the operator taking the call continues to act as casemanager, though strictly relying on the knowledge provided by his colleagues,while in the EMS of Lecco the role of case manager is assumed by the operatorwho best knows the area of the accident. This implies a quick reorganization ofthe operator’s activities, as the EMS personnel’s expertise is centered on theability to alternate individual activities with collaborative ones, in a way thatcannot be easily planned. Moreover, the operators’ reorganization—in order tomanage the request for aid on the grounds of the territorial knowledge—leads tothe personnel’s role change. Despite the organization identifying the doctor incharge in the control room as the professional who has the duty and theresponsibility to guarantee the efficient operation of the emergency service, eachrescue intervention may require the identification of a “chief operator”, whomight not be the official one (and to change him many times if necessary). Duringthe phase of locating the patient, a nurse or a technician may become the “chiefoperator”, playing a strategic role in the rescue activities. Moreover, as all thetelephone conversations are recorded, what the operator in charge is saying gainsinstitutional importance. Therefore communication technologies contribute tostrengthening the leveling of the different professionals operating in the control


room, as the possibility for each member to be the “chief operator” (althoughonly in some of the rescue phases) affects his professional status too (Tjora 2001).

But the EMS operators don’t rely only on their colleague’s competence inlocating a place. As we noted above, they usually encourage the callers to sharetheir knowledge, asking for landmarks that sometimes are the sole elementsavailable in locating the patient. The EMS operators, particularly when the callerisn’t able to give out an address, need to adopt well-known and easy-to-usepractices to locate a patient, having little time to spend on discursive practicesaimed at defining the patients’ locations. Since the EMS is a time critical domain,the request for landmarks is an opportunistic use of known and widespreadpractices that enable the caller-taker to localize a patient even if the caller doesn’tknow the area, simply asking him to look around and describe what he sees.

“If you don’t know the area, you ask the caller for landmarks that may beuseful for the rescue team who usually know the area better than us”.

In short, the essential knowledge that enables the proper functioning of the EMS istransversely shared by personnel, callers and tools. In the common effort of locatingthe patient, the callers and the call-takers use both formal and informal procedures,building an ad hoc, temporary community of practice (Wenger 1998, 2000). Thiscommunity benefits from the merging use of two positioning systems, which make itpossible to code the territory by means of addresses and mark some elements of itwith concrete landmarks. During the telephone interview both of them are mutuallyengaged in guaranteeing the medical assistance, and share the same repertoire inlocating the patient. Moreover, according to our data the caller’s competence inlocating a patient is fully recognized by the EMS staff. As a general rule, theoperators don’t rely on callers’ descriptions of patients’ conditions, because the calleris usually unable to report the medical symptoms in a useful way. On the other hand,during the process of obtaining addresses or adjacencies, the carefulness of thecaller’s description about the location of the patient is never questioned. Supportedby technology enabling interactive shared knowledge, the callers are accepted in theknowledge community of the call-takers, a communication network that connectspeople with questions to people with answers.

Relying on their everyday life and/or professional experience, the callers’ andthe call-takers’ expertise on the territory can vary widely. Moreover, the relevanceof the expertise is subject to the social distribution of knowledge. According tocircumstances, the call-taker could be more or less of an expert than the callerabout the accident area, implying major changes in call management. Forexample, if the call-taker knows the area very well, he doesn’t need morespecifications from the caller. Consequently, the cooperative work to locate theplace is reduced to the minimum. In case n.10, the operator immediatelyrecognizes the place described by the caller. Therefore, not only does he notrequest adjacencies but, speaking with the fireman involved in the intervention,he is also able to add information that the caller didn’t mention.


Case n.10, Call n.1 (from line 16): O\ Operator; C\ Caller; F\ Fireman1. O\ Yes, yes, wait a moment! The street name is?2. C\ Tell me3. O\ In what street are you?4. C\ We are at the V. dealership [in which lorries are sold and repaired] in C.

