SOC][AIL

(OR(GAN 1[ZAT 1[tQ)N

tO]F MEIDI[CAL
WORK
ANSELM L. STRAUSS,
SHIZUKO FAGERHAUGH,
BARBARA SUCZEK, AND
CAROLYN WIENER
WrrH A NEW NTRODUCTION BY ANSELM
L STRAUSS
Tlansaction Publishers
1 New Brunswick (U.S.A.) and London
(U.K.)
 Contents
Introduction to the Transa
ction Edtion
Preface
xiii
1 Chronic Itlness, Technology,
and the Hospital
2 Illness Trajectories 1
3 Machine Work
4 Safety Work 40
5 Cornfort Work 69
6 Sentimental Work 99
7 Articulation Work 129
8 The Work of Patients 151
9 Macro to Micro and Micro 191
tO MaCrO Impacis:
The Intensive Care Units
10 Theoretical lmphcations 210
238
Appendix: Methodological
Note 291
References
297
Author mdcx
305
Subject mdcx
307
1
 Preface
cine operating in tandem with or embedded in a context of ahernative
conceptions of health, illness, and medicine. (That phenomenon is not
really foreign to Americans, either, biit it is less obtrusive, to use the
1
western medicineoriented practitioners term.) So in those countries,
tlie substantive detail written about here requires more qualiflcation
for varied conditions than in the United States. We have been explicit
about that: after ah, things were different and will he different again.
Chronic Illness,
For support of the research on which much of this book is based, Technology,
the authors are greatlv indebted to the Health Resources Administra
tion, Bureau of Man power, United States Public Heatth Service, Divi
sion of Nursing, Grant #NU-00598. We are indebted to the staffs of
and the Hospital
the following Bay Area hospitais where we did extensive fleldwork:
Alta Bates, Herrick, Letterman, Mt. Zion, Presbyterian, Stanford, and
University of California, anci to St. Bartholomew, London, with special
thanks to Helen Collyers.
Our thanks also for their various contributions to this bookfor
data, ideas, reading of the draft manhiscriptgo to Diane Beeson,
University of California, San Francisco; Robert Broadhead, Universty
of Connecticut, Storrs, Connecticut; Rue Bucher, Department of To understand properly the work of managing illness today, one needs
Sociology, University of Illinois, Chicago; Wolfram Fisclier, University irst to understand a few salient feawres of the larger
context within
of Muenster, West Germany; Berenice Fisher, New York University, which the work takes place. Its features include (1) the contemporary
New York, New York; Elihu Gerson, Tremont Research Institute, San prevalence of chronic illness, (2) images of acute care,
(3) medical
Francisco, California; Roberta Lessor, School of Nursing, University of technology and its impact on hospitals, and (4)
che hospital as a set of
California, San Francisco; Evelyn Peterson, School of Nursing, Uni work sites. These will be discussed briefly in chis chapter, but their
versity of South Dakota; Fritz Schuetze, University of Kasset, West imphications for the kinds and organization of medical
work will be
Germany; Leigh Star, Department of Social anci Behavioral Sciences, evident throughout the book.
University of California, San Francisco, and Tremont Research Insti
tute, San Francisco; Steven Wallace, Department of Social and Be
havioral Sciences, University of California, San Francisco; Irma Zuck Prevalence of Chronjc Illness
errnann, Department of Social and Behavioral Sciences, University of With regard to issues of health and illness, mankind is passing through
California, San Francisco. Wc are especially grateful to Barney Glaser a new era in its long civilized history. Though hardly as
dramatic as the
for his valuable consuhation on the research and to Rue Bucher for her arrival of the atomic bornb or as well noted as the current population
careful reading, editng, and general comrnentary on the next to final explosion, there is unquestionably something starthngly new about the
draft. Finally, our very special thanks go to SaBv Maeth for her patient biological condition of a considerable, and increasing, porton of the
and persistent secretarial assistance and to the Department of Social earths population: namely, the prevalence now of the chronic rather
and Behavioral Sciences, UCSF, which contributed additional secreta- than acute ilhnesses. There is a fateful paradox here:
although che
rial funding aher otir grant monev ran out. chronic illnesses are prevalent, and that has been recognized by sorne
OhSeTVerS fOT two or three decades
(Mao 1 956, p. 9), neicher the
general public nor the health professionals, as we shall see, recognize
anything like the full implications of this for training, care, insuranee,
indeed for the health institutions themselves. We are just begnning co
pass into a period when chronic lllness per se (rather
than specific or
Chapter 1 Chronic ltness, Technotogy, and the Hospital
categorical chronic diseases) is referred to, thought about, acted upon While the hospitals organi zation has been radically change d by the
as a general reality. This seems to be no less true in England, Sweden, ncurable, long-term lllness es of its clients , this acute-c are mentality,
and other medically advanced nations than n the United States (Ger derived from the previous era of the acute illnesses, still
profoundlv
son and Strauss 1975, Strauss and Glaser 1975). colors the operations of the hospital. Even nursing home
care is, aside
Until the late 1930s, in industrialized countrles, as in thrd-world fi-orn its housekeeping functions, modeled along notions
of medical
countries today, the prevailing and often terrible afflictions were due care. Indeed, federal regulations emphaszejust those aspects
of care.
to bacteria and parasitesthe so-called acute diseases. A dramatic
change took place when antibiotics and various improved immuno
logical measures turned out to be so effective against many of the Impact of Medical Technology on Hospitais
infectious and parasitic diseases. Those diseases still reign in the less The diagnosis and treatment of the chronic illnesses have contrib
uted
fortunate countries, but in the highly industrialized ones (especially the to the widespread use of a great array of drugs, rapidlv increas ing
United States, Canada, the Soviet Union, Japan, and in Europe) what numbers and types of machinery (clinical laboratory tests
are now
people are sick from mostly are the chronic illnesses. They include the thoroughly dependent on machin erv), and, of course, variou s surgica l
cancers, arthritis, and a great host of others that are currently incur and other procedures. In the United States, as in other industr
ialized
able. Men and women have always suffered from these, of course, but nations, a considerable industry has evolved for manufacturin
g and
they never were the prevalent illnesses. These now constitute the supplying drugs, machines, and other etements of these techno
[ogies
equivalent of plagues and scourges of yesteryear. They are what bring (fagerhaugh et al. 1980). New occupations are growing up
around the
people to the doctors office, the clinic, and into the hospital: they are servicing and utilizaton of this rnachinerv (bioengineers,
safety en
what people in developed nations mostly die from. gineeri, respiratory therapists, phvsiotherapists, radiolo
gy techni
Among the prominent characteristics of chronic illness (Gerson cians), and many of the medical specialties are central ly depend ent
and Strauss 1975, pp. 218) are that they (1) are long term, (2) are on its use. The larger hospitais are speedily becom ing machin e
uncertain, (3) require proportionately large efforts at palliation, (4) dependent, as the various specialty wards press to fulfihi their
respec
tend to be multiple diseases, (5) are disproportionately intrusve upon tive technological requirements. (Since our own recent researc h has
the lives of the ill and their families, (6) require a wide variety of been centered especially on medical machinery, we shall empha
ancillary services if they are to be properly cared for, (7) often imply size, in
this section, its impact especiallyahhough, of course, much
of that
confiicts of interpretation and authority among patients, health work machinery is utilized in conjunction with drugs.)
ers, and funding agents, (8) mainly require primary care, and (9) are
expensive to treat and manage.
Halfway Technology
The Imagery of Acute Care Before we discuss the impact of the forego ing trends on hospita is and
on medical care, it should be noted that despite the growth
In the hospitalsthe special focus of this bookthe personnel still tend of this
technologyand the obvious success of sorne of ita govern
to think of themselves as treating patients who are acutely ili. This can rnental
commission has aptly dubbed it as only halfw ay techno logy.
only mean, however, that their clients are suffering from an acute The
term has been popularized by Lewis Thoma s (1974) , who notes that
phase of one or another chronic disease. What can be accomplished this technology constitutes medica l nterve ntion applied after the fact,
with these patients s, in common parlance, mainly checking the in an attempt to compensate for the incapacitating effects of
disease (or
progress of the disease, getting them back on their feet, slowing up to postpone death) whose course one is unable to do much about. This
the inevitable, and so on. Most personnel would certainly agree that technology is located in varyin g amoun ts and kinds in hospita ls, clinics ,
they were not engaged in cure in the old-fashioned sense of curing doctors offices, and increas ingly in the homes of the chroni cally ill.
pneumonia. Nevertheless, they tend to think of chronic patients as Medical technology has protonged lives, but it has also [nade both
the
those so incurably ilI that they belong in nursing homes or other professionals and the patients more dependent on techno
specialized warehousing institutions. That is why one sociological re logy
throughout the course of long chronic illnesses. Patients cycle ihroug
h
1
searcher recently found that hospitalized stroke patients seemed, from ihe hospital, to the clinic or doctors office, to their homes and back,
the staffs viewpoint, to be out of place (Hoffman 1974). again to the hospital during acute episodesand again to their homes
.
