EMS for Democracy: The Case of Människan Bakom Uniformen


By Mark S. Weiner
Published in Ambulance Today, Issue 3, Volume 13, Ahead of the Curve, Education and Technology Special, Autumn 2019

A hard rain was falling on the streets of Stockholm that night as a man lay unconscious in the parking lot, his face illuminated by flashing blue lights. While onlookers snapped photographs—me foremost among them, because I was observing this special simulation exercise—police led the dazed bus driver from the scene and the medics got to work.

A neck brace. A spine board. TBI? An elevated train raced overhead with a deafening roar. Where was that smoke coming from? A firefighter dragged a hose through the hazy dark.

More medics arrived—more blue lights on, off, on, off. They carefully boarded the bus through the rear, boots thumping as they walked. A man sprawled in the aisle was complaining of chest pain. Smoke began to billow through the door. What to do?

On the tarmac in front, meanwhile, the lead medic checked that his patient was secure, and he prepared his team for the lift. His glasses reflected the flashing blue lights back into the shadows. “One, two, three,” he called. His team wheeled the stretcher toward the open doors of the waiting ambulance.

Perfectly done—textbook.

He’s just a teenager, I thought admiringly, as I walked through the smoke, hoping that my camera would survive the downpour. I was thinking not of the patient, but of the medic. I was thinking in fact of
all the participants in this special evening organized by Människan Bakom Uniformen (MBU), the Person Behind the Uniform. Most of them were young people from rough, ethnic minority neighborhoods.

MBU students navigate a high-level simulation involving a bus

I caught the gaze of one of the firefighters. “Bra,” I said admiringly (that’s “good” in Swedish). He nodded, smiled, and reached for a nozzle to switch off the smoke. The second patient smiled as he walked off the bus.

Novelists use fiction to reveal the truth. Literature creates a moral universe that allows readers to see the world as it really is. One could say something similar about EMS simulations. A fictional emergency exercise reveals something basic about the nature of the profession—and in the case of MBU, I think it shows something in particular about its social and political role. It highlights its public importance well beyond medical outcomes.

In a book that I am beginning to research, I aim to explore this broader aspect of EMS, which I believe is underappreciated even within the profession itself. The book has the working title of A Social Theory of Emergency Medical Services, and in writing this essay, and a series of occasional articles to follow, I hope to explore some of its themes in an open-ended way. In doing so, I am reaching out to you, the readers of Ambulance Today, for input and advice.

The largest underlying questions of the book are these: How can we understand ambulance work not simply in medical terms, but in social and political ones, too? What social and political values are enacted by EMS personnel in their daily professional practice and by the EMS system more generally? Finally, what is the social and political role of EMS in a modern liberal democracy?

These are somewhat unlikely questions, I know. I have been led to ask them through an unlikely train of events. Before I return to that rainy night in Stockholm, let me share a story about how I got there in the first place—a story about how two different ways of thinking gradually came together.

I have spent my career not in ambulances, but rather in libraries and lecture halls. By training, I am a professor of cultural history and constitutional law. I teach students about the basic principles of democracy, and the books that I have written consider how those principles are expressed in social practices. Many of them touch on issues of citizenship and civic belonging, and they have a philosophical bent.

Snapshot of a training exercise between professional medics and MBU students

One day when I was at my kitchen table writing one such book, I heard a crash. Or, rather, I felt it—the sound struck me like a body blow to the core. By the time I reached the old sedan that had smashed into a wall at the end of my street, carbolic smoke was filling the cab. Through the window I could see the driver, a bariatric middle-aged man, twitching and foaming at the mouth, turning blue as I wrenched open the door and began tugging at his jammed seatbelt. I felt utterly helpless.

I started hack coughing. Frantically coming up for air, I saw that a crowd had formed. Among the onlookers was a young gentleman in a button-down shirt. “You!” I shouted, pointing straight at him. “You. Come help.” The only time I had ever pointed at someone like that before was when asking a student an especially tough question in class. Together we dragged the driver from the car and lay him on his side. He vomited and began to breathe in rasping gulps.

A few minutes later, he was whisked away in an ambulance. “We’ve got it from here,” intoned one of the EMTs as I sat on the curb, dazed and panting. Sirens blared as I watched them pull away.

When one of my first EMS instructors asked, months later, “so what was the emergency you thought you couldn’t handle that brought you to this course?”, that was an easy question.

One EMS course led to another, and another, and eventually I found myself with a basic EMT license—and that very nearly led to … nothing. After I certified, I looked for ways to participate in wilderness search and rescue (I spend a lot of time outdoors), but opportunities near me turned out to be scarce. Without regular training, my skills began to wane. Things got busy. In time, I began to count my EMS training as just an interesting interlude.