[village name]5. O\ V. along the road. Ok, we are arriving, thank you

Case n. 10, Call n.21. O\ Hello, you have to go out. I suppose you will need the crane. You will use it

for sure, in C.2. F\ C.3. O\ On the road, the V. dealership, the Renault V. dealership4. F\ C., R., V.5. O\ You see the dealership along the road. It’s a lorry that carries soil that

turned over. The driver is trapped inside

Otherwise, the call-taker has to question the caller in order to obtaininformation not expressed before. In case n.1, the operator isn’t able to recognizea place, so he asks the caller for more details.

Case n.1, Call n.1 (from line 9): O\ Operator; C\Caller1. O\ Yes, you are calling from?2. C\ Listen to me, I am in T. [the name of the village], I’m in M [the name of the

town in which the village is]3. O\ M. village. The street?4. C\ I don’t know, I don’t know. I’m in T. village.5. O\ Can you tell me your phone number?6. C\ [the caller gives his phone number]7. O\So, you told me [the operator repeats the phone number]. Ok, the village

you told me?8. C\ T. village [the caller asks someone who is with him: ‘Do you know the

name of the town in which we are now?’]. It’s on the road that, if you come offthe highway, takes you straight towards M. but at the crossroads you turnright towards M., T. village.

9. O\ Wait, we are looking for it

The knowledge relevance about the patient’s location is also connected withthe ongoing clarification of the case. For example, if the call-takers realizethey do not have enough information in order to reach the patient, theymay ask the caller for more information not expressed before, as in call n.4,case n.10.


Case 10, Call n.4 (from line n.12): O\ Operator; C\Caller1. O\ You are inside the dealership parking area or on the road?2. C\ We are in the parking area around the dealership3. O\ So, arriving at the traffic island4. C\ If you arrive at the traffic island, you pass it on the way towards B.

[village name]5. O\ So on the left, inside the dealership parking lot6. C\ Yes7. O\ Ok8. C\ No, wait!9. O\ Yes

10. C\ After that you have to go/ inside on your left11. O\ Yes12. C\ There is the lorry dealership on your right13. O\ Yes14. C\ You have to enter from A.’s furniture shop entrance.15. O\ A.’s furniture shop, ok16. C\ You enter from A.’s shop, there is a slope on your left, that road leads to

the workshop [that is a service offered by the lorry dealership]

It is interesting to compare the difference between the EMS guidelines and theoperators’ practices as regards the knowledge relevance of patient’s location.According to the EMS guidelines, operators are by definition conceived as expert,whereas callers are commonly considered as inexperts (due, for example, tohysteria or other emotional biases). Consequently, only the call-takers are seen as“experts”, trained to respect a protocol about speaking to the “inexpert” caller,with the aim of obtaining clear references just in time using the tools availableinside the control room (paper and digital maps).

Conversely, according to the operators’ point of view a caller able to providean address is a recognized “expert”. Sometimes a caller could even be a “superexpert”, who knows an address and at the same time supports its identificationdescribing concrete landmarks (Table 1. See case n.20, call 1).

Table 1. Caller levels of expertise.

Locating a place

CALLER

Address Landmarks Address and adjacency Neither address nor landmarks

Inexpert X XExpert XSuper expert X


Moreover, differently from what the EMS guidelines suggest, the datadistinguishes different kinds and levels of “inexperience”. For example, a callercould be unable to give out an address because, although recognizing a clearlandmark around there (a farm), he is not able to provide further informationabout it (its address), as in case n.19.

Case n.19, Call n.1: O\ Operator; C\ Caller1. O \Emergency service 1182. C\ Good evening. You have to send an ambulance here, in front of M.’s farm3. O\ What is the village name?4. C\ C.5. O\ In front of the farm?6. C\ M.’s farm7. O\ Is there a street name?8. C\ I suppose, we know it is M.’s farm9. O\ and

10. C\ Over the secondary school it is ... near the secondary school

A caller could also be “inexpert” if unable to locate the patient providinglandmarks because, for example, the injured person is in the mountains and thecaller isn’t able to single out “something particular”.

