from first aid to paramedical: ambulance officers in the health division of labour

COMMUNITY HEALTH STUDIES V O L U M E X , NUMBER I , 1986

FROM FIRST AID TO PARAMEDICAL: AMBULANCE OFFICERS IN THE HEALTH DIVISION OF LABOUR

Evan Willis and Liam McCarthy

Department of Sociology, La Trobe University, Bundoora, 3083

Abstract This paper utilises a case study approach to

the emergence of the division of labour in health care. Such a phenomenon, the key feature of which is medical dominance, needs to be examined through the historical sociology of different medical occupations. In this case study the occupation of Ambulance Officer is analysed. From basically entailing driving the sick and injured to hospital, the work of Ambulance Officer has expanded to an established paramedical location in the social structure of health care delivery. Other themes in the sociohistoric- a1 development of Ambulance Officers examined include its voluntary origins, gender, industrial organisation, training and careers; as well as the development of its status as ‘adjunct’ to medicine.

Introduction Recent years have seen a revival of interest

in human service occupations for so long waylaid on essentially peripheral questions of the attri- butes of professional status. Spurred by writers such as Freidson and Johnson, and by growing interest in the labour process in general, the essential questions have become the extent of control exercised through power and domination between different occupations in the division of labour.2 Rather than being accepted as the result of technological imperatives or the inherent nature of particular occupations, the division of labour has come to be recognised as being essentially political in character.

The key analytical feature of the division of labour in health care is dominance by the medical profession.’ Medical dominance is ‘a shor- thand concept for a complex historical process of the establishment of control’, the study of which, in the health division of labour, must be ‘rooted in a more historical sociology of medical occ~pations’.~ In particular, the case study approach of the emergence of particular occupations in the health division of labour allows a greater understanding of the complex historical

WILLIS & McCARTHY 57

process by which medical dominance has emerged.

One such medical occupation little studied in the literature is that of Ambulance Officer. Drawing upon sociohistorical evidence from personnel records and oral histories from the city of Melbourne, this paper examines the emergence of the paramedical Ambulance Officer from his origins as a first-aid giving stretcher bearer. The focus is upon Victoria; the political organisation of Australia into seven semi-autonomous political States, has meant considerable variation in the manner in which ambulance services are provided, such as to make generalisation to the whole of Australia hazardous.

The occupation of Ambulance Officer is sociologically interesting for a number of reasons. Most studies of health occupations in the health division of labour have been concen- trated in the middle and upper echelons of the health hierarchy. Relatively little is known about those occupations which at least began very much in the lower echelons. From a primary identification as a driver of the sick and injured, Ambulance Officers have gradually become more involved in actual treatment of patients prior to hospitalisation. Indeed, until about the 1960s it is probably inappropriate to describe Ambulance Officers as a health occupation at all. Ambulance Officers themselves have tradi- tionally been drawn from working class back- grounds, expressed in a history of industrial militancy in Melbourne probably unparalleled elsewhere in the health workforce. The occupation of Ambulance Officer in Melbourne, furthermore, is now probably the only gender- specific occupation in the health workforce and one of a declining number in the workforce in general. Despite the existence of Equal Oppor- tunity Legislation, Ambulance Officers remain exclusively male in Melbourne. Furthermore, Ambulance Officers operate without an identifi- able occupational territory of their own in the

COMMUNITY HEALTH STUDIES

conventional sense that, for instance, optometrists or podiatrists have. Their domain can be very broad or can be very narrow, its defining characteristic is the emergency nature of the services provided.

In this paper we examine the emergence of the occupation of Ambulance Officer themati- cally rather than chronologically in order to draw out issues relevant to understanding its development.

Before considering the various sociohistorical themes in the emergence of Ambulance Officers it is appropriate to indicate something of what their work entails. While the image most people have of Ambulance Officers is the flashing lights and wailing sirens of emergency transportation, this in fact makes up only about 15 per cent of their work. The work also entails relatively routine transportation of patients from one hospital to another, or from hospital to home. Some of these transports from the ‘Car Division’ indeed involve vehicles of the mini-bus variety where patients are able to walk and are actually transported in seats. Secondly it entails ‘stretcher-transports’ of which emergency stretcher-transports constitute only a small proportion.

At the opposite end of the continuum from mini-bus transport, in terms of technological sophistication and the application of emergency medical treatment, are the Mobile Intensive Care Ambulances (MICA). Officers who staff this more paramedical part of the service constitute about 10 per cent of Ambulance Officers and undergo special training in the delivery of pre-hospital emergency medical procedures particularly in coronary and intensive care. While much of the subsequent analysis concerns the MICA segment of Ambulance Officers as the medically more sophisticated part of the work of Ambulance Officers, it should be kept in mind that the bulk of ambulance transports are of the more routine, non-emergency nature.

Voluntary Origins Like a number of other health occupations,

such as medical social workers, the origins of the occupation of Ambulance Officer are associated with a voluntary service which gradually became organised onto a full-time, paid basis. As Davies argues, the bulk of health care has always been provided in an informal, voluntary basis and usually by women in the home.5 Part of the general process of commodification has been the replacement of the notion of personalised voluntary service with the cash nexus as different


occupations have emerged. In the case of Ambulance Officers, their

origins lie with the St John Ambulance Brigade and the early occupational ideology is steeped in the philosophy of ‘The Order of the Hospital of St John of Jerusalem’. The first St John Ambu- lance Association in Australia was formed at a public meeting in Melbourne in June, 1883, with the objectives of teaching first aid and home nursing, and affording relief from suffering. The transporting of patients to hospitals was an issue from the start and in 1887 six ‘Ashford Litters’ (basically stretchers with wheels) were purch- ased with funds raised by the women’s auxiliary , and placed at Police Stations.

In 1899 the first horse drawn ambulance was provided and located at the metropolitan Fire Brigade Station at Eastern Hill near the centre of Melbourne, staffed on a voluntary basis, mainly by off-duty Firemen.6 A voluntary service was quite soon unable to meet the demands for such a service and with the Fire Brigade, Police and Salvation Army all declining an invitation to operate a transport service, the St John Ambulance Association called for tenders. The tender was won by Livery Stable pro- prietors, Fiske Bros., and the service com- menced on 1st January, 1903. Part of the con- tract was that all the men employed would be trained in the St John Ambulance First Aid Training Course.

In 1913, the St John Ambulance Brigade took over direct control of the service. In 1916 it was renamed the Victorian Civil Ambulance Service (VCAS) to establish a separate identity from the St John Ambulance Service and thereby assist in the task of raising funds to operate. To this end also the VCAS was registered under the Companies Act as ‘not-for-profit’. It was still operated directly through the St John Ambu- lance Organisation, a situation which persisted until 1938-39. At that time the VCAS reconsti- tuted itself as a charitable society (not-for- profit) under the Victorian Hospitals and Char- ities Act to bring it into line with other public hospitals and charities in Victoria in 1938, thus establishing a formally separate identity. The charter though, as well as specifyinf the rendering of first aid and transportation of the sick, also still specifically designated part of the charter ‘to assist particularly the St John Ambulance Assoc- iation and Brigade in their activites’.’ The formal administrative links with the St John Ambulance Brigade were severed finally in 1939 with the resignation of the Superintendent of the VCAS


as Secretary of the St John Ambulance Associa- tion.

While formal links were severed in Victoria at that time, (though remaining in other States such as South Australia) informal links remained important to the development of the service. Most senior administrators still have high positions within the St John Ambulance Association. On the training side, the First Aid Certificate and then the ‘Bronze Medallion’ of the St John Ambulance Association was the requisite qualification for Ambulance Officers until 1963. These St John Ambulance Courses were open to others besides employees of the VCAS, ‘graduates’ became members of the voluntary St John Ambulance Brigade which still provides first aid in a number of contexts, particularly at sporting events. The existence of a ‘reserve army’ of trained volunteers has been important to the development of Ambulance Services in two ways. First in situations such as the outbreak of typhoid in Melbourne’s south- ern suburbs in 1942, volunteers from the St John Ambulance Brigade were able to provide addi- tional staff on a temporary basis to meet the heavy demand. Second, and more negatively from the point of view of the Ambulance Offic- ers themselves, the existence of a reserve workforce diminished their industrial strength. By Ambulance Officers being unable to achieve closure of the occupation, the administration could call upon volunteer drivers in the event of industrial disputation and thereby diminish the effectiveness of Ambulance Officers’ withdraw- al of labour in a strike situation, as indeed occurred in 1938 and again in 1973.

Financial basis A further inheritance from the St John

Ambulance Service was the subscription financial basis. Like much else in Australian society, the financing of Ambulance Services represents a mid point between the total governmental financing of Ambulance Services in Britain and New Zealand and the minimal governmental involvement and entrepreneural basis of Ambu- lance Services in the United States. Almost half (48 per cent) of the 1984 revenue in Victoria came from government sources (either directly as grants or indirectly as reimbursement for transporting such groups as pensioners), 46 per cent from subscriptions and around 6 per cent from internal sources (sale of vehicles, et cetera).8 The Ambulance Service is thus semi- autonomous from the Victorian Health Com- mission. It is registered with the Health Com-

mission as a non-profit organisation although it is dependent on government sources for a substantial proportion of its revenue.

The original subscription model was the financial basis also of the St John Ambulance Association. Adequate financing has been a problem throughout the Service’s development and deficits have been a regular feature. The particular difficulty has been what have been called ‘charity calls’ where the patient has paid no fee or only a nominal fee. These seem to have constituted about one-third of all transports for much of the Service’s history. In 1984 the cost of ‘free’ transport to pensioners and health benefit card holders amounted to almost half the transport fees raised.8 Subscriptions could not cover these and increasing reliance has been placed on government grants with the help of some donations and benefactions.

The organisational history of the Service revolves, in considerable part, about the difficulties in obtaining adequate finance. This extended even to the level of the drivers themselves who were required, at the cost of their jobs, to attempt to collect fees from individual patients before transporting them. The name changes and restructuring outlined in the pre- vious section represented attempts to secure finance. As well there has been a continual concern with efficiency with the aim of en- couraging public donations. In 1926 for example, the Sehice introduced a number of mea- sures to this end including the installation of emergency call pillars in central locations setting a maximum 30 second delay in ‘turning out’ as well as establishing an Employer Subscription Scheme to cover accidents at Until 1950 the subscriber was entitled to one ‘free’ trip per year but after that time it became a contributor scheme as a form of insurance against ambulance costs. An important operating basis has always been that a subscriber was not entitled to receive special priority or treatment over non- subscribers.

Grants from local government municipali- ties were an important early source of finance, though in 1948 as part of a general rationalisa- tion of ambulance services and taking greater control, the government began making annual maintenance and capital grants with a portion earmarked for ‘indiginents’.lo Prior to that, government assistance was periodic and patchy. In that sense, and somewhat paradoxically, the greatest boosts to the Service have come at times when their services were most needed. The infantile paralysis outbreak of 1938, the ‘Black

WILLIS & McCAXTHY 59 COMMUNITY HEALTH STUDIES

Friday’ bushfires of 1938-39 and the typhoid outbreak in 1942 were all important in this regard. During the influenza epidemic of 1919, the ambulance staff level of 20 permanent officers, drivers and attendants, increased to 85. As Skea comments, ‘it took this severe epidemic to bring home to the authorities . . . and to the public, the need and the value of such a service in the community’.” Likewise, wars also provided a stimulus and the military connection has always been important to the Service. As a senior administrator commented:

Wars (unfortunately) are a good thing for Ambulance Services . . . in that they increase field-medical technology and provide vast experience in terms of medical and paramedical skill application . . . Both after November 1918 and October 1945 there were a significant number of serving Royal Austra- lian Medical Corp, Royal Australian Air Force and Royal Australian Navy sick bay attendants who joined Ambulance. Their knowledge and skills not only raised the overall standard but was also passed inform- ally to those who hadn’t served.

The armed services have always provided a career experience ,valued in the Ambulance Service. Until recently as well, Ambulance Officers wore military-style uniforms with stripes of rank on them.

Technological change One of the important factors of the evolu-

tion of the work of Ambulance Officers has been in changes in both transport and medical technology utilised. Like many other occupations, an enormous growth in technological sophistication has been apparent. The ‘Ashford Litters’, wheeled stretchers pushed by an attendant, were the most primitive with little concession to patient comfort, not even, apparently, equipped with a blanket. Horse drawn ambulances followed between 1899 and 1925. The first motor ambulance was brought into service in 1910 and designs gradually were developed in favour of patient comfort and staff convenience. The Air Ambulance Service was begun in 1962 to extend ambulance coverage to remote country areas as well as offshore islands. These utilised fixed- wing aeroplanes, though trials utilising helicop- ters were conducted in 1968 and form a part of the present service in one region adjacent to Melbourne. On the medical side, the amount of medical equipment carried has gradually in-


creased, the culmination of which are the MICAS which, as the name suggests, are able to provide an intensive care service at the scene and in transit and carry such equipment as defibrillatorslECG recorders and specialist anaesthetist’s aids,

Training Associated with increasingly sophisticated

technology has been the need for appropriate training, at least on the medical side. Indeed it is interesting to note that driving training has only been provided in the last few years; the minimal competence of a Drivers’ Licence has been assumed to be sufficient in the past. Medical training however has changed considerably. Un- til 1961 a Drivers’ Licence was the only employment qualification required, though Officers were expected to attain the St John Ambulance Brigade’s ‘Bronze Medallion’ in the course of their employment (and in their own time).

In 1948 the Victorian State Government took greater control over the Ambulance Ser- vice as part of its centralisation and rationalisa- tion of existing Ambulance Services. Prior to this the VCAS had been the largest of a number of different Ambulance Services, the others run by hospitals. Part of the Government’s concern was to ensure uniform training but practical difficulties prevented implementation of this aim for more than a decade.

In 1963, following a successful pilot training program in the Geelong region near Melbourne, the Hospitals and Charities, Commission appointed a Training Officer and established the Ambulance Training Advisory Committee to decide the duties and responsibilities of Ambu- lance Officers; that is delimiting their occupational territory.I2 The duties were defined pri- marily as threefold; rendering first aid, movement of the patient to medical aid and nursing care during this movement. In addition ‘it was agreed by the Committee that the concept of training should be broad enough to help Ambu- lance Officers develop initiative and individual thinking as well as become efficient technicians well versed in routine work’.” In other words a degree of autonomy was envisaged, without the medical supervision and following of medical instructions implied by the notion of a ‘techni- cian’.

Formalising and institutionalising the training of Ambulance Officers also required con- fronting the issue of their location in the social structure of health care delivery. As the treat-


ment aspect of their work increased in import- ance relative to the transport aspect, designation of Ambulance Officers as paramedical personnel began to appear in the 1960s. The Royal Australian College of Surgeons in 1969 defined Ambulance Officers as ‘members of the paramedical profession and an important adjunct to hospital and medical se~vices’.’~ In other words they exist outside the formal medical division of labour but are part instead of the wider health division of labour.

A training centre for Ambulance Officers was established in Melbourne in 1963, the first of its kind in Australia. This centre trained other paramedical occupations as well and was the location of training until 1978, when training of Ambulance Officers became more directly controlled by the Ambulance Service with the establishment of the Ambulance Officers’ Train- ing Centre. In time, with the growth of credentialism generally as occupational training and qualification became more formalised, a new qualification was established; the Certifi- cate of Applied Science (Ambulance Officer). This was a combination of classroom and on-the- job training spread over three years.

The establishment of the new training course and its output of new graduates with formal credentials also created an industrial problem. The older, less formally trained officers were suspicious of the new graduates (refer- ring to them as ‘bionics’). In a successful attempt to deal with this issue the Ambulance Service Administration granted ‘Certificates of Equiva- lence’, a sort of ‘grandfather clause’ for existing Officers with at least five years service.

Ambulance careers: an occupational sociology Until the employment of the Service’s first

specialised Personnel Manager in 1972, recruitment into the Ambulance Service followed fairly haphazard lines. Until the 1960s for instance, ‘collar and tie’ recruitment operated. Interested applicants were invited to present themselves on a designated Saturday morning, lined up and those not wearing ‘collar and tie’ immediately rejected. Next, those who could not produce their Drivers’ Licences were rejected. Having survived these two selection procedures applicants were preferred if they were married, had a background in the armed services, and were currently employed. If they survived all these selection criteria and showed they could drive an ambulance round the block, they were hired on the spot. Only with the employment of a Person- nel Manager did re.cruitment mechanisms such


as aptitude tests eventuate. From its inception until relatively recently,

the occupation of Ambulance Officer was a low status working class occupation akin to being a ‘driver’ or ‘stretcher bearer’. Although first aid was practised, the primary function, as the recently retired Operations Manager commented, was to ‘get people to hospital or medical aid as quickly as possible’. The inherent symbol- ism in the design of early ambulance uniforms attests to the primary function as being that of a driver. As the same respondent commented ‘it was just like a chauffeur’s uniform’.

The low status was also the result of the public image of ambulance work held at the time; the ‘blood and guts’ image of the ambulance and its perceived synonymity with the work of undertakers. All this did little to encour- age the notion of an ambulance career. As well as this, the early administration appears to have reflected its military background and was reported to be very authoritarian and overbearing by several retired Officers in interviews, dismis- sals occurring often for the most trivial reasons such as minor driving offences. These factors combined with the extremey stressful nature of the occupation meant that labour turnover was very high for much of the Service’s history.

Analysis of personnel records for the period 1945-1965 reveals interesting features of the occupation’s development. It shows for instance an average age of 25 years at commencement of service and also that a significant proportion came into the Service from other driving jobs. In 1945-50 for instance, 54 per cent of entrants came from driving jobs. In 1982 by contrast, the largest career background group of Ambulance Officer recruits was other health care occupations (34 per cent), such as medical orderlies, theatre technicians, ‘State enrolled nurses’ (nurses’ aides) and a small proportion of nurses.

Personnel records also demonstrate the high labour turnover rate. In the period 1945-50, 80 per cent of Ambulance Officers remained in the Service less than one year. By 1961-65 this figure was still 64 per cent. The figures bear out the suggestion made by a retired administrator that prospects for a career in the job were non-existent and, more importantly, that induc- tion and training procedures were inadequate for the tasks to be performed. Sending poorly trained and ill-prepared Officers to serious illness and injury cases, on a sustained basis, was not conducive to low labour turnover rates and high job satisfaction.

In the face of poor working conditions and


consistent with their working class position, the Ambulance Officers sought to improve the situation by trade unionism. In 1938 they affili- ated themselves with the Hospital Employees’ Federation (HEF) in an attempt to improve wages and conditions. So began several decades of industrial unrest, a feature which plagued the occupation up until the 1970s. In response to Ambulance Officers affiliating with the HEF, the management, in an action typical of their approach, withdrew the contributory Super- annuation scheme which had been introduced in 1929. A strike ensued but with little effect as the administration was able to utilise voluntary St John Ambulance workers.

The other response was to attempt to gain collective upward social mobility for Ambu- lancemen by changing the occupational ideology towards that of Ambulance Officer rather than driver. In line with this they left the HEF in 1976 and formed their own occupational organisation the Ambulance Employees’ Association (not trade union). In other words, a conscious, attempt was made to emphasize the treatment aspect of the work of Ambulance Officer and de-emphasize the driving work. While this has been successful to a considerable extent, it is still noteworthy that the editorial of a recent issue of the official Journal of the Ambulance Em- ployees’ Association commented:

Unfortunately in 1983 we are still faced with the title and rank of ‘bearer’ and all its connotations of a jungle safari in the days of Rudyard Kipling. At the least it suggests a class distinction that has no place in modern times. If Ambulance Services are serious in their attempts to raise and maintain stand- ards then we believe that action should be taken immediately to have such outdated titles deleted in favour of ‘officers’ . . .”

In other words the difficulty for Ambulance Officers has been to change their occupational identity with their employers and also in the public eye.

Industrial conflict through the 1960s cul- minated in a strike in 1973 when Melbourne was left with virtually no ambulance staff for a one week period. Again St John Ambulance Bri- gade, and this time also Red Cross volunteers, were utilised as strike breakers but the government intervened, dismissed the elderly Board of Management for their intransigent attitude to the Officers’ demands and appointed an interim

administrator. Flowing from the settlement, as well as substantial wage increases, Ambulance Officers gained a monopoly over the transportation of patients. No one else may transport patients for gain. This was important as it prevented encroachment on the occupational territory of driving, by organisations such as the St John Ambulance Brigade. It thus represented a form of ‘closure’ akin to that achieved by other health occupations who secure statutory registration.

Gender The Melbourne Ambulance Service re-

stricts entry into the occupation of Ambulance Officers to men only. While Ambulance Women are employed in other States of the Australian Commonwealth, such as New South Wales, Tasmania and the Northern Territory, the Mel- bourne Ambulance Service remains exclusively male at the level of Ambulance Officers. Victor- ian Ambulance Officers are probably unique in being ,the only gender-specific health occupation. While medical receptionists are overwhelmingly female and hospital porters overwhelmingly male, at least there is no barrier to members of the opposite sex being employed.

This situation persists despite the existence in Victoria since 1977 of Equal Opportunity Legislation which makes it illegal for employers to discriminate on the grounds of gender. Diffe- rent legislation is invoked to justify the exclusion, in this case Section 132 of the Labour and Industry Act which takes precedence over Equal Opportunity Legislation and does not allow women to regularly lift more than 16 kg, although this legislation has not prevented women being employed in other occupations such as nursing and the Police Force. Indeed, the operation of hospitals would be threatened if this restriction was enforced for female nurses.

Historically the closest women have come to being employed was during the Second World War when the ‘Air Raid Precaution State Com- mittee’ enrolled 150 female Red Cross transport drivers to operate commercial vehicles designated as ‘ambulances should the need arise’.16 The need never did arise and the female volunteers were unused. Indeed as part of the 1926 attempts by the VCAS to raise its efficiency and thereby justify public donations, a ruling was made by the Ambulance Administration that every employee be a fully qualified driver and certified first aider. This meant that even the office staff were all male, the idea being that ev,eryone could be called upon in the event of a

WILLIS & McCARTHY 62 COMMUNITY HEALTH STUDIES

disaster.” The first female office staff appear to have been employed in the 1950s.

The gender issue is complicated, furthermore, by having become a contentious industrial issue. In general, male Ambulance Officers are opposed to women being employed. A number of reasons have been suggested for this position, some reflecting more general male attitudes of opposition to women working and ‘taking’ jobs from men. Opposition has been reported from the spouses and girl friends of Ambulancemen to women being employed; a similar issue which emerged over Policewomen performing squad car duties. Other possible reasons are more specific, from concern with the ‘blood and guts’ nature of the work (though nurses’ work could probably be described in part at least as similar) to concern that the entry of women may dilute the industrial strength of the workforce.

In response to this issue, the Victorian Health Commission established in early 1983, a working party to consider the physical require- ments for Ambulance work. An ergonomist was employed to devise physical tests for entry into the occupation but reports thus far have stressed the difficulty of establishing these and remain inconclusive. In line with changes occurring in society at large, however, it seems reasonable to assume that this will remain a contentious issue.

Domination in the health division of labour As has been argued elsewhere, medical

dominance is the key analytical feature of the division of labour in health care.’ Hence it is necessary to consider the location of Ambulance Officers in the health division of labour. Else- where it has been argued that the medical profession has developed modes of domination over other health occupations to secure its pre-eminent position. These modes, subordina- tion, limitation and exclusion, reflect the different relationships which other health occupations have to the medical profession.

Ambulancemen cannot be neatly fitted into this framework. While in a general sense they are subordinated to medicine, the emergency nature of their work, outside formal medical settings, makes them an interesting and important case through which to understand the division of labour in health care. The discussion here, it should be noted, applies mainly to the MICAS, the medically most sophisticated segment of the ambulance workforce. General Ambulance Officers’ work appears to have changed little in fifteen years.

Ambulance officers have no clear occupa-


tional territory and no statutory registration. Transporting patients is, strictly speaking, their clearest task and this function is legally restricted to them but driving as such is not a medical procedure and Ambulance Officers historically have attempted to play down the driving part of their work.

Training and curriculum is, ultimately, approved by the medical profession. Operating procedures are set down by ‘expert’ (that is, medical) committees in the form of protocols. Yet the emergency nature of the work, particularly in the MICA units, allows for a certain autonomy in the performance of duties in life- threatening situations. AS the pocket manual for MICA Officers states:

The protocols outline treatment guidelines which, under normal circumstances, MICA Officers are expected to follow in the management of patients presenting such emergency problems. Protocols should only be varied by MICA Officers after consultation. However, it is recognised that circumstances may arise where the management of a particular patient in life threatening situation may require the guidelines to be varied in some aspect. Each such instance will be reviewed. (Emphasis added)ls

The existence of the ‘life-threatening’ pro- viso allows Ambulancemen to ‘trespass’ on core work activities of the medical profession of diagnosis and prescription of restricted drugs. As has been argued elsewhere, those health occupations which have competed for the core work areas of medicine (such as chiropractic in claiming to be a complete alternative system of health care) have faced the most severe opposition.’ Yet Ambulancemen are able to make a diagnosis (albeit provisional) and pro- ceed with treatment without direct medical supervision. A medical practitioner is available for consultation if the need arises in difficult cases but practical difficulties (not the least of which is elapsed time in making contact) mean this rarely occurs.

The ability to perform medical procedures and use drugs normally restricted to medical practitioners is the key issue. To understand this phenomenon it is necessary to consider the background to the MICA service. One specific stimulus originated from the Vietnam war which, as the Assistant Superintendent of the MICA Service recently wrote:


. . . proved that the stabilisation of seriously injured servicemen in the field by specially trained medics and their rapid evacuation by medevac helicopter to the front line hospitals, resulted in a very high recovery rate.I9

In battlefield situations the paramedical staff were able to demonstrate that a number of emergency procedures could be safely and effec- tively performed by nonmedical staff. Its im- portance was thus in the precedent that it set, as paramedical NCOs were able to perform procedures and administer drugs normally only done by doctors and nurses.

Two particular areas of work emerged in civilian life as requiring an expanded occupational role for Ambulance Officers: heart attacks and road accidents. With these areas in mind, the MICA service was initiated in 1971 with medical impetus and medical supervision.m At first, medical practitioners (registrars) travelled with the ambulances but, on their own recommendation, this practice was ceased after eighteen months. The doctors had developed confidence in the ability of specially trained Ambulance Officers to deal with medical problems presented and felt there were too few occasions when their skills were required.

As the MICA service has become better established and its effectiveness in saving lives demonstrated, the range of medical procedures utilised has gradually expanded. Some of these are medically complex and in non-emergency medical settings would be performed only by doctors. These procedures include initiating intravenous therapy, interpreting electro- cardiogram readouts and inserting endotracheal tubes. The performance of the latter has brought informal opposition from anaesthetists since it is an important aspect of ‘airway management’, otherwise their occupational territory. Indeed it has been suggested that the performance of this procedure by Ambulance Officers is permitted only in Australia; nowhere else can it be performed by Ambulancemen.

From time to time there have been instances of more complicated procedures being attempted outside ‘protocols’ in an attempt to save a life. As the operating manual for MICA Officers suggests, these departures from protocol are reviewed by a medical panel. In a recent example where a MICA Ambulance Officer attempted a chest wall drain in an unsuccessful last-ditch attempt to save the life of a patient, the review- ing committee exonerated the Officer in ques-


tion but expressed its concern about Officers attempting such procedures.

The other area in which Ambulance Offic- ers have gradually come to perform work usually restricted to doctors, is in the prescription of drugs. Because of the nature of emergency work, pain-killing drugs have been an important part of Ambulance Officers’ pre-hospital ther- apeutic repertoire. The most powerful of these, in the past, was morphine. Because morphine, being opium based, is defined as a ‘drug of addiction’, its utilisation in medical settings is tightly restricted to medical practitioners under the Poisons Act. From the early 1960s ambulances began to carry morphine but its usage was carefully controlled by regulation and it would only actually be administered by medical practitioners. In other words ambulances carried morphine which was available for use by medical practitioners at the scene of accidents. This restriction was removed in 1971 because attend- ance by doctors at road accident scenes was infrequent. At much the same time other pain- killing drugs became available which did not have the ‘political baggage’ of morphine but were also restricted under the Poisons Act and Ambulance Officers gradually came to be able to use these.

The occupational territory of MICA Offic- ers has thus been expanding in terms of what they can actually attempt. At first attempted only as a last-ditch effort to save a life, procedures can gradually become a more routine part of their work. The formal occupational territory has thus been expanded by this process of negotiation and two particular areas of work have gradually become recognised as the ‘pro- vince’ of Ambulance Officers as a result; the pre-hospital emergency treatment of road accident and suspected cardiac victims. By treating and stabilising patients at the scene, more leisurely transport to medical services can pro- ceed.

Yet the negotiation over occupational territory has proceeded on another front as well. Historically the work of Ambulance Officers finished at the hospital doors. Once a patient was unloaded from the ambulance into a medical setting, the responsibility of that officer for the patient ended. Yet there is also evidence that this ‘boundary’ to the work of particularly MICA Officers is breaking down as Officers follow their patients beyond the ambulance doors into hospital settings.

MICA units are based not in Ambulance


Stations like ‘general transportation’ units but at public hospitals. This is for two reasons: ‘to provide the MICA Officers with opportunities to practise their skills in a hospital environment when not out on calls . . .’ and secondly ‘the development of better understanding and working relationship between the MICA Officers and Medical and Nursing Staff‘.2’ MICA Officers, furthermore, do a period of their training in hospitals, particularly in coronary and casualty units. While officially there to learn, MICA Officers are often called upon to assist in performance of procedures normally carried out by doctors, such as suturing and applying plaster casts to fractured limbs. This is not to imply any deliberate policy of expansionism on the part of MICA Officers, rather at times when there is a heavy demand on medical personnel, for instance in casualty, MICA Officers can be called upon to assist in performing medical procedures under medical supervision.

The ability of MICA Officers to act as emergency oriented paramedics is recognised outside the hospital setting. Oil companies actively solicit the services of MICA Officers to become First Aid Officers on the off-shore oil rigs, presumably a lower cost means of providing expertise in accident situations and presumably also reflecting the difficulty of attracting a medical practitioner to work in such a situation for any length of time.

These developments in the work of MICA Officers have not been unrecognised at the official level, with two inquiries being conducted into the ambulance service in recent years. The first, in 1980, focussed only on the MICA system, evaluated by two senior medical academics Opit and Christie, at the request of the Victorian Health Commission. They recognised the situation which had emerged of Ambu- lancemen ‘being used as paramedical personnel with a task in the emergency treatment of serious illness’, and being seen as ‘the mobile wing of hospital coronary care units’.2) Their recommendations were threefold: the MICA service not be extended further but Ambulance Officers generally should receive training to ‘approx- imately’ MICA level; present MICA Stations be retained as ‘centres of excellence’ for training of new crews; the emergency side of ambulance transportation should be separated from the general transports, the latter to be organized more through hospitals, though still run through the Ambulance Service organisation.


In other words, limits were recommended to the development of MICA services. On one hand, training all Ambulance Officers in most MICA techniques would result in greater homogeneity, at least amongst officers involved in emergency transports, thus lessening the likelihood of MICA Officers splitting off from the rest of the ambulance workforce to form a separate occupation. On the other hand it also represents a partial de-skilling of existing MICA personnel since all would be trained to a level lower than that which MICA Officers currently perform. Furthermore, the capacity to perform MICA procedures would be extended to more officers, with each individual officer likely to perform less of these procedures as a result.

Action on the Opit and Christie report was not forthcoming, in part because a wider review of the Ambulance service as a whole was com- missioned by the Victorian Parliament in late 1983. The review, conducted by the Public Bodies Review Committee, was submitted in November 1984 and the response to its recommendations is so far u n d e ~ i d e d . ~ ~ The principal recommendations concern administrative arrangements, in particular centralisation of services, but several other recommendations are relevant to the discussion here. The issue of the extent to which the skills of non MICA Officers should be upgraded are analysed in the context of what is called ‘Advanced Life Support’ (ALS). This is a range of skills performed by MICA officers such as defibrillation and intravenous therapy. The ambulancemen themselves indicated they were keen to see ALS techniques introduced, and the report does advocate its gradual introduction, though notes that the exact technical (that is, medical) details are still being worked out by the Ambulance Medical Sub-committee of the Victorian Health Com- mission.

The report also considers issues of the health division of labour. Generally it advocates promotion of “organisational co-operation and operational co-ordinati~n”~‘ between ambulance services and medical officers. To this end it recommends neither medical control over ambulance services, nor formal “recognition of the specialised professional skills of ambulance officers”25 as Emergency Medical Technicians- Paramedics, a model which, exists elsewhere such as the United States. In other words it recommends little alteration in the division of labour between Medicine and Ambulance Offic- ers. Both the Parliamentary report and Opit and


Christie’s, however, have the effect of confirm- ing and institutionalising the paramedical role of emergency ambulance services.

Conclusion The occupation of Ambulance Officer is

sociologically interesting in a number of ways, not the least of which is the insight it allows into the ongoing process of the development of the division of labour in health care. Contrary to earlier accounts of the division of labour in health care, which assumed a consensus basis,z its development must be seen as an ongoing social process involving conflict, particularly over occupational territories. As Bucher and Straws argue, the boundaries of occupational territories between health occupations are pro- duced in political struggle in which occupations attempt to defend or extend their relative positions. as

Second, ambulance work allows consideration of the relationship between the formal paid health division of labour and the informal un- paid voluntary division of labour pointed to by D a ~ i e s . ~ The effect of the existence of trained first aiders in the form of St John Ambulance Brigade and Red Cross members has been examined briefly here. This subject would war- rant further investigation.

Third, examining the work of Ambulance Officers allows a consideration of the effect of the emergency life-saving nature of some medical work on the division of labour. What is a major event in the life of the patient is a relatively routine event for Ambulancemen and further analysis of a more phenomenological nature of this issue would also be relevant.

WILLIS & McCARTHY

Further to this, though, and drawing upon the insights derived from interactionism, the emergency nature of the work of Ambulance- men highlights the manner in which the division of labour is a negotiated as well as an imposed phenomenon. As Freidson comments, the division of labour must be seen at least partially as:

a process of social interaction in the course of which participants are continually engaged in attempting to define, establish, maintain and renew the tasks they perform and the relationship with others which these tasks presuppose.2’

Finally it remains to consider the relationship of Ambulance Officers to the domination by the medical profession of the health division of labour. The complex historical process, the current phase of which is medical dominance, has seen Ambulance Officers emerge from their working class, low status, poorly trained ‘meat wagon’ driving origins, through a process of collective social mobility to an established paramedical location of which the MICA Officers are the ‘cutting edge’. Developments in medical and transport technology have helped expand the occupational territory of Ambulance Officers. Their relationship to medicine however remains best described as ‘adjunct’, partially separate and therefore not particularly threatening. The historical process continues, however, the possible entry of women Officers, further technological innovation and increasing governmental involvement and direction are all likely to considerably influence the work of Ambulance Officers in the future.

66 COMMUNITY HEALTH STUDIES

References

1. An earlier version of this paper was presented at the Annual Conference of Sociological Association of Australia and New Zealand, Melbourne, August 1983.

2. Freidson E. Profession of Medicine New York: Dodd Mead, 1970. Johnson T. Pro- fessions and Power London: Macmillan, 1972.

3. See Willis E. Medical Dominance Sydney: Allen & Unwin, 1983.

4. Larkin G. Medical dominance and control: radiographers in the division of labour. Sociol Rev 1978; 26:853.

5. Davies C. Comparative occupational roles in health care SOC Sci Med 1979; 13A:

6. Skea L. The Victorian Civil Ambulance Service 1903-1970. Unpub. thesis, School of Health Administration, University of New South Wales, p. 3, 1970.

7. Ibid, p. 146. 8. Ambulance Service Melbourne. Annual Re-

port 1984. 9. Skea L. op cit, p. 44.

515-21.

10. Ibid, p. 415. 11. Ibid, p. 29. 12. Ibid, p. 235-245. 13. Ibid, p. 241. 14. Quoted in Skea, ibid, p. 256. 15. Editorial. Ambulance World p. 3, May

1983. 16. Skea L. op cit, p. 62. 17. Ibid, p. 44.

18. Health Commission of Victoria. Drugs and Protocols for Mobile Intensive Care Ambu- lance Officers. 4th edition, August, 1982.

19. Blosfelds J. The development of MICA in Melbourne. Ambulance World 1982; 7: 1, 35.

20. Luxton M. Pre-hospital coronary care. Coronary Care Workbook 4th ed. In- gelheim: Boehringer, 1980.

21. Blosfelds J. op cit, p. 39. 22. Opit L and Christie D. Mobile intensive care

ambulance Report to the Health Commis- sion of Victoria (The Opit Report) p. 7, 1980.

23. Public Bodies Review Committee: Final Report on Victoria's Ambulance Service 13th Report to Parliament, November 1984.

24. Ibid, p. 269. 25. For example, Greenfield J. Allied Health

Manpower Trends and Prospects New York: Columbia University Press, 1969.

26. Bucher R and Strauss A. Professions in process. A m J SOC 1961; 6&325-364.

27. Freidson E. The division of labour as social interaction. Sociol Prob 1976; 23:311.

WILLIS & McCARTHY 67 COMMUNITY HEALTH STUDIES

from first aid to paramedical: ambulance officers in the health division of labour

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