Chapter 1
So, articulatng the care given in hospitais, clinics, and homes has
become a major problem. The technological explosion and its effect
both on the organizational structure of health care and on the work of
health professionals, in turn, have affected the kind and quality of
patient carethat is, of medical, nursing, and technical work.
Medical Specialization and Technology
A special feature of medical specialization and technological innova
tion is that the two are simuhaneously parallel and interactive, creating
an impetus to further technological innovation and specialization.
Medical specalization leads to technological innovation: the techno
logical innovation then leads back to production through industry
(drug, machine, supplies, etc.). Then, through the utilization of tech
nology, with reports feeding back to industry, technological improve
ments are made and often with great rapidity. Ah of this results in
increasingly sophisticated medical specialties and their associated
work.
In turn, this expansion of specialized departments and services in
hospitais requires (1) the expansion of physical facilities, (2) the re
ahlocation of workers aud the integration of new skihled personnel into
a continuously changing division of labor, and (3) the establishment of
complex relationships among a multiplicity of hospital services and
departments. Understandably, those developments have had pro
found impact on hospital organization, including that of even the
smaller hospitais, for the rate of technological migration to smaller
hospitais and their associated communities is also rapdly rising. That
diffusion is furthered by the increased role of industry in medical
technology and its perceived need for expanding the market; the
spread of trained personnel from large research and trainng centers
who are seeking opportunities to practice their skills; the prestige
requirements and the competition of hospitais for attracting patients
and physicians; and the demand that services and resources be distrib
uted equitably among all citizens. Thus, the impact of technology on
hospital structure and work in smaller hospitais parallels that felt by
the personnel in larger institutions, dffering only in rate and intensity.
Technology and Its Impact on Chronic Care
Increased technological specialization and complex bureaucratic
health structures together have resulted in two additional important
developments: first, the hagmentation of chronic care, with increasing
possibilities that continuity of care wihl go awry, accompanied by
Chronic Illness, Technotogy, and the Hospital
accusatory cries of dehumanization; second, the incorporation of new
workers and roles to remedy the effects of fragmented care and de
humanization.
During patients hospitalizations, they are frequently moved to
and from specialized machne aTeas where machines are used to do
tests, monitor the course of diseases, or provide treatments. Patients
are also being moved according to the acuity of disease, from acute to
intermediate to rehabilitation wards or back to acute and intermediate
wards as their condition changes. In addtion, a constant stream of
workers comes and goes, performing tasks on patients. The scheduhing
of work for diagnostic tests and monitoring of illness status, treat
ments, and general nursing care is comphex; there is a high likelihood
that schedules will go awry since each machine area and patient care
unit has its own schedules and contingencies. for example, in any
specialized servce or patient care unit there may be a machine break
down for which staff are unable to command immediate repairs, or a
key staff member may be tied up elsewhere, or a higher prioritv
emergency may suddenly develop. When muhiple services are
scheduled for a given patient, there is a high probability that his or her
total schedule will go awrytwo meals missed in a row, delays in
meeting requests. As a consequence, patients become angry, anxious,
and discomfitedmaking for accusations of neghigence or of deper
sonalization. Health professionals are becoming more cognizant of the
untoward effects of fragmented care and are working toward re
medying the situation by adding liaison nurses and fashioning new
roles like that of the primary nurse (Mundinger 1973) of primary
doctor (Andreopohous 1974) and patient advocates (Hamil et al.
1976). But given the organizational considerations outlined earlier,
remedying the situation is shatteringly difficult.
The Hospital as Multiple Work Sites
A useful way of conceiving of the hospital is as a large number of work
sites. A walk around the different floors and sections of any fairly large
or complex hospital gives one an astonishingly varied visual experi
ence. Over here is the X-ray departmentfamiliar to us allwith its
huge mobile machines, its shielded area where the radiologist or X-ray
technician pulls switches while the patient lies or stands immobile
under or in front of a machine, having been carefully positioned by the
technician, while other patients are hined up in a nearby area, usually in
wheelchairs, each waiting to be worked on. Not far away is the car
diologists terrain, where a single patient is hooked up to a complicated
cardiac monitoring machine, operated by another kind of technician:
5
Chapter 1
Chronic ttness, Technotogy, and the Hospital
the patient is sitting, standing, or walking on a treadmili machine, the
technician is carefully operating the equipment and keeping an eye on laborator for doing the host of diagnostic tests ordered froto the
the patient; meanwhile, a physician is iookrng at the unwinding print various chinical wards. Hospital administration, too,
has proliferated
out, interpreting what the patients heart s doing during his or her into its own specialist sections. though in this book we shahl hardly be
performance. Down in the basement is the central supply department; concerned with them, except as they touch on the
hospitals clinical
no patients are in sight, but low-salaned personnel are doing numbers work. In general, the administrators do not enter directly into that
of tasks related to sending supplies up to the clinicai wards. work but their poilcies, decisions, and operations affect the resources
Upstairs, on the main floors of the hospital, are a variety of wards, avalable to the various wards, which typically compete
vigorously for
each visuaily and often spatially different to the vistors quick glance. those finite resources.
The postoperative recovery room is heavily staffed with highly skiiled A ciosing reminder: the hospitaUs many and varied workshops
nurses who carefully, minute by minute, monitor their reiatively few operate directly or indirectly in the service not
merely of managing
and initially unconscious patients, who in turn are hooked up to muki illnesses. but of managing illnesses that are overwhelrnin gly chronic in
pie machines. Nearby is the intensive care unit (ICU) with its relatively nature. The careers, stakes, and satisfactions of the personnel aside,
few heds, with patients largelv nonsentient who are relatively exposed that is what clinical-oriented work in the hospital
s ah about.
to each other, its battery of machines for monitoring each patients vital
signs, its one-to-one ratio of nurse to patient, its floating population of
easily accessible physicians, its auxiliary specialists like respiratory tech
nicians, its frequent patient crses and quick gathering of staff for fast
action. In the cancer ward, the work pace is much slower (we take our
cues frorn the patient): sorne patients are dying, others are there for
X-ray treatments or chemotherapy and are suffering from varied
degrees of physiological and psychoiogical distressso the nurses are
doing much comfort care (medical and psychological) with most pa
tients, while working on their own threatened composure and over
involvernent with the patients.
In short, a hospital consists of variegated workshopsplaces
where different kinds of work are going on, where very different
resources (space, skills, ratios of labor force, equipment, drugs, sup
pues, and the like) are required to carry out that work, where the
divisions of labor are amazingly different, though ah of this is in the
direct or indirect service of managing patients illnesses.
Decades ago the hospital was much less differentiated. Of course,
there has long been a division between surgical arid medical sections,
thotigh in many hospitais in developing countries there often is little
difference to be seen between such sections. The hospital included
servicing departments like X ray and pharmacy but had nothing then
like the complex array of wards that reflect todays explosion of medi
cal specialization or the immensely varied chronic illnesses found in the
contemporary hospital. If one focuses only on the clinical wards,
however, it is easy to miss the similar explosion in the number and
variety of support and servicing departments like transport, physical
therapy, respiracory therapy, nutririon, safety, equipment repair,
bioengineering, echotherapy, EKG, and even a full-scale clinical
6
7

2 A concept like trajectory is necessary for sociological understand
Illness Trajectories
A distinction central to the analysis presented in this book is that drawn
between a course of illness and an illness trajectory. The first term
offers no problems to the reader since everyone has experienced an
illness that did not merely appear but developed gradually over time,
getting worse and then perhaps clearing up. To the knowledgeable
medical, nursing, and technical staffs, each kind of illness has its more
or Iess characteristic phases, with symptoms to match, and often only
skilled intervention will reverse, hak, or at least slow down the progress
of the disease. Course of itlness is, then, both a commonsense and pro
fessonal term. In contrast, trajectory is a term comed by the authors to
refer not only to the physiological unfolding of a patients disease but
to the total organization of work done over that course, plus the impact on
those involved with that work and its organization. for dfferent ll
nesses, the trajectory will involve different medical and nursing ac
tions, different kinds of skills and other resources, a different parcel
ing out of tasks among the workers (includng, perhaps, km and the
patient), and involving quite different relationshipsinstrumental
and expressive bothamong the workers.