Otherwise, the call-taker could also be “inexpert” in several ways: if he isn’table to obtain an address or landmarks, or if he isn’t able to match the landmarksobtained during the telephone interview with codified references (Table 2).

As emphasized by the analysis of the calls, not only do the organizationalconditions affect the achievement of information about the patient’s location, butthe EMS protocol also doesn’t provide for an adequate achievement ofinformation. Actually, if the call-takers followed what the protocol suggests,they wouldn’t be able to locate the patient in a large number of cases. With theintention of locating the patient in almost any conditions, the operatorsspontaneously started to introduce, after the request for an address, the requestfor landmarks. Doing so, the operators established a practice that highly increases

Table 2. Call-taker levels of expertise.

Locating a place

CALL TAKER

Address Landmarks Address and landmarks

InexpertExpert X

XSuper expert X


EMS efficiency, as the aid may be guaranteed on the basis of the landmarksprovided by the “inexpert” caller. As a result, the EMS fails only if the call-takerisn’t able to obtain references, or to locate the referred landmarks.

In short, the call-taker’s real expertise in locating a patient rests on a divergentinterpretation of organizational requirements that highlights the use of practicesreferring to the “community of practitioners locating a place”. This way theoperators are able to guarantee medical assistance in a wide range of situations,using information overlooked by the EMS organization.

As the knowledge about patients’ locations is geographically and sociallydistributed by the mediation of communication technology through EMS staffand callers, merging the caller’s expertise with the personnel’s expertise becomesa vital task. The knowledge relevance depends on “emergent properties ofsituation” (Normark and Randall 2005) and it is related to organizationalrequirements and informal procedures. This situation requires the operators to beable to coordinate in complex organizational activities that are unpredictable andunforeseeable, combining precise protocols with flexible skills.

Contrary to the positivist view based on the perspective of context assomething stable—what is relevant is definable once and for all—and separatefrom the activity that happens inside, our data outlines the context as aninteractional domain, emerging from the connection of activities and objectives,and definable according to a specific action. The context is actively built,supported and promoted by the range of unfolding activities, not fixed in advancebut dynamically defined. Accordingly, the context of the emergency service thatwe described can’t be reduced as merely a setting; rather it is something thatpeople do, a process rather than a requirement (Dourish 2001, 2004).

The use of non-EMS-codified data appears to be a consolidated practice among theEMS personnel. Consequently, an important question arises about the usefulness ofthis data. Actually, it is really difficult to know in advance which kind of knowledgemay be relevant, especially if the caller doesn’t provide an address. It is hard to saywhat knowledge will be displayed and by whom, depending on callers’ and call-takers’ knowledge of the territory, on the caller’s emotional state or ability to single outlandmarks, and on the call-taker’s ability to acquire useful information. Similarly, it isdifficult to say howmuch information is enough. A large part of this knowledge seemsto be resistant to codification. However, the way the operators are facing problems,like how to obtain knowledge and how to adjust callers’ information, is clear. First ofall, the EMS personnel obtain information about patients’ locations using citizens’well-known, widespread and easy-to-use experience. Then, they translate “analogicallandmarks” into addresses or map coordinates through a specific system—the“adjacency system”.

2.2.1. The “adjacency system”The EMS operators, and the most relevant tools used to guarantee a successfulrescue, are located in the control room. Each operator’s unit is composed of a


telephone, a radio and some computer terminals (three screens and a keyboard),which have functions that are interconnected thanks to the operation system. Thisway, for example, the operators can use the phone through the keyboard and seethe list of the radio contacts on the screen.

Moreover, the operation system enables the visualization of the rescueoperations that are in progress (and those completed), the calls and the radiocontact registration, and the digital case sheets’ compilation and management.When the operators register the rescue operation (which is mandatory for eachcall received), one of the monitors shows the digital case sheet to fill in with thename of the village, while the map of the area automatically appears on thesecond monitor. The digital map offers a zoom function, which lets the operatorview the area with different enlargements, while the information systemautomatically calculates the latitude and longitude of the area as thesespecifications are essential for guiding the helicopter team. Although the digitalmap database offers the operators indispensable information not achievableelsewhere, its functions need to be implemented by the EMS personnel. Someareas (for example in the mountains) are not represented in the database, so theoperators have to integrate the maps with new ones. Moreover, the operators usepaper documents such as maps, street indexes, or protocols defining, for example,which ambulances to send for each village.

These documents aren’t mere objects to look at. Some maps, for example, maybecome tools useful for planning and modifying the territory they represent.

“We had some problems with tourists because we have the lake (Lake Como).There are a lot of beaches that surround the lake, crowded with tourists whoaren’t able to tell you where they are. So we marked the beaches on the mapand identified them with numbers. Then we put signs on the beaches withcorresponding numbers fixed on the map. So, if a caller says “I’m inMandellodel Lario” we ask him “What is the number of the beach?” We don’t have tocheck each beach anymore in order to find the patient”.

This concurrence of different maps and overlapping representation systemsdefines the emergency service as a “heterotrophy” (Foucault 1998), a single realplace partially isolated in which several spaces co-exist.

Furthermore, the maps may enable the operators to follow the bends in the streetsin order to be ahead of time, and direct the rescue teams to the desired place.

“Very often, we can ourselves intervene to direct the vehicles. Using maps,and based on our experience, we can say: ‘Go straight and then turn left’”.

As the emergency service’s effectiveness is related to the use of technology, aswell as to the operators’ knowledge of the province, the staff has to know themost common “callers’ landmarks”. The EMS personnel belong to two differentand partially overlapping communities of practice: the practitioners in locating aplace, and the medical practitioners. These communities share with the callers the


same way of coding and highlighting the territory (Goodwin 1994, 2000;Goodwin and Goodwin 1996), but they need to define standing associationsbetween “callers’ common landmarks” and map coordinates in order to face theorganizational requirements of the EMS. Using the maps and exploring theterritory, the operator succeeds in defining what they call “adjacencies”, which aremaps on which abstract coordinates are interconnected with common landmarks.

“Our experience with road number 36. Frequently the callers don’t know theterritory, so we thought of helping them in this way: we highlighted theroad, marked the kilometric landmarks and covered the entire road. Than wenoted down, for each landmark, what is visible. So, if nowadays the callertells us ‘I don’t know where I am now’ we ask him ‘What do you see? The‘x’ factory? Ok, we know where you are!’”.

Moreover, the operators create and update a particular kind of link between theinformation system and maps, called “adjacencies system”. When an operatorenters the village name into the digital case sheet, near the name the indication ofsomething important in that area (such as the name or the identification number ofa main road, a village name or the name of a district) appears immediately. Theadjacencies may be references well known to the callers but, above all, they areinformation defined by the EMS operators about how to reach an area as quicklyas possible. Usually, a series of numbers are visible on the bar, referring to theplate number of the “papered” maps. This way the operators can choose thecorrect page in the street index, available to each call-taker, as the digital mapsaren’t updated as quickly as the paper ones (new settlements and new streets areconstantly being built).

To understand what the operators see on the list of the ongoing rescue interventions,we can look at the last case in the list of Figure 1. There is the small town’s name(“Barzago”), the number of the main road that leads to it (SS 342) with the direction tofollow (towards “Como”) and the plate number of the paper map (15H5).

Figure 1. Example of information based on plate numbers.


The name of the village is basic information. Actually, it is hard for the call-takers and rescue personnel to know the position of each street, whereas theposition of the villages is better known (as is the position of the main roads of theprovince). So the call-takers may provide indications to the rescue team aboutwhich area to reach, despite none of them knowing the location of the streetexactly. This information lets the operators get their bearings rapidly, in a waythat wouldn’t be possible if the monitor showed only the plate numbers (Table 3).

The “adjacency” may be used in different ways, according to the territoryknowledge referred to each rescue intervention. When the caller gives out an address,the operator inserts the data into the case sheet, so the adjacencies and the relatedelectronic map appear. Then the operator relays the address to the rescue team,specifying (or not) the landmarks the caller may have provided, and the adjacency.

Otherwise, if the call-taker obtains little information, for example the name ofthe town, he may insert this data into the case sheet. This way he obtains theadjacencies, which help to direct the rescue team to reach the patient, as in case18. The caller said that an accident had happened in an area between two towns,over “F.’s x-ray factory”. The operator, filling in the case sheet with the name ofone of the two towns, obtained an adjacency (the number of the road that leads tothe town: 62), the electronic map of the area and the paper map coordinates.Verifying on the paper map that the road reported as the adjacency was the onlyroad connecting the two towns, the operator was able to direct the rescue team.

Case n.18, call n.3: O\ Operator; V\ Volunteer1. O\ 118 Lecco2. V\ Hi M.3. O\ Hi F., you must go to M., there is a person who was knocked down4. V\ Ok5. O\ We don’t have doctors available now. Between E. and M.6. V\ Between E.7. O\ On road number 62, a woman knocked down, conscious, she doesn’t move

her legs

When the caller is mostly able to provide landmarks (for example when the injuredperson is along the main motorway across the province), the operator may search formore information on the map where the “common landmarks”were registered. Doing

Table 3. Example of adjacencies system.

Town name Street number [visible only when the fileof a single rescue intervention is open]

Adjacency Map coordination

Barzago SS 342/Como 15H5Vercurago Via Roma 11 Gerolamo San

[a village name]31C5


so the operator may increase his knowledge about the area obtaining the town name,which, inserted into the case sheet, enables him to look at the adjacencies.

Case n.16, Call n.2 :O\ Operator; V\ Volunteer6. V\ N.? [The volunteer responded by saying the village name of the assistance

association headquarters]7. O\ Hello, you have to go out8. V\ Yes?9. O\ on 36

10. V\ Yes11. O\ Towards the south, past the O. [the small town name] exit, after the Barro

mountain, on the downhill slope

The special use of information technology connected with “old tools” such as papermaps and street-indexes, shows that the operation system can become part of a frameof actions in ways that the computer programmers didn’t make a provision for(Pettersson et al. 2004). The “old-fashioned tools”, far from being out of use, can takepart in courses of action in which they have a basic rule. The paper maps, namely, canbe combined with information technology in innovative ways that let the operators bemore efficient. This use of the tools can be defined as “technological blending”, as thetools’ exploitation is strictly interconnected. The “adjacency system” composes thetool affordances, making the proper information for each case available, developingthe technological blending not as occasioned knowledge sharing, but as a strategy ingathering information (Hutchins 2005). Briefly, the “adjacency system” seems to be a“hyper-tool” because it is a device with references to other graphic representations thatthe operators can rapidly access. The system allows each tool to overcome the linearconstraints designed by their foreseen use, intertwining the paper and electronic mapsby links making up a non-linear medium of information.

The “adjacencies system” testifies that the call operator’s job is performed on thefine line between respecting protocol and creating new forms of formalizedknowledge. In doing so, the operators translate the information that comes from theprovince into stable points of reference on which to plan and carry out the rescueactivities, reducing improvisation. Although improvisation is one of the most useful ofthe operators’ skills, as the “adjacencies system” may not be viable in all the possiblecases, to improvise means to increase the operator’s risk of errors. The adjacencysystem lets the call-takers maintain knowledge bases which allows the EMS operatorsto localize a patient and to send the aid timely, even if no one in the emergency serviceor in the rescue teams knows the adjacency referred to by the callers.

By and large, the complex interconnection between the information collected bythe paper/electronic maps and the personnel/callers’ knowledge constitutes a non-linear medium of information. All these kinds of knowledge are constantlycombined, aiming to face the unpredictable feature of each patient’s location. TheCSCW technology, supporting technological blending and knowledge sharing


between callers and call-takers, plays a strategic role in supporting the organizationalproperties of the behavior seeking knowledge in a patient’s location. In gatheringinformation, the operators employ a strategy that we define “opportunisticexploitation of the expertise”, using “profane” strategies—the common people’sway of coding and marking the territory—as they are ready-to-use and functional forthe call-takers, who are facing time critical problems. Furthermore, creating theadjacencies the operators take advantage of another “callers’ orientation strategy”,using the “point of reference strategy” that refers to the “common people” way tolocate a place. Better than the exclusive use of landmarks, the adjacencies are aninformation process supported by the EMS operators and/or the rescue crewpersonnel’s knowledge, enabling the operators to correctly frame the understandingof the area that needs to be reached (Landgren 2005).

In case a call-taker doesn’t know the area, or the person who knows it doesn’thave the time to manage that particular case, the “adjacency system” lets theoperators translate vague information into organizationally useful information,that is, an address or map coordinates. Moreover, the adjacency system enablesthe operator to check the caller’s vague information in order to detect unfoundeddata, saving them having to call the citizen back for more details.

The “adjacency system” is a tool collecting different kinds of territory representa-tions and positioning systems, enabling the operators to find their bearings in it. Thevisual representation and organization of data plays a strategic part in the rescueactivities, offering quickly available information, and creating an environmentcharacterized by information redundancy, suitable for continuous cross-control ofinformation.

The combined use of these tools provides complementary information, enablingthe operators to face the organizational requirements to protect themselves from legalimplications, and to save time providing the most useful information to the rescueteams, thanks to the socially distributed nature of expertise.

3. Conclusion

In this paper, ethnographic data has been analyzed in order to highlight thecomplexity of locating the patient as a core phase of the rescue activities, and toshow which role tools and technology play in this process in order to harmonizethe different kinds of knowledge owned by operators and callers.

The control room operators’work repeatedly goes through the space in and outsideof the control room. Their work creates a hybrid space in which the representation ofthe events happening outside of the control room is coherent with the activities in thecontrol room. The tools, the personnel’s knowledge of the territory, and the documentsused, integrated and created, build a frame on which to create spaces of intervention.

Moreover, locating the patient proves to be an emerging phenomenon as acollaborative job. The rescue intervention is a multi-layered process involvingvarious subjects: the control room operators, the callers, the rescue teams, and


different agencies. Therefore, the decision-making process is more open than itappears on emergency service protocols. Knowledge of the territory is sociallydistributed and its relevance is connected to each case’s development.

Our study stresses the need for collaboration between professionals workingwith the public. Information-gathering during the telephone interviews is acomplex interactional, interpretative and collaborative process. The data showsthat collaboration with the callers may be hindered by organizational proceduresand prescribed response options. At the same time, the prescribed information theoperator has to obtain is worthy, giving the minimum information necessary tolocate the patient, and protecting the personnel from legal implications. Theprotocol, however, doesn’t make provisions for the caller’s inability to give anaddress. In these cases the operators have to recognize how much information isenough in order to locate the patient. It is not an easy task, as a lack ofinformation increases the potential for errors and, conversely, collecting too muchinformation may lead to a waste of time resulting in a bad rescue intervention.Legitimating both different positioning systems used by them and the callers, theoperators create a system of references which make it possible to translate theelements of one into the other, and vice versa. This complex task forces the EMSpersonnel to increase its knowledge of the territory. On the one hand, the operatorsexplore the territory looking for the “analogical landmarks”, that is, looking at theterritory through the callers’ eyes. On the other hand, they associate the abstractcoordination respecting the service rules, which means developing the serviceterritory knowledge through various and flexible tools. Using the “paper” maps’plate number and the possibility of inserting new data into the computer, theoperators create an opportunistic network between maps and the information system.As a result, the tools are used to generate new configurations, according to theiravailability in this peculiar work context, producing a blended use which exploits thedata organization and enhances the visual (“at first sight”) dimension of the tools.

From our analysis some questions about the future possibility of designing asystem for local knowledge suitable to the call-takers’ needs arise. Landgren(2005), for example, suggested providing first-hand information to the crews,enabling them to listen to the conversation between caller and call-taker.However, this is not an easily manageable solution, for technical and legislativereasons, as in many countries—Italy included—the current laws about privacydon’t allow for this. Conversely, according to our analysis, the “adjacencysystem” emerges as a tool able to check and enrich the caller’s information. Allthe functions of the “adjacency system” may be provided by an operative systembased on digital maps displaying a representation of the territory. These maps areset up with abstract coordinates, concrete landmarks, and adjacencies (asinscriptions and/or marked elements represented on the map). As a recommen-dation for future research, it will probably be useful to test digital maps viewedon a monitor on a table, offering enlargements of the activated area—for examplethanks to a touchscreen—by the operator following the bends in the streets.


Landgren, moreover, proposed enriching the digital maps with complementaryinformation coming from a sensor system. We suggest, instead, creating a searchengine for visible landmarks which enables a search for information, although westill need to face the problem of how to define the landmarks to report on themaps. The callers usually draw on two strategies to identify somethingrecognizable in an area that they don’t know very well. They may describe whatthey see (a factory, the chemist’s, a parking lot, a shop ...) or what they assume iswell known (a farm or a workshop). Accordingly, the landmarks may be based on“visual recognition”, or may come from the people’s knowledge of a place. Thisimplies that the “visual landmarks” could be coded more easily than the secondones. Consequently, it will be necessary to translate, as far as possible, thelandmarks coming from the callers’ experience into the visual ones. The data thatwould come from the exploration of the territory and the use of databases (suchas a list of the companies and shops in the province) could be utilized by call-takers adequately trained to ask for visible landmarks. Of course, as the territory’slandmarks are constantly changing, and the development of a search engineshould provide for a constant updating of the data, in order to ensure an evenmore accurate and rapid rescue service.

Appendix

Transcription of calls n.1 and 2 of case n.15. (original language). Thetranscriptional convention derives from “La banca dati del “Progetto di Pavia”sull’italiano lingua seconda” (Bernini 1994)

Call n. 1 (1’20”): C\ chiamante; I\ infermiere di centrale operativa; V\ volontario del soccorso sulterritorio1. \I\ centodiciotto2. \C\ senta telefono da- O. C’è_ qui_ mio_ cugino_ A._ di_ cinquant’_anni che si è/sta

male. Si è sdraiato &sul divano&3. \I\ &O.& in che via signora?&4. \C\ O. noi siamo in basso. Avete presente l’ombrellificio=5. \I\ no mi deve dare la via6. \C\ sì se voi venite all’ombrellificio B._sapete_ dov’è_ l’_ombrellificio_ B.?7. \I\ !no! non arrivo io da L. signora8. \C\ a ecco9. \I\ le mando l’ambulanza della zona10. \C\ !sì appunto! Dica lì, sopra il cortile. Io mi faccio trovare/ quando prende la strada no,

per venire=11. \I\ = signora ascolti una cosa, ci sarà una via no?12. \C\ !via B.!13. \I\ ok14. \C\ ma non è conosciuta

(continued on next page)


(continued)

15. \I\ !fa niente! Lei mi dia la via &perché&16. \C\ &via B.&17. \I\ è inutile che lo spiega a me18. \C\ numero ventuno però se dice adesso all’ambulanza19. \I\ sì20. \C\ che ci facciamo trovare !sulla strada!, all’imbocco della strada che sale per O.21. \I\ sì22. \C\ noi_ ci_ facciamo_ trovare_ e_ lo_ accompagnamo_ perché_ è_ una_ via_ un_

po’_ fuori23. \I\ sì, va bene, quello va bene però24. \C\ sì25. \I\ almeno_ per_ avere_ un_ punto_ di_ riferimento26. \C\ sì_ sì, via B.27. \I\ la via/ il_ il nome della famiglia28. \C\ B.E.29. \I\ B. E’ uno che soffre già di qualcosa?30. \C\ no_ no_ no_ no_ no.31. \I\ e’ sano32. \C\ sano_ sì33. \I\ adesso si è sentito male?34. \C\ si sta sentendo male35. \I\ &è sveglio però^&36. \C\ &no_ no_no (XX)& sta sudando37. \I\ va bene glielo mando subito, grazie_buongiorno38. \C\ salve. Allora ha capito bene? O.49. \I\ sì, al limite ho il numero di telefono_ signora_ se_ rimane_ qualcuno-40. \C\ sì41. \I\ a casa42. \C\ sì, io43. \I\ va bene, grazie44. \C\ un po’ in fretta eh^Call n. 2 (40”)1. \V\ C. ?[risponde dicendo il nome del paese in cui ha sede l’associazione del

soccorso]2. \I\ sì_ ciao_ mi_ vai_ per_ cortesia a [+] O. m’ha detto che la via si chiama via B.3. \V\ via B.4. \I\ ha detto che è una via difficile da raggiungere nel senso che O. giù in basso dove

c’è l’ombrellificio B., &qualcosa del genere&5. \V\ &ah in fondo, si ho capito&=6. \I\ = ecco. Arriva anche il medico un uomo di cinquant’anni, nulla in anamnesi

adesso malore improvviso, svenimento, pallido, sudatissimo7. \V\ &giallo?&8. \I\ &ti mando anche il medico&9. \V\ va bene10. \I\ è un giallo_rosso11. \V\ giallo_rosso?12. \I\ sì, ciao



(continued)

Call n.1:; C\ caller; O\ Operator (registered nurse); V\Volunteer1. O\ 1182. C\ I’m calling from O. [the village name]. My cousin A., fifty years old, doesn’t feel

very well. He is lying down on the sofa3. O\ Oh, what is the name of the street?4. C\ Oh, we are in the lower part [of the village]. Do you know the umbrella factory?5. O\ No, you have to tell me the street name6. C\ Yes, if you come to the umbrella factory. Do you know where B.’ s factory is?7. O\ No, I’m not coming to you from Lecco madam8. C\ I know9. O\ I’m sending you a local ambulance10. C\ Yes, ok. Tell them above the courtyard. I will be there. When you take the road to

come11. O\ Madam, listen to me. There is a name for that street, isn’t there?12. C\ B. street!13. O\ Ok14. C\ But no-one knows it15. O\ It doesn’t matter. You have to tell me the name because16. C\ B. street17. O\ you don’t have to explain to me18. C\ Number twenty-one but call for the ambulance now, please19. O\ Yes20. C\ We’ll be on the road, at the entrance of the road that ascent to O.21. O\ Ok22. C\ We’ll meet on the road and I’ll go with you because it’s a out of the way23. O\ Ok, good, all right but24. C\ Yes25. O\ Is there at least a reference point26. C\ Yes, Yes, street B.27. O\ The street, the family name28. C\ B.E.29. O\ B.E. does he already have some illness?30. C\ No, no, no, no31. O\ He’s healthy32. C\ Yes, he is healthy33. O\ And now he feels ill?34. C\ He is ill now35. O\ Is he awake?36. C\ No, no, no he is sweating37. O\ Ok, I send you someone immediately. Thank you, good morning38. C\ Hi. So have you understand? O.39. O\ Yes, at least I have your telephone number too if someone stays40. C\ Yes41. O\ At home42. C\ Yes, I’ll stay43. O\ Ok, thank you44. C\ Quikly



Note

1. This definition echoes a similar distinction proposed by the environmental psychology between“survey” (abstract understanding of the spatial relationships between locations) and “route” (thepersonal knowledge of places or landmarks and the routes that connect them). See Münzer et al.2006; Tversky 1993.

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