Then the world threw me another curve ball. I was at an academic conference in New York, about to deliver a philosophical paper, when I heard a voice call out, “has someone called 911?” I turned and saw a colleague slumped against a wall, gasping for air, his eyes bulging. This time, I reacted differently. My training kicked in just enough for me not to fumble things completely.

When the pros arrived in an ambulance a few minutes later, I handed them my notes. “Thanks,” said one of the EMTs, looking them over. “Really helpful.” I am con dent that they must have been the most poorly organized, illegible set of patient vitals he had ever seen, but his words still felt good. Letting my EMS education go to waste suddenly seemed like a very bad idea.

I recertified. I renewed my license. I began to volunteer for a suburban ambulance service not too far from my home (I am still just a probationary fledgling). Then, as I watched my colleagues work, trying to learn from their example, I naturally began to ask the kind of questions about EMS that I have been asking about other institutions and practices throughout my life: questions not about technique, about how to do, but rather about societal significance. When first responders do what they do best—saving lives—they also send important social and political messages to the whole community. What messages do they send?

Cooperation between professional medics and MBU participants during the main simulation exercise

Take lights and sirens. On one hand, they serve a utilitarian purpose: to clear a path so an ambulance can reach its destination swiftly and safely. That’s why there is growing empirical literature about whether driving with them is truly helpful or, ironically, increases EMS vehicular accidents.

But consider lights and sirens not from the perspective of a medic behind the wheel, but rather from that of average citizens going about their business blocks away. For them, the siren’s wail isn’t utilitarian; whether they hear it or not is immaterial. Instead, it plays a cultural role. The siren tells a story: “there has been an emergency, perhaps an accident, but medics are taking care of the victims.”

That story has a profound political importance. One of the first purposes of government, at least in liberal democracies, is to protect life. Government’s ability to protect life is indeed one of the basic justifications for the state’s existence. In the words of the American Declaration of Independence of 1776, life is an “unalienable right,” and it is to secure life that governments “are instituted among men.” When an ambulance siren sounds, it signals that this basic aspiration of government is being fulfilled.

MBU founder Janina Sabra shows the signed helmet she received as thanks from first responders and MBU participants

Switching on lights and sirens, then, is an act of political communication as well as a utilitarian tool. Switching them on proclaims the benevolent character of public authority. Medics using the siren make this proclamation nearly every day they work, weaving it deep into the social fabric.

Or consider the interaction between a medic and patient. On one hand, the encounter is a pragmatic one. Making patients feel secure, taking their vitals, treating major injuries, getting them to definitive care—that’s the chief goal of EMS. Yet something happens in the encounter that also goes to the core of civic life.

A long line of philosophical thinking, reaching back to G. W. F. Hegel in the nineteenth century, tells us that people come to know themselves as members of their political communities only when they are “recognized” as individual subjects by an institution that wields public authority. Indeed, Hegel argued that it’s only by encountering and being recognized by something or someone outside themselves that people become full psychological beings at all.

In these terms, when a medic approaches a patient, he or she implicitly announces—as a community representative—“I see you.” When the patient in turn responds by placing trust in the medic, he or she accepts a relation of dependence on the community that is providing for his or her care. He or she comes to self- consciousness as a community member through EMS as an institution. The patient sees his or her own image reflected back in the mirror of the medic’s eyes.

Mark Weiner in conversation with Swedish Ambulance Nurse/Ambulanssjuksköterska, Leila Haddadi

This psychosocial moment of recognition means that the way medics interact with patients is significant for political, as well as medical reasons. When a patient feels disrespected, it not only erodes the conditions for optimal treatment but also degrades public life. Remember the 1990 hit single “911 is a Joke,” by the American rap group Public Enemy? Watch the video. It builds its wide-ranging critique of American society on the back of a completely slanderous portrayal of EMS.

As unfair as its portrait is, the video teaches an important lesson. For civic culture, a medic who acts dismissively toward a patient is the medical equivalent of a police officer who roughs people up without cause.

Alternatively, medics can treat patients in ways that foster community cohesion. For instance, when a patient speaks a foreign language and a medic can say a word or two of greeting in it, the medic “recognizes” the patient as a full person, which in turn can help bind together the separate parts of
a pluralistic society. Likewise, when medics invite patients to participate in their own care, for instance by asking them to hold a bandage on their own wound, they encourage a sense of personal agency and self-sufficiency, which helps support democratic life.

Finally, consider the fact that one of the most common locations to which medics are dispatched is a family home. Patients often need our care precisely when their families are incapable of handling a health crisis on their own.

According to Aristotle, the family is the core political association that gives rise to all later, more complex political units. Family to tribe, tribe to village, village to city, and, now, city to nation— the family lies at the heart of it all. In arriving on scene at a home, then, first responders step in and perform one of the key roles of the family, caring for one another, but they do so as agents of the larger political community.

Moreover, by doing so they participate in a vital drama of public sacrifice. In assuming the family’s role, first responders often put themselves in personal jeopardy. They suffer in all the ways that readers of this magazine know well. They expose themselves to blood-born pathogens. They confront the danger of angry bystanders. They endure post-traumatic stress.

In all societies, modern as much as ancient, complex as much as simple, such sacrificial activity makes community possible. And it draws the boundaries of the community to include those for whom a sacrifice is made. (This dynamic, indeed, lies at the ancient core of most religions, but that’s another matter.) We are used to thinking about the personal sacrifice of ambulance medics as the basis of their public reputation as heroes. But it also establishes and fosters the cultural preconditions of civic life.

The stakes of EMS, in short, are social, political, philosophic, and even metaphysical. I think most of us recognize this fact instinctively, and we may even talk about it in a general way in after-work conversation. But I believe that we could help ourselves professionally, and personally, by speaking about these issues more than we do, and by developing a systematic way to understand them.

Close up of the famed MBU helmet, a testament to the deep bonds and inspiration created through the program

This brings me back to MBU. Channeling Hegel and Public Enemy, both philosophy and politics came to mind as I watched the emergency simulation in Stockholm’s deep December dark. That was no surprise: I had been prepared by my conversations with Janina Sabra.

Sabra, 31, is the tough yet caring director who heads up MBU from its base in Gothenburg, a bustling port city on Sweden’s west coast. I was spending the 2018-19 academic year in Sweden as part of an American citizen-diplomacy program, and I had been speaking with Swedish ambulance personnel in various cities as a way to get to know the country. Along the way, I heard about MBU, and I thought it could provide an interesting window into Swedish society. Sabra offered to show me the group’s headquarters.

As we strode through the swinging glass doors of a youth center in the eastern half of the city, two bearded hipsters playing guitar on an old couch looked up and smiled. Both clearly had ethnic roots in the middle east. In the meantime, a young woman wearing Doc Martens, whose parents hail from east Africa, was preparing sandwiches in the communal kitchen. Her hand gestures were straight out of American hip-hop, even though she had never been to the United States. Sabra led me up a set of open metal stairs to her office, where she proudly displays a hardhat signed by dozens of first responders—a gift of gratitude for her work.

The children of immigrants, Sabra and her colleagues embody one of the most significant facets of contemporary Sweden: it’s a country in the midst of a demographic revolution. Long known for its ethnic homogeneity—in 1930, only 1 percent of the population was foreign born, half from neighboring Nordic countries—Sverige has become a coveted destination for economic migrants and asylum seekers. Today the foreign-born population stands at nearly 19 percent of 10.1 million inhabitants. The majority of new arrivals are Muslim, an important point of difference in historically Lutheran and now deeply secular Sweden.

Humour acting as the best teacher during an MBU training session

Many of these foreigners have ended up living in the majority-minority districts that the Swedish government officially calls “socially vulnerable areas.” Swedish ghettos. Sabra grew up in one herself. Not surprisingly, social tensions have emerged in these neighborhoods, and first responders have been among the first to feel the heat. In a spate of headline-grabbing incidents, for instance, minority youth in numerous cities have pelted emergency vehicles with stones. Police have been the most common target, but re trucks and ambulances have also been on the receiving end of the violence.

It’s unclear just how widespread these incidents have been, but it would be difficult to overstate how deeply they trouble citizens in a country known worldwide for its respect for state authority.

One especially dramatic incident took place in Gothenburg in 2009 and led to the creation of MBU. Sabra speaks sadly when she talks about it, her voice trailing off into silence. Some young men standing on a bridge pushed a breadbox-sized rock onto a passing re truck below, smashing the front window and sending a firefighter to the hospital. He soon left the service in frustration. Episodes of petty violence had been common at the time, but this felt like an escalation. Concerned service members felt that something needed to be done, fast. But, ironically, what they created wasn’t fast, but slow.

Människan Bakom Uniformen is a community outreach program with a twist. Rather than the usual one-off meet-and-greet, it’s an extended, focused seminar that requires significant time and effort from everyone involved. Imagine a college class called “First Response 101,” taught by the coolest professors you’ve ever met, with individual sessions devoted to different branches of the field: EMS, re, police, private security guards, and even tram operators.

Each MBU term runs for a full 10 weeks and includes about 20 participants between the ages of 15 to 25. Attendance at all sessions is mandatory to earn a certificate of completion, which adds real value to school and job applications. After each semester ends, graduates are encouraged to continue to be a part of the organization in a leadership role, tutoring new participants and serving as MBU ambassadors in their communities. It’s all about time, commitment and focused attention—yet despite its demand for resources (in fact, I would guess precisely because of the good things those demands produce), what began in Gothenburg has now spread to over a dozen cities throughout the country.

The program begins gently. Participants and first responders play games and shoot the breeze, enjoying each other’s company. Each student receives a stylish black T-shirt bearing the MBU logo. There’s plenty of comfort food—this being Sweden, that means cinnamon buns and coffee. The participants create a warm community based on good times. But the next meetings—each lasting three hours, at night—are far more dramatic and intense.

MBU founder, Janina Sabra

Sabra leans forward in her chair as she explains. Half of the sessions feature first responders talking frankly about the difficulties of their work and participants sharing their own prejudices about first responders. That can be tough, but the groundwork for serious exchange was laid in previous sessions. On other nights—and this is the part that interests me most as a scholar—participants are taught practical emergency skills by each service. They study CPR. They learn how to roll a patient on backboard. They climb a fire ladder. They use handcuffs. They drive a tram as it is pelted with stones, and they learn how to respond to an argument on board. The kids not only step into the shoes of first responders, they step into their boots.

Now that the participants are equipped their new real-world abilities, the program culminates in a multi-casualty incident—one that goes all out for realism. Sabra invited me to watch the exercise taking place in Stockholm a few months later.

From my home in Uppsala, I took a night train to a dark suburban station and met my contact, Ambulance Nurse Daniel Björsson, 43. Tall, bald and muscular, he looks like a Viking from Erik the Red’s medical response team, if Erik the Red had employed EMTs. I knew he was a deeply respected member of his service—an obvious leader.

Earlier that year I had tagged along with Björsson on an all-night shift to see the Stockholm service in action. I had watched him hold up a half-naked girl as she vomited into a bag after drinking herself into a stupor, take an ECG of a man panting on his bed as his wife watched on anxiously from above, and coordinate EMS response to a multi-alarm re in a high-rise apartment block. Now I would see him in a very different role—a civic one.

Could an EMS simulation play a positive part in helping Sweden through its demographic revolution? And if it could, what might that reveal about the nature of EMS? Björsson was going to help me find out.

Ambulance Nurse, Daniel Björsson

Björsson invited me to sit in the back as he drove an ambulance to the scene of the simulation. Sitting in the front passenger seat was a diminutive girl dressed in the service’s green-and- yellow uniform. If she had been holding a couple of electric cables in her hands, I suspect that the excited energy she was radiating could have been used to power the ambulance itself. She was absolutely still and silent while she waited for dispatch. The call came through the crack of the radio. Priority one.

For its drama and adrenaline-inducing special effects, the scene at which we arrived surely would have made Steven Spielberg proud. There was a large red bus pulled over at the edge of a parking lot, stopped at a distinctly strange angle. A man lay beneath the front wheel. The back door of the bus opened and out stepped a long line of talkative young women in headscarves. They began snapping pictures. With the rain, smoke, and flashing lights, it felt just like the scene of a major accident.

Björsson pulled his ambulance into position. The girl in the passenger seat stepped out. Remembering that her hair fell beneath her shoulders, she secured it tight. She got the stretcher from the cab. The last time I saw her, she was wheeling it toward the bus.

Björsson was proud of how his students worked that night—especially proud of the young medic who took care of the injured man at the foot of the bus. He did just as he had been taught to do. “Sometimes you think they don’t listen—but they did!” Björsson laughed. But what struck him most, he said, was that the young man had actively assumed a leadership role during the incident. He took command. I witnessed that myself. “On my count: one, two, three”—it was the voice of a young man growing up through EMS, imagining himself performing a vitally important civic role.

The main simulation involving a casualty with a bus, organised from MBU

Could he or his peers ever look at EMS the same way again? Would they ever look at Sweden in quite the same way again—this place for which they were learning to take responsibility and, thereby, make their own? Could I ever look at EMS the same way again, seeing how it was used here as a vehicle through which young people could envision a society in which they would take care of others at the same time that others pledged to take care of them—a society of mutual interdependency?

EMS was helping bind this society together. But perhaps that’s what it’s always done, and is always doing, even as each of us focuses our attention on the patient immediately in front of us.

The opening scenes of the high-level simulation, organised by MBU, involving a bus

There are many other ways that EMS has a social and political role beyond its medical outcomes. Can you help me think about them? Are there some that you would especially like to see addressed in these pages, or in my book? I would love to hear from you, either directly or through Ambulance Today’s social media platforms. Next time, I’ll be meditating on the cultural perception of ambulance personnel as “heroes”—who are nevertheless apparently not important enough to pay sufficiently, and on the frequent conflation of EMS and police.

To share your thoughts, feedback and ideas over this article and any others by Mark Weiner feel free to get in touch with us via: https://chat.whatsapp.com/AmbulanceToday

Mark S. Weiner, Ph.D., J.D., EMT-B, is the author of The Rule of the Clan: What an Ancient Form of Social Organization Reveals about the Future of Individual Freedom, among other books. In 2018-19, he was the Fulbright Distinguished Chair in American Studies at Uppsala University.

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