This distinction was irst utilized in B. Glaser and A. Strauss 1967, but the analysis
of trajectories was not then focused on sorne of the more subtle features of types of work,
as in the current monograph. See also fagerhaugh and Strauss 1977 and Strauss and
Glaser 1975.
Ittnes Zra1ectorze,
ing of illness management. It protects the researchers from being
confined by ihe perspective of the heahh workers themselvesmini
mizes the dangers of simply appreciating or criticizing the natives as
judged essentially from within their own framework. At the same time.
this concept is rooted in close observation (seeng, hearing, interview
ing) of health workers and so, we hope, doesjustice to ther viewpoints.
So much so, that those studied ought to recognize themselves in our
account of them and their work, and not disagree with the major thrust
of that aCCotiflta requisite for our kind ofresearch. But the concept is
ahoye ah a means for analyticallv ordering the immense varietv of
events that occurat least with contemporarv chronic illnessesas
patients, kin, and staffs seek to control and cope with those illnesses. Of
course, ah workindustrial, commercial, artistic, domesticinvolves a
sequence of expected tasks, sometirnes routinized but sometimes sub
ject to unexpected contingencies. It rnay be that trajectory fits the
organization of those kinds of work also.
But there are two striking features of heahh work shared only with
certain other kinds of work. One consists of the unexpected and often
difflcult to control contingencies stemming not only from the illness
itself, but also from a host of work aoci organizational sources as wehl as
from biographical and life-style sources pertaining to patients, kin, and
staffrnembers themselves. A second and crucial feature of health work
is that it is people work. The product heing worked on, over, or
through(!) is not nert, unless cornatose or temporarily nonsentient.
Two things follow: (1) the patient can react and so affect the work;
(2) the patient can participate in the work itself, that is, be a worker.
The latter point is equivalent [o saving that the product is not only
worked on or over but also sometirnes with. As will be seco, both major
features (contingencies and people work) of lllness trajectories affect
the various specific kinds of trajectories. aoci differentiallv so along
their various phases. Taken together, both features insure that trajec
lory work harbors the potential tor heing complex and often highly
problematic.
furtlier Sources of Problematic Complexity:
Chronic Illness and Technology
fwo other sourcesthe prevalence of chronic ihlness and associated
technologies for dealing with itmake for complicated and often
highlv problematic trajectories. In hrief, ther comhined imnact is as
follows. Sorne knds of technohogv (like the machinerv, drugs, and
9
Chapter 2
Itlness Trajeclories
various procedures used for kidney dialysis patients) are producing trajectory work, also, within the hospital especiahly is that
new trajectores (Plough 1981). Untl the health professionals gain new micro
phases and the lengthening of trajectories bring in the
experience with the novel twists and turns of the illness and with it and services of
multiple departments, involving the work of their respec
the regimens impact on other bodily systems, and with the organiza tive techn
cians and specialists, sme of whom are strugghing with
tion of work to manage ah of that, the resulting trajectories can be new phe
nomena.
difficult indeed, as the history of dialysis treatment has shown. At the The hospital staffs increasingly recognize that patient
other end of the age scale: babies saved in the sophisticated ICNs may s need to be
taught requisite skills for handling drugs and equipm
develop disabihities and systemic hlnessessome not known until ent and for doing
various therapeutic procedures when at horne.
somewhat laterthat are not necessarily curable and their extent is still So something else is
being added to the trajectories, in the last days or
not at ah known (see chap. 9, and Wiener et al. 1979). hours before the
patient leaves the hospital. In the days or weeks afterw
Improved technology has also produced a lengthening of isa ard, the patient
may be visited and worked on by visiting nurses , social
jectores. By this we mean that akhough the technology (for example, workers, res
piratory therapists, and other kinds of health profess
open heart surgery) keeps iii persons alive, and may even improve ionals.
It is easy to see that the complexities of trajectory work
them symptomatically they then face uncertain futures regarding are added to
by the host of new speciahists (medical, nursing, and technic
both the physiological consequences of the surgery, drugs, etc. al) who are
working on the patients illness and having to relate
including drastic impact on other bodily systemsand in the organiza to each other and
to each others work. These heahh workers are
tion of work to manage regimens and attendant life-styles. Even in various degrees
experienced or inexperienced. Worse yet, since rnany
without the creation of such related physiological disturbances, the specialties are
quite new, their practitioners are essentially finding
lengthening of the trajectory poses new medical, organzational and their way in their
work on the patients illness.
biographical problems: for example, the diabetics who, now living In a very real sense, contemporary medical efforts
longer, encounter end-of-the-trajectory complications that neither not only are
producing new chronic illnesses and phases of illness
they nor often their physicians dreamed of. and the associ
ated trajectory workbut are also producing new kinds
Since many patients suffer from multiple chronic illnesses of chronically
ill people. They are predominandy older persons, of
(whether related systemically or not), their respective regimens need to course but also
,
include the ICN graduatessometimes referred
be balanced carefully or else there are physiological aftermaths that to by staff as dam
aged goodsand, in fact, people of all ages. Naturally,
result in unexpected and sometimes uncontrohlable kinds of physio the interplay
of life cycle and hife-styles wth the purely physiological
logical, and so work-related trajectory, developments. (We offer a case conditions is
immensely varied; said another way, so are the trajecto
a few pages below, which serves as a poignant illustration.) Sometimes ries.
the balancing is hampered by lack of knowledge of, say, the side effects
of new drugs or even older ones used with a given patient; or by the Trajectories, Routine and Problematic: Case Illustra
tions
staffs own focus on a primary trajectory to the virtual exciusion of Despite ah the conditions that further the problematic
others regarded as secondary; also of their lack of knowledge that the character of
trajectories, of course, many are relativ ely routine . Certain
patient has other illnesses. ihlness es
and their possible developrnent s are well known , as are the
Advances in halfway technology utihized in the service of managing impact of
therapy and the resources and organi zation needed
difhcult chronic ihlnesses result in unexpected contingencies during to contro l those
illnesses. In the pages below and in later chapte rs, we shall
the acute illness periodas when experimental or relatively new be discuss
ing trajectories that run the fuil range frorn quite routine
drugs, or familiar ones used with specific patients, produce unex to highly
problematictotally out of control or partly out of contro
pected physiological occurrences that amount essentially to new phases l. It should
be useful for readers who are little acquainted with hospita
in the illness and its attendant work. Surgical nurses have remarked to l work if
first they are provided with sorne images of trajectory work
us about avant-garde surgery that in postsurgical phases it is difficult through
the presentation of two case illustrations drawn from our
even to assess what is going on and to what degree the surgery has research.
The commentary on these cases will be minimal, just enough
been successful. Because everything is so new, they literally do not to high
hght a few features of trajectories and trajectory work
quite know what w expect or how to evaluate it. Complicating much that wilh be
addressed in later pages.
11

 Chapter 2
1. We begin with a case that iliustrates such phenomena as: (a)
multiple trajectories, (b) emergency (acute) hospital care, (c) initial
steps n diagnosing or mapping of a major trajectory (heart failure), (d)
the complexitv of the division of labor, including that among trajectory
managers as well as among various technical specialists from different
clepartments, and (e) the several kinds of work involved in trajectorv
ma nagemen t.
fhe patient, Mr. Einshtein, was hospitalized for possible conges
tive heart failure. He had had a myocardial nfarction eight years
previousi when he was 57 years oid, but had since lived quite a normal
lite except for self-administered medication to control angina. Em
shtein liad recently experienced much more angina but attributed itto
the action of coid weather, which had aiways affected him somewhat,
for he liad been on an extended visit to Australia during its winter
season. His chronic bronchitis was also acting up, for he was
coughing up much more phlegm daily than usual. (Before hospitaliza
tion he did not realize that bis increased coughing was intimateiy tied
with a maifunctioning heart.) Ten days before hospitalization, he liad a
checkup by his internist who discovered, through a routine blood test,
that he liad mild anemia. A barium X ray was then ordered to check for
possible blood loss in the colon. The internist awaited this report
before rnoving to his next diagnostic tactic of taking a bone biopsy.
Meanwhule, the internist knew that the patient had appointments the
following week with both his cardiologst and his res piratory specialist.
Besides the anemia, a possible cardiac ftare-up, and difficuky with his
lungs, Einslitein had, sorne months before, developed such severe neck
pains that he now could only sleep sitting up, despite being put on
borne traction by an orthopedist.
The cardioiogist and the respiratory specialist, seen on successive
days, both suspected congestive heart failure (a heart gallop and
considerable edema haci now appeared) and so hospitalized him
speedily. for three or four days he was given intense, virtually
emergency care. A host c)f laboratory tests were orderedEinshtein
giving freely of biood, urine, and so onfKGs were taken at the
bedside, he was sent to be X-rayed and then for an echocardiogram
procedure. Cardioiogist and respiratory physician worked closely
together, each in his own province, but essentially the lungs took
immediate precedence. So the lung probtem was attacked by giving
antibiotics and by utilizing the services of physiotherapists and physical
rehabilitation technicians who trooped in and out of Einshteins room,
giving mist and bronchosil treatments and pounding Einsht eins rib
cage aiea u u effi t tu bosen bis phlegm and clear his iungs of it. Ah
those respiratory treatments went on undiminishedand uitma
telv
Itlness Trajectories
had a successful outcorneduring the two weeks of bis hospitalization.
After the first days of emergency treatment the respratory physician
moved into the backgroundthe cardiologist moving into the fore
groundevncing this by manner and iess frequent face-to-face moni
toring of the patient.
Einshteins cardiologist was actualiy new to this case, had indeed
never seen him until just before the hospitalization, Einshtein having
switched from another cardiologist. One reason for Einshteins choice
of this cardiologist, recommended by the internist, was that he
reasoned that alI of his physicians (internist, cardiologist, respiratory
specialists) couid Wt)rk together, tor they were associated with the same
hospital and knew one another. During the first days of hospitalization,
the cardioiogist awaited the results of various tests including the echo
gram both to verify the suspected congestive heart failure and to locate
which section of the heart was most affected and with what degree of
damage. He attacked the edema with a diuretic, but within three or
four days changed to a second diuretic when it became clear that
Einshteins body liad overreacted to the first one. Meanwhile the
nurses were making frequent checks of the patients blood pressure,
which was quite low and unstabie, while keeping careful watch over his
urine output. When the diagnosis of congestive heart failure became
clear, then the cardiologist moved to the forefront in the patients
management. He informed Einshtein of the diagnosis agreed on by alI
three phvsicians involved in the case; he put him on isodil every three
hours to prevent angina and explained that a couple of days later he
was going to treat the heart failure wth the drug apresoline, which, by
affecting the vascular system, would allow the heart to function more
strongly because of the lessened resistance. He explained that if this
worked, then the dosage of apresoiine eventually woutd he increased.
Patient and physician discussed the impossibilitv of predicting accu
ratehv how far back the patient would come: a wait-and-see attitude
was necessarv, and indeed it would be manv months before the out
come would be known. The cardiologist also explained the necessity of
cutting down on sodium to lessen edema and had a representative of
the dietary department visit with the patient and explain the low
sodium diet.
Meanwhule, for his neck pains the patient was doing sorne trajec
tory management himself, as welI as making sorne operational dcci
sions, which affected at least temporarilv the cardiac and iung trajec
tories. He requested pain medication so that he could sieep at night
and vas allowed it. He asked for a large chair and several pillows, and
each night surprised each new night nurse by sleeping in that chair;
only at the verv close of bis hospitalization did he discover, through
13
 Jttnes Trajectories
experimentation, that he could now sleep fairly comfo rtably by raising ing to questons about potential progress and limits to complete
the movable bed so that his head was about eighteen inches recov
aboye ery, anticipated posthospital phases
normal sleeping position. Most evenings he reques ted , expect ed length of the recoverv
back rubs from period, and, during one session, about the possible effect
whatever nurse was on duty, and they were cheerfu lly given, of congestive
in part no heart failure on longevity. The cardiol
doubt because he accompanied each request with at your ogist also careful lv explor ed the
conve patients life-style and expressed a
nience, when you arent too busy. wait-an d-see attitud e about whethe r
Einshteins pain management occasionally interfered with the and how much it would have to be altered . In fact, though
res he did not
piratory management; sometimes he reveal bis suspicion, he had real doubts about how much
made choice s in favor of the recove ry was
former at the possible expense of the possible. Einshtein discovered this only three month s later
latter. for instanc e, prop er through bis
placement of his body during the rib-pou internist who told hirn that the cardiologist was happily
nding and stimul ation of his surprised at the
lung area cailed for having the lower rate and degree of recoven.
part of his body raised aboye the
upper part, but since this increased his neck pain marked As the day of leaving the hospita l approa ched, the cardiologist
ly, he per carefully explained to Einshtein
suaded the physical therapists to do their work while the borne regime n to be followed and
he lay fiat. Again, answered ques tions about alternative treatments
he was supposed to posture, that is, lic on his side and cough, considered and
but reasons for discarding them; he
sometimes he deiayed posturing, or omitte d also explain ed how the drug therapy
it, becaus e lying down would be altered depending
hurt too much. Paradoxically he also learned how to attack the on how things turn out. for the next
immedi weeks would be essentially
ate respiratory probiemcoughing up the phlegm an experim ental, drug-ju ggling period.
, which was sorne- The chief respiratory therapi
times very difficult or wracked himby putting together bits st turned up and talked about horne mist
of in treatments. A physical therapi
formation garnered over severa days
l of queryi ng the st taught Einsht ein a set of breathing
seven or eight exercises. A dietician carefully explained the rules
different respiratory technicians who arrived at his bedsid e. of a low-sodium
Nobod y diet, leavng a list of sodium
thought to coacli or query him about possible dfficulties in coughi values found in ordina ry food and loaning
ng a book on cooking without salt that might be useful.
he was just supposed to do it. The wracki ng cough, of course , The intern, who
inter had taken a deep interest
fered with the cardiac regimen of resting as much in this case and clearly had been instrum ental
as possib le, so by in sorne of the daily operational
better management of the coughing he was, in however minor medica l decisio n makin g, drop ped in
a way, for a ceremonial farewell. Then
contributing to better management of the cardiac trajecto Einsht eins wife, who liad perform ed
ry. many functons whule he was
Once he played a more prominent part in the cardiac in the hospita l and would do varied
drama. The trajectory work in the months to come, called for cab
cardiologist had cut down drastically on the diureti c dosage a and took hm
because it home.
was contributing to too low a blood pressure; but hours
later a nurse Ihere he would be subject to
gaye the oid, stronger dosage. Einshtein, groggy at the the cardiol ogists provisi onal pro
time, did not gram of juggling drug dosages and
immediately notice the familiar pili, but minute s after would carry out the respira tory
swallo wing it regimen faithfully. As for bis manag
queried the head nursewho got fiustered, calied in the ement of the neck pain, he asked
intern, who in bis internist to recommend a reputable
turn apologized for the error and ordered an IV, explain acupun cturist and switclied to
ng that it another orthopedist, who recommended
would be necessary now to counteract the diuretic with physio therapy . Within two
a twenty-four months, Einshteins neck pains liad so dirnini
hour intravenous drip. shed that he was finally
About four days after hospitalization, Einsht able to posture properly and sleep lving down so that
eins interni st re he coulcl get the
ported the barium X ray was negative and did full measure of rest required by bis cardiac conditi on.
a bone biopsy to check 2. Next is a case illustrating a rajectory
out another possible source for the anemia. And he ordere which is highly prob lern
d iron pilis atc from everyones point of view: phvsic
to counteract the anemia. Einshtein would continue ians, nurses , and patient.
to take this Sorne features of this case that stand out
medication for many months. are: (a) the multip le trajecto
The internist, long familiar with his patient ries, (b) the rnultiplicity of trajectory manag ers and the
, assured him from time confus ion over
to time that the cardiologist was on top of things. coordination of their efforts, fc) the numbe r of medica
The cardiol ogist also l and technical
contrihuted measurably to relieving Einshteins departments drawn upon as resourc es, (d) the sheer
anxiety by relatively difficu ltv of pre
unhurried visits, clear explanations, and after several days dicnng outcomes o1 the medical interve ntions and
by respond the difhcuhy of
deciding which to utilize, (e) the patients active role both
in reacting to
i
Chapter 2
staff decisions and making her own daily decisions, and (f) the
cumulative impact on everybody, including frustration because of
great difflculty in gaining and maintaining control over the various
courses of illness, anger and upset over the patients uncooperative
behavior, conflict and resulting anger among the staff members them
selves, and dismay and upset over the issue of dying.
Mrs. Price, 45 years oid, was hospitalized for the fourth time
(Fagerhaugh and Strauss 1977). She had been diagnosed as having
lupus erythematosus two years previousiy. As a result of her lupus, she
now had (a) pericarditis, (b) pleuritis (both of which caused pain), (c)
cerebritis, which caused sorne personality changes and a tendency
toward tremors and convulsions, and (d) chronc obstructve lung
disease from the lupus and her heavy smoking. As a result of the
steroid treatments she also had (e) gastric ulcers and (f) cushingoid
syndrome.
She was readmtted to the hospital because of continued chest
pain. The lupus specialist suspected a pleuritic ftare-up frorn the lupus
and recornmended hospitalization at the university hospital for re
evaluation and readjustment of the steroid drugs. During her flrst
three days of hospitalization, the house staff was busy evaiuatng her
illness status: this involved innumerable blood studies, an electrocar
diogram, and chest X rays. Meanwhile, she was having increased chest
pain. By the seventh day she developed abdominal pain, which in
creased during the next week. All early tests for the source of that pain
were negative. On the seventh day she became very nauseated. Con
tinuous intravenous infusons were started because she was developing
fluid and electrolyte imbalances. With continued nausea the house
staff decided that gastric suction wouid relieve the discomfort, but she
objected because in the past she could not tolerate the gagging caused
by the tube. Therefore, antinausea drugs were added to her drug list.
Dr. Ambrose, a gastrointestinal specialist, was next consuhed about her
abdominal pain. He suspected pancreatitis and recommended a
barium X ray and gastric analysis tests. To accommodate the possbility
of painful pancreatitis, extra pain drugs were ordered whenever an
uncomfortable test was done.
With the appearance of numerous new symptoms the nurses be
gan monitoring Mrs. Prices vital signs more closely. On the fourteenth
day a definitive diagnosis was made: she had developed a huge gastric
ulcer. A chest X ray also showed broken ribs. Both were attributed to
the steroids, and yet they could not be stopped because the lupus would
then get out of control. Everyone was upset by this news, as well as by
the general deterior ation of dic patients condition. The nursing staff
had long since been upset over the patients uncooperativeness con-
Ittness Trajectories
cerning medications; indeed, sorne nurses recollected experiences with
her during her previous hospitalizations.
Irnmediate treatment problems were posed. The medical choces
were limited. In the patients current physical state she was a poor
surgical risk. Yet the sze and location of the ulcer, unless immediately
treated, had dangerous consequences: there could be erosion of the
ulcer into the peritoneal caity or it could cause pancreatitis, both
potentially fatal or at least extremely painful.
Numerous specialists were consulted. After much debate, the dcci
sion was made to radiate the stomach to knock out the acid-producing
cells and so prevent further extension of the ulcer. The radiation
dosage would be low so that other organs would not be comprornised.
Concurrently, hyperalimentation treatment (special intravenous feed
ing through a tube placed in the subclavian vein, located in the neck)
would be started to overcorne malnutrition. The physcians explained
to the patient the limited choices, why the treatrnents were necessary,
and that the radiation dosage would be extremely low. Mrs. Price
agreed reluctantly because she was very frightened of the radiation;
later she wanted to stop it but was finally talked into continuing it by her
husband, who was a physician.
In the ensuing twelve days, her nausea increased and she had
several days of diarrhea, each related to the radiaton. She would
frequently resist the treatrnent, either because she felt too ill or because
she doubted the wisdom of the therapy. Sorne days she would be
persuaded by the staff, but increasingly she resisted. Or she would
agree in the morning but change her mmd in the afternoon. Finally the
staffin desperation gaye her intravenous tranquilizersjust prior to the
test to make her sleepy and less resistant.
Over the weeks innumerable specialists streamed in and out with
no one person coordinating the patients care. After considerable
discussion, pushed by the house staff, a decision was reached: house
staff and the gastrointestinal specialist would together be the major
coordinators, and ah new orders issued by the attending staff would be
discussed first with the house staff. The nursing staff sighed in relief
because at least the mess would be under control. However, the
coordination continued to break down from time lo time. One phys
cian in particular would telephone the nursing desk with orders based
on his past experiences with the patient. This created much tension
within the house medical staff.
Blood studies next ndicated a low hemoglobin count as a result of
the ulcers as well as the lupus; a blood transfusion was given. The
nurses were becorning increasingly weary of daily hassles with the
patient who wished lo delay various treatments.
17
Chaper 2
Qn the twenty-seventh day the patient developed tremors of the
hands and legs. She became very anxious since this was seen as a
possible forerunner to convulsion, but because of her great anxiety the
staff had difficulty making an assessment of her actual condition. They
decided to wait and see. Mrs. Price thought immediate action was
called for and again phoned an attending physician who ordered drugs
without consulting the house staff, which angered them. The tremors
(lid subsde a few days Later.
Because of continued nausea, al! drugs were administered by
mjectionssome thirtv a dav. The injection sites were becoming
fibrous knots and so the nurses were concerned not only about the
poor drug absorption but also about the possibihty of infections be-
cause of the high steroid dose.
On the thirtieth day, Mrs. Price developedjoint pains and swellng
of her hands, elbows, feet, and kneesall symptoms of lupus. The
steroids were adjusted. In a few days the symptoms subsided. On the
forty-first day, X rays showed no decrease in her ulcers size. There was
much troubled discussion among the staff. The patient was blamed for
her uncooperativeness in taking the antacids and for her chain smok
ng, which had increased the gastric secretions. The patient, of course,
was very upset. She remarked to the researcher: 1 knew ah along the
radiation woutdnt work. Ah 1 probably got out of the radiation is
kidney damage.
During the next days there was much discussion about the next
course of treatment until a decision was reached: the only alternative
was a subtotal or total gastric resection. There were surgical risks hut
without intervention there would be danger of peritonitis or pancreati
tis and hemorrhage. With surgery she might uve several more years.
She was informed of the recommendation, the staff realizing her
decision to accept surgery would be a difficult one.
for the next three weeks, she agonized over whether or not to have
the surgery. Her husband thought it the only alternative. The psychia
trist thought that the patient, if discharged home, would drive the
husband crazv and that she would not consent to a nursing home. So
surgery, the staff reasoned, should be done.
Over the next days the patent talked about dying te her husband,
to the psychiatrist, and te the social researcher. The three had many
discussions among themselves about her sad dilemma and how to help
her. The staff now had difficulty in talking about as well as interacting
with her.
By the fifty-eighth day, she was wavering on whether to have the
gastric surgery, though it was becoming more evident it was required.
She frequently stated now that she had been saved from death twice
4 9
!tlness Traject.3ne
and didnt know if she wanted to be saved again. She would take her
chances with no surgery and so hemorrhage and die. She was weary of
ah the uncertainty and the pain. She was talking more about wanting te
commit suicide, too. The psychiatrist consulted with a suicide expert,
who thought the probability of her seriously considering suicide was
low; still the staffcould not dismiss this possibilitv. As a precaution, her
clothes were taken home and money and drugs were removed from
her purse because she was talking about taking a taxi andjumpng off
the bridge.
On the sixty-seventh day the X rays showed an increase in the size
of the ulcers. There was total agreement among the phvsicians, includ
ing the psychiatrist, that a gastrectomv was required and should occur
while the lupus was stable. For the next seven days she agonized over
whether to have a gastrectomv. The surgeons and psychiatrist tried te
answer as best they could any questions she might have. She consulted
other attending physicians. They ah agreed a gastrectomy was essen
tia!. Her husband backed them. A relative also persuaded her the
surgery would be the only solution. She flnallv signed the consent sup
for surgery. She was transferred to a gastrointestinal surgical unit. fhe
surgery was successful, and the patient was weaned finahly from the
hard drugs but not without considerable interactional difficuhies be
tween staff and her. Indeed, the purely physiological (surgical-pain
trajectory) orientation of the surgica! staff maximized the interactional
difhculties. On the one hundred and twelfth day, she was discharged,
free of her uhcers but, of course, stil! having to uve with her lupus.
Control and Contingency
It is the interplay between efforts to control ihlness and contingencies,
whether expected or not, that make for the specific details of varous
trajectories. On!y under quite routine conditions is control over the
medical process and product !ike that exerted over industrial pro
cesses. Although the latter can be tremendously complicated in se
quence and great in range of resources and dvision of labor utihized,
nevertheless, once the trial-and-error perod of working out the bugs
is completed, then the number and range of interfering or upsetting
contingencies are minimal. Managing ihlness trajectories is more like
the work of Mark Twains celebrated Mississippi River pilot: the river
was tricky, changed its course slighthy from day to day, so even an
experienced, but inattentive pilot could run into grave difficukies;
worse yet, sometimes the river drastcally shifted in its bed for sorne
miles into quite a new course. As Mrs. Prices case illustrates, the
physicians and staffs managernent rnay be even more cornplex and
Chapter 2
Itlness lrajectories
the outcome of their work even more fateful than the pilots. Sorne of
the various contingencies may be anticipated, but only a portion of detailsprobably it rarely isbut it does involve an imager
y of se
them may be relatively controtiable, while sorne contingencies are quite cjuences of potential events and anticpatable actons.
unforeseeable, stemming as they do not only from the illnesses them The point can be brought home by remarking that twenty -five
selves but from organizational sources. In sorne instances, contingen years ago one of the author s of this 1)00k, while makin g held observ a
tions of physicians in a teaching hospital, noted that with difficu
cies rnay also stem from sources external to the hospital. lt cases
thev frequentty were not prepar ed to make definit ive diagno ses,
As the pages below will suggest, a helpful image of what goes on hut
would sav, we wihl wait ami see that is, wait until more sympto
with relatively problematic trajectories is this: efforts to keep the trajec ms
had appeared that would fali unto a more interpr etable gestalt .
tory on a more or less controllable course look somewhat gyroscopic. Then
they would know what they were dealing with and what sequen
Like that instrurnent, they do not necessarily spin upright but, meeting ces of
actioflS thev needed to take. Physicians still do this, despite
contingencies, they may swing off dead centeroff coursefor a the enor
mons increase un the diagnostie means available and the great
while before getting righted again, but only perhaps to repeat going improve
ments in their effectiveness in specifying a patients illness
awry one or more times before the game is over. Sometimes, though, and the
current phase of its developing course. Such improved diagno
the trajectory game finishes with a total collapse of control, quite like stc
means allow for gready improved tocating of the specific illness
the gyroscope falling to the ground. and the
maping of anticipatable tasks.
At any rate, the interplay between control and contingency chal
The initial diagnostic work is, of course, only the beginning
lenges the very idea of illness (and trajectory) rnanagement per se. As a of the
trajectorv work. Chronic illnesses often insure that the first
terrn, managernent does not catch anything like the fuil complexty phases in
trajectorv work are done by patients themselves. Characteristic
of this work, its medical outcome, or the consequences for ah who are ally thev
notice certain new occurrences affecting their bodies, often
working at t. For that reason, we need to add to management two disregard
these for a time, and then, growin g concer ned or alarme d, they visit a
other ideas. One is that managing the problematic trajectories is
physician. The latter mav offer a tentative diagnosis, or
better understood as shaping them, that is, handling the contingen an incorrect
diagnosis. or even decide nothing is reallv wrong,
cies as best one can, although being far frorn fully in control of the or counse a wait
l
and-see penod. Continued symptoms mav lead the physic
trajectory. (This point will be discussed again later.) The second idea is ian tO con
suhations with colleagues but alternatively mav lead the
that trajectories are also experienced. Unless we are inclined to think unsatisfied
only of the social and psychological impact on patients and kin, it is patient to make the rounds of severa l physic ians (and/o r aherna tive
necessary to recognize that staff inembers can be affected profoundly care practitioners) in search oa diagnosis with associated therapv
that
by their work on particular trajectories. Together the three terms, can control the disease or at least its symptoms. (Hence the anger
evidenced by patients whose cancer s or other illness es had
managing, shaping, and experiencing, give a much more adequate been fate
fully misdiagnosed by one or more physic ians before correct
picture of what happens when trajectories are complex and prob identif ica
don.) A diagnostic search of varving duration, then, made
lematic. by either
patient or physician can somedmes precede a diagnosis upon which
everyone agrees.
Diagnosis and the Trajectory Scheme The difference between the patient and the phvsician is that the
latter has more experience hoth in diagnostic search and injudging the
Diagnosis is the health professionals terrn for ihe beginnings of trajec reliability of his diagnostic means. In urban centers today, physicians
tory work. To do anything effectve, other than just treat symptoms, may need to be very careful in assessng that reliability, since clinical
the ihlness has to be identified. Once that is accornphished, the physician laboratories, X-ray centers, and the like ma> varv in the quality of their
has an imagery of the potential course of the ihlness without medical work. Thus, an experienced and skeptical oncologist:
intervention. The physician also has a rnapping of what the interven
tions might be, what rnight happen if they are effective, and what 1 think youjust learn to know who you can trust. Who
resources are required to make them. In effect, he has then what might overreads, who underreads. have got X rays alI over
town. so ve had the chance ro do ir knnw rhr wbp
usefully be termed a trajectory scheme. This rnay no be fihled out in all its .
Schmidt at Palm Hospital says, Theres a suspicon of a
20
21
Chapter 2
tumor in this chest, it doesnt mean much because she, like
1, sees tumors everywhere. She looks under her bed al
night to make sure theres not sorne cancer there. When
Jones at the same institution reads it and says, Theres a
suspicion of a tumor there, 1 take it damn seriously be-
cause if he thinks ks there, by God it probably is. And you
do this ah over town. Who do you have confidence in and
who none.
But the diagnostic reliabihity is not at ah foolproof, and physicans
who are increasingly at the mercy of the work of the clinical laboratory
workers and other diagnostic technicians do not necessarily find it easy
to judge their diagnostic reliability; nor because of their own busy
practces do they have sufficient time to judge that reliability accu
rately. Asked by the researcher how a physician canjudge the results of
a CAT scanner, the physician quoted aboye answered:
1 dont behieve them anyway: 1 se them ah myself. 1 make
them show me. And even so, not being an expert in it, they
can puli the wool right over my eyes. But at least Ive seen
the actual readout they get from the scanner. Most guys
dont have the time to do that, or make the time. 1 think
you tend to take what you get. Though they can become
expert enough to know when somebodys saying, 1 think
this is bigger. This takes a lot of time, it really does, to
spend the time to go over them.
The question of laboratory or technician error, then, is at least occa
sionahly a real possibility. Error may arise not only from msinterpreta
tion, but from machine error, too, since sorne machines ac least have to
be calibrated carefully or the test results that they produce may be
inaccurate. (See chap. 3 and 4.) Moreover, while a physician obviously
can rely on the laboratory not to err in sending the right report for the
right patient, he cannol always be absolutely certain. Therc is sorne
irony, then, assocated with todays diagnostic procedures, since the
very increase in resources for diagnostic accuracy has made the physi
cian more dependent on those resources for accuracy in interpreting
and reporting test results.
It is worth notng, too, that with chronic illness, diagnostc locating
and mapping do not necessarily occur just once, at the outset of
therapy. Quite aside from monitoring an ihlness and the effect of
interventionsphenornena to be discussed laterthe physician may
believe an illness is relatively in check. Later, the appearance of other
symptoms may be read by hirn OF another physician as requiring a new
diagnosis, involving another ihlness, or forcing him into a diagnostic
search that leads eventually to rediagnosis of the original illness.
22
Iltness Trajectories
Ive got a patient who had a melanoma four years ago,
which was excised from his nose. Then about a year later it
recurred in a node in bis neck. it was a bad form of a bad
tumor. Yet going over it, we wouhdnt find any evidence it
had spread at ah. Seven months ago he developed a pan in
his back, and lis doctor saw him, and because of his history
of cancer got sorne X rays of his spine, but found nothing.
And he developed ah the symptoms of a disk, was put on
bed rest and got better, then finahly got worse again. Even
tually, not as soon as one might have hoped, but eventuahly,
he carne for a bone scan, and the scan showed a red-hot
lesion in his sacrum. It was very hard for them to behieve
that meant cancer, except thats reahly what it means. Un
less youve got a clear-cut fracture. So they took tomograrns
of it and showed destruction of a couphe of the bony pro
cesses of the sacrum. Hes gol a metastic melanoma. Welh,
the state of the art is such that f they had not really been
very reluctant to find out that this guy had cancer, theyd
have done a bone scan six months ago and found the
cancer.
However, even if this oncologist had heen seeing the patient reguharly,
a kind of rediagnosis would have been attempted once suspicious
symptoms appeared or oid ones increased: the physician needs to
know just where the disease course is now.
This suggests, in fact, that even for the initiai diagnosis many
chronic ilhnesses require not only that an identification be definitive but
also that the tocation ahong the course of the disease be made as specic
as possible: Where is the lesion, tumor, or deterioration of vertebrae?
What kind? How large or how much? Impinging on what? Remaining
static or getting worse? And at what rate? Such questions hint al an
additional paradox that attends the diagnostic search. Often the phys
cian now enjoys rnuhtiple options for getting the desired diagnostic
specificity. But sorne tests cost more, cause the patient more pain or
discomfort, are potentiaily more dangerous, or are of stihl debatabhe
efficacy. The physician wili balance those considerations and what they
mean for the patient against the generahized rule that the more specific
a diagnosis, the more potentially effective can be the prescribed treat
ment.
For the sociologist, the medical term treatmentbased on di
agnosstransiates into a plan of action involving: (1) things tobe done
to control present or anticipatabhe developments in the disease course
(X-ray treatment, use of specific medications, EKG monitoring, biood
pressure rnonitoring, types of surgical intervention) and (2) those
things to be done in sorne sort of sequence (3) by specified or assurned
23
Chapter 2
knds of personnel(even by specifically designated persons). This is the
trajectory scherne touched on earlie;: it includes not only the physicians
visualization of potential disease developrnents, hut also foreseeable
actions in relation to those events. Irnplicit, and sornetirnes explicit, in
that visualization is the coordination of those actions, which usuallv
involve rnanv different kinds of technicians and specialists, and often
several different hospital departrnents.
Complexities of Organizing Therapeutic Action
The complexities of organizing therapeutic action derive mainly from
two sources. The first is the problernatic character of so many trajecto
ries. As wifl he noted directly helow, f the lllness course is well under
stood and no untoward contingencies arse, then the stereotypical
picture of a single phvsician insttuting therapeutic plans and having
thern carrieci out successfully is a realistic picture. If the trajectory is
problernatic, however, then that classic image of medical work can be
very far fi-orn accurate. The second source for the complexities of
therapeutic action is the number and range of tasks as welt as the
organization of those tasks, So that even relatively routine expectable
trajectories can develop unanticipated complexities around organiza
tional issues. These, in turn, can profoundlv affect the organization
and efficacv of therapeutic action. In the next pages, sorne of these
cornplexities will be cliscussed.
Trajectort management is relatively routine for courses of illness that
turn out to be relativelv standardthev are ah well known and the
phvsician and staff [nernbers have had rnuch experience with them.
Hospital wards are equipped to handie routine cases with sorne effl
ciency, using standard operating procedure: the needed machinery is
on the ward, the desired rnedications are on hand or easily obtainable,
the nursing staff understand the procedures, and the head nurse has
had rnuch experience in coordinating the scheduling and timing of
various resources or services needed fi-orn other departments. Indeed
each ward tends to have what ve would term its characteristic shape
(Strauss, Schatzrnan, Bucher, Ehrlich, and Sabshin 1964a), for it has jis
characteristic types of ihlness, which are handied thereand though
cornpiex, the requisite tasks are well understood and their larger
organization relativelv worked out. An example would be a recovery
room for postcardiac stirgicai patients, where the latter are initiaiiy in
parlous conditions, where the clusters of tasks require highly skilled
nursing and physician staff, but where the routines are well laid ouL
even for handhing emergencies and the orgarlization for ah ihat is
f more problernatic cases, he may institute a search for otions other than
nicely coordinated. The chief physician, as the main trajectory man-
24
llness Trajectones
ager, can count on ah that organizational machinery for handling
hopeully without undue hitchesanticipatable routine cases, through
the fi-st days of postsurgical recoverv. By contrast, ifa patient is placed
on a ward into whose shape he does not flt at allthat is, the staff have
little f)i- no experience with his illness, have no experience with the
equiprnent used on him or with rnedications ordered for hirnthen
the routine trajeCtOrv tui-ns into a nonroutine and, also, often highly
probhernatic one. Worse yet, difficuit cases become even more prob
iematic under these out-of-shape conditions.
Cases that are, f)n diagnosis, viewed as potentially probhernatic will
requ ii-e a more complicated order of task organization anci coordina
tion. To begin with, the phvsician rnay not be ahie to foresee ciearhv the
course that the iliness will take, or perhaps its rate of deveioprnent. with
or without medical intervention. Or the disease cotirse may be rela
tively recognizable, but the impact of experimental drugs or proce
dures (oid ones not being effective) are not well known. He can,
however, visualize sorne of the tasks to be done and rely on the ward
personnel to cari-y them out, but thev and he know or suspect that
other resources (specialists, departments, treatrnents) rnay have to be
cahled upon as unanticipated developrnents occur to suppiernent the
more usual standard operating procedure of the ward. In extreme
cases (as with Mrs. Price) whole cltisters and sequences of tasks are
unanticipated, and a great deal of ad hoc organization is required to
get them decded upon and to get them done.
Fo hack up a bit, however, the initial diagnosis leads the phvsican
in charge of the case to considerations of medical irnervention, of
treatment. Here again, modern medical technohogyhowever half
wayis iikely to c)ffer several initial therapeutic options. Breast cancer,
for instance, can be treated with surgery, radiation, or chernotherapv,
and there are several types of each; they can be used singlv, in combina
ion, and in different sequences. Which options to choose? The physi
cians experience rnav lead hirn to one choice or another; so rnay his
medical or social ideologies; his set of behiefs about surgery or particu
lar kinds of surgerv, or about various drugs or machine treatment, or
his more sociahly tinged convictions about womanhood and about
sexual relations. Considerations of cost, convenience, avaiiabihity,
speed of irnpact, skill, risk, discomfort, and psychological impact on the
patient will also be halanced.
In managing more-or-less standard cases, the physician will not
rieed to search for viable options, since he wihl know most of them. for
ihose he has already had experience with, utilizing literawre and
collegial consuhations. House staff rnay be involved in both the search
25
 Uhapter 2
and the decisions about which options shall be tried. Typically the
physician will anticipate certain outcomes from medical interventions,
sorne undesirable (drug side effects), and will alert the nursing and
physician house staff to monitor for those cffects and, if they appear, to
stand ready with countermeasures.
There may also arse, however, sorne of those unanticipated con
tingencies discussed earler. When they appear, the responsible physi
cian may not have ready options to utilize as counterrneasures. Again,
he may insttute a search for options, or house staff (even nursing staff)
may press alternative courses of action on hm. So while one physician
may make the option decision, others may also be involved in that
decision. Moreover, at these unexpected option points whoever is pres
cnt may sometimes need to make strictly operationat decisions, needing to
choose one or another option quickly, without consulting the physi
cianproviding that the danger to the patient is perceived as great and
immediate. In that event, the trajectory management is further diluted
or, necessarily, shared. (One example is the incident in the Einshtein
case, when the cardiac patient discovered the nurses error concerning
his diuretic medication, alerting then the head nurse, who in turn
called the intern, who made a quick decision to counter the potentially
dangerous contingency with an intravenous drip.)
Each new contingency, whether large or small, requires sorne
choice of ahernative unes of action in order to get the trajectory into
the best possiblc manageable order, that is, to keep the gyroscopic
shaping of the trajectory as successful as possible. Again, we say trajec
tory rather than simply refer to the illness course, because so much
more is involved than thc illness itself. for example, the physician may
not only order a procedure changed but request that a specific skillcd
person carry it out. Moreover, at crucial option points, severa! persons
with somewhat different stakes in the case may be wcighing, and
pressng their respective views on, various possible options.
One important implication of that last sentence is that, under
conditions of contemporary hospital practice, it is not always a simple
matter to say who is in charge of rnanaging the trajectory. In routinc
cases, the principal physician is primarily responsible for visualizing
the trajectory: for ordering, evalua ting, and acting on diagno stic tests;
for laying out the lines of work that need to be done; for utilizing
the
wards organizational machinery. When the course of illness becomes
problematic, however, when things get out of hand, when other phys
iological systems go awry, when other chronic illnesses impinge on the
primary oneand even begin to take prioritythen the trajectory
management begins to get shared
with other medica l special ists. And
as the case of Mrs. Price has illustrated, these specialists may disagre
e why the new symptoms or ihlness have appeared, what alternative limes
26
Itlness Trajectories
or their orders mav conflict, so that problems of coordination can plav
havoc with house staff and, not incidentally, also with patient care.
Lack of coordinaton amounts to a blurring of the division of labor,
with untoward consequences then flowing from unclear or disagreed
upon conceptions of responsibitity.
On the other hand, the specialsts may work well together, sharing
in the shaping of the trajectory. II is important to understand that with
complex trajectories, this shaping, which rnvolves a complicated divi
sion of labor, may be parceled out not only among several speciahsts,
including a psychiatrist, but may also involve the efforts of km. Patients
themselves may enter this process at key option points, entering as
intensely interested parties or being invited in by the physicians, who
may even press them to make certain decisioris when the options are
verv risky, or their potential psychological or biographical impact is
great. But they may enter as intensely interested parties who weigh the
option criteria differently from the physicians. Their own option
searches may lead them to propose and even to insist on consideration
of alternative options (see chap. 9). One patient with severe respiratory
disease whom we followed closely in and out of the hospital was
astonishingly and successfully assertive in his own trajectory manage
ment, pressing his physician repeatedly on ah kinds of issues, but one
of bis major controlling strategies was to know the whole range of
pharmaceutical possibilities and to utilize them with or without his
physicians knowledge.
An additional complication is that precedence in the trajectory
managernent is directly affected by the existence of multiple illnesses.
As the case of Mr. Einshtein illustrated, when the lungs were under
control and the cardiac condition was specifically diagnosed, then the
rnanagemern shifted from respiratory to cardiac specialist, while the
internist stayed in the background managing the minor and nonin
terfering condition of anemia. If, however, the illness that brought the
patient into the hospital affects anotheror starts anotherthen the
first can drop into a position of secondarv importance, at least (or
a while, dic other taking precedence. Usuallv this means that the
chief trajectory manager, until illness priorities change again, will be
another medical specialist.
One feature of highLy problematic trajectories, especally when
there are several deeply interested parties or even trajectory managers,
is what might be called trajectory debates, which involve not merely
technical but also ideological issues. As the trajectory (or trajectories)
goes badly awry, rnany voices are heard, sorne soto voce, but sorne loud
and clear, expressing different views on why the llness is out of hand,
27
Chapter
of action ought to be taken, who ought to be brought into the act and
who pulled out, and so on. In every highly problernatic trajectory
whose unfolding we have watched over the years, we have observed
this kind of debate, exemplified, of course, by Mrs. Prices case. lhe
debate encompasses not only the medical specialists, but rnost of the
wards personnelsometimes right down to the nursfrig aides who
may express themselves publicly, tooand the argurnents and attempt
at persuasion take place in conferences, at the nursing desk, in the
corridors, and inevitably, since the patient is involved, passionate argu
rnents occur n the sick persons room, too. Since particular decisions
about options at critical points can profoundly affect the shape of the
trajectory (and the patients life!), it is worth thinking of those decisions
as, in the profoundest sense, potentially very fateful. A poignant scene
drawn from our fleid notes should make this point graphically and, not
incidentally. illustrate how sorne of the operational decisions made on
the ftoor can be quite invisible to the man physician hirnself. The
action takes place on a cardiac recovery ward; the central figure is an
elderly, very iii, lady scheduled for surgery the next day.
She is now sitting up in bed, glasses on her fose, writing on
a clipboard, absorbed in her writing, struggling with it. Her
daughter is at her right, helping to hoid the clipboard. The
physician is at her left, the nurse hovering. When the pa
tient finishes writing, the nurse takes the clipboard and
puts it on the bedside table. As she leaves the room, 1 fol
low her and ask what this scene is all about. The nurse
draws me further nto the hall, and with sorne passion tells
me the patient has been facing whether to die or to go
through another operation. She has had three previously.
(She is now bleeding into her lung.) The nurse had toid
her that it was her own option to decide. Now the daughter
is angry at the nurse for saying that; but the nurse ques
tions whether it rnakes sense for the patient to go on. She
added that 1 could see the patients note later if 1 wished. It
said approximately that: 1 have decided to die. Its up to
God. Doctor Smith says that have oniy a fifty-fifty chance,
and that makes no sense.
Then 1 glanced back into the patients room. The daughter
and the physician were still at the bedside in their respec
tive positions. The patient was looking frorn one face to the
other, but had now agreed to the operation (the daughter
had persuaded her), smiling through her tears at the physi
cian. Both he and the daughter then disappeared down the
hall together.
28
Illness Trajectones
Then a young resident began to enter the roorn, saying
something to the nurse. She swept him back into the hall.
He said the tube now in her is not long enough to reach
her lungs; that the blood then wiIl flow frorn one lung to
another. He wanted to put a new tube in. The nurse an
grily said no, that this woman had just been through a
dramatic scene. Nothing doing! The resident then said at
least they could shove the tube down a bit further, since
there was about one centimeter left, and that could make
the difference. He led her over to the X ray to show her
the patients film and to point out that if they didnt get the
tube lower, the right lung would look like the left lung be
fore tornorrows operation, if there was one. She reluctantly
agreed.
Immediately after, the nurse having cued the resident to
the patients live-or-die dilemma, the two of them entered
her room and stood opposite each other at the bedside.
The nurse said gently but passionately to the patient that
the decision was up to her; and the young physician agreed.
The next afternoon when 1 returned to the ward, the
nurse said sadly that the patient had died in surgery.
The drama reflected in the field note concerns dying, but, of
course, rnany decisions concerning the choice of options do not actually
confront that dire issue. Yet those choices represent a fateful shaping
of the trajectory and ultirnately rnay have profound impact on the
patents Life. In seeking to control highly problernatic trajectories, the
very choice of sorne options early in the trajectory closes off others,
leading to developments that force confrontation with other sets of
options, whose selection again may later foreclose of options that
might earlier have been feasible. The biographical and medical con
sequences may be rnomentous.
Now, we shall conclude this section on the complexities of organiz
ing therapeutic action by reiterating that for even relatively unprob
lernatic trajectories, let alone highly problematic ones, the terrn shaping
is quite as applicable as managing the trajectory. A single physician
may, in fact, hoid fast to the rnanagerial helm, handling the case in a
very organized and brilliant fashion. Nevertheless, because (1) he is not
doing ah the work hirnself and because (2) the work involves the
organization of countless tasks, it follows that even the principal trajec
tory manager is supplemented by numerous other persons (including
patient and kin) who are helping to shape the fuil evolution of the
trajectory. Sorne patients elect to die rather than struggle on and others
can in an eme rgency prevent their own immediate deaths because they
29
Chapter 2
know their own physiological reactions and the personnel do not. (Wc
observed this once.) These are simply dramatic instances of how
trajectories get shaped rather than simply managed.
While the more technical managernent entails prirnarily medical
and organizational sklls, the total range of trajectory work requires
dfferent additional types of work that help to shape the entire trajec
tory. Each of these types of work will be discussed in later chapters, but
first it will be useful to look at trajectories n terms of the ctusters and
sequences of tasks that constitute the detals of trajectory work. One
ought not to be unduly surprised if the discussion is rerniniscent of the
Shakespearean For want of a nail, a horse. . .a kingdom was lost,
.
since tasks can pile on tasks and errors or failures that require addi
tional corrective tasks can occur significantly at any point (see chap.
13). The next pages, then, will focus on more microscopic details of
trajectory work, touching also on the variants of work involved other
than the purely medical and technical. They will also bring out sorne of
the organizational underpnnings necessary for carrying out that work
and those tasks.
Trajectory Phases, Arc of Work, and Task Sequences
Since trajectories extend over time, they have phases. The physicians
and staffs trajectory scherne includes visualization of sorne of those
phasesmore accurately for routine than for problematic trajectories.
When the trajectory manager anticipates these phases, he or she has in
mmd certain things that will need to be done per phase, beginning with
the diagnostic period and rnoving along through various therapeutic
steