Bodies Out of Place: On Josh Seim's "Bandage, Sort, and Hustle"

Josh Seim | Bandage, Sort, and Hustle: Ambulance Crews on the Front Lines of Urban Suffering | University of California Press | February 2020 | 272 Pages

Close your eyes and picture an ambulance. Do you hear the jarring shriek of a siren? Are there flashing red lights in your rearview mirror? Or are you imagining yourself pulled over at the side of the road as an ambulance, in defiance of all traffic laws, flies past you, transporting a person in peril to the nearest hospital? Many of us have a particular conception of the ambulance—of traumatic injuries, lives saved, and desperate urgency. And while that conception is not false, Josh Seim’s Bandage, Sort, and Hustle will convince you that moments like those are the exception, not the rule.

For close to two hundred pages, Josh Seim, a sociologist at USC, dismantles the ambulance’s adrenaline-fueled mythology. He approached his study first as an outsider, observing crews working 12-hour shifts. He then followed this year of shadowing with a brief stint working as an EMT, continuing his research now as an insider in the paramedical world. Through these dual perspectives, Seim explores the labor of the ambulance workers hired to “bandage, sort, and hustle” patients off the streets. Driven by an interest in urban suffering, Seim acknowledges that “suffering […] gravitates toward destitute and stigmatized bodies,” and he sees the ambulance, with its promise of treating and transporting everyone, as a unique case study through which to explore how the poor and marginalized are regulated in American society.

In the introduction, Seim gives the reader a brief overview of the historical, political, and sociological factors that influence the ambulance. He debunks assumptions about the ambulance (for example, ambulances are not disproportionately tardier in poor areas) and describes his argument’s scope. Much like his claim that ambulances and hospitals are “generally disinterested in eradicating the root causes of suffering,” Seim’s objective is not to follow the upstream causes that lead to suffering pooling downstream, “but to make sense of the workers who are waist-deep in the water trying to pull people out.” The main argument calls for a “labor-centric” approach when studying the ambulance because it is only by seeing how “frontline workforces are positioned, organized, and activated” that we can understand how “suffering bodies are assisted, punished, or otherwise treated on the ground.”

In the first section, “Bandage,” Seim situates the reader inside the ambulance itself. Using the language of paramedics and EMTs, Seim explains how ambulance crews make sense of their daily operations: there are “legit” cases, and there are “bullshit” cases, and every case falls somewhere along the “legit-bullshit” spectrum. Legit cases are those that allow crews to use their training to make medical interventions (place IVs, intubate, administer medications). In contrast, bullshit ones make them feel like little more than glorified taxi drivers.

Seim makes an important distinction: cases, not people, are categorized as bullshit. Even so, Seim does not shy away from acknowledging that an individual’s race, body mass, and gender influences how ambulance crews perceive them. He presents himself as a fly on a wall, playing witness to biases and behaviors without explicitly condemning or condoning them. The burden of managing people’s suffering on a daily basis exacts an emotional cost. Once again adopting the language of the crews themselves, Seim characterizes the emotional veneer of crews during patient interactions as leaning one of two ways: “being a dick” vs. “having heart.” Both are strategies that help workers cope with the underappreciated tension between the celebrated goal of the ambulance—“to  pull people out of a stream of suffering”—and its more concealed secondary goal—to “temporarily cleans[e] certain sections of the world of certain abnormal bodies.” 

In the second section, “Sort,” Seim digs deeper into the question of how certain bodies are regulated in public spaces, and he does this by situating the ambulance amongst the “horizontal” forces impacting the day-to-day routine of the ambulance crew—namely the other frontline workers  (primarily police and nurses) who deal directly with patients. Once a “body” has been deemed out of place (through illness, injury, or disruption), both the police and ambulances have the authority and means to relocate them, as either a patient or through arrest. Seim points out that police ultimately hold the power over ambulance crews in deciding whether someone will go to the hospital or to jail, but that ambulance crews have some power in deciding which hospital, and ergo which nurses, will assume responsibility for the patient’s care. There is a hierarchy to these decisions, with each party shifting who will bear the brunt of the labor. Though Seim clarifies that he interviewed and observed both some nurses and police officers, he did not immerse himself as deeply in their worlds, and his explanations, while very compelling, feel less robust for it.

But that weakness is not present in the final section, “Hustle,” where Seim looks at the “vertical” forces acting on the ambulance, namely supervisors. He avoids looking at vertical forces beyond personnel (questions about contract negotiation, union politics, and the tension between private vs. public control of emergency services are only briefly mentioned). Instead, he focuses on teasing apart the differences in the priorities and motivations of supervisors back in “the barn” (the warehouse where ambulances are housed) and supervisors out in the field. The supervisors’ goal is to maximize efficiency by “hustling” as many bodies through the ambulance doors as possible, and they have a variety of different tactics to achieve that goal. Particularly memorable is when crews with the shortest turnaround times at the hospital are rewarded with permission to wear a company-approved “T-shift” on their shifts—apparently a significant improvement to the “thick and itchy” button-up shirts otherwise required. There is an underlying tension between the crews and the supervisors, and the ways ambulance workers carve out some limited autonomy and mild rebellion will be familiar and understandable to anyone who has ever worked underneath a supervisor’s scrutiny.

Given the state of the world, one cannot help but wonder how the current pandemic has changed the structures Seim describes throughout his book. There is reliable evidence that the poor and marginalized are disproportionately impacted by Covid-19, and shouldering that burden falls in part to the ambulance crews who serve as a social safety net. It is a credit to the strength of Seim’s analysis in Bandage that I find myself reconsidering my most recent experiences in the Emergency Department as a fourth-year medical student. Why do the majority of nurses and physicians in the Emergency Department wear N95 masks, while the paramedics and EMTs wear respirators? Who is responsible for providing ambulance crews with PPE? Have ambulances experienced similar decreases in utilization as emergency rooms in general? How has concern for Covid-19 exposure diminished tolerance for “bullshit” cases? If Seim chooses to follow-up this ethnography with an article or addendum reflecting on the impact of Covid-19, I would be keen to read it.

It is hard to say whether Seim’s book will find a robust readership outside of those who already have a strong background or interest in healthcare, and emergency services specifically. For those readers without experience or interest in sociology, the strength of Bandage lies in its detailed world-building. In accessible academic language, Seim captures the essence of ambulance work: the plethora of mundane moments interspersed with brief bursts of excitement—excitement that is always tempered by the inevitable paperwork. Undistracted by trying to impress readers with flashy stories of traumatic life or death scenarios, Seim focuses on presenting the conflicts and struggles that ambulance crews face in the course of the day.

In the middle of writing this review, I came across an article from The Marshall Project by Christie Thompson, entitled “When Going to the Hospital is Just as Bad as Jail.” The article was about a recent lawsuit claiming that black Americans with mental illness are being forced into traumatic emergency room stays. As soon as I read it, I recognized the phenomenon being depicted as the same one that Seim had described in Bandage. Reading the article allowed me to appreciate how Bandage had provided a framework through which I could better interpret how and why this overlap between the health and penal systems existed. Bandage does not offer detailed solutions for unraveling the complex and knotted web that makes up America’s social support network. But it is a sharp reminder that, for many Americans, the gateway to social support and control is through the back doors of an ambulance. Those doors are manned not by policies, but by people, and it is worth taking the time to understand the conditions in which they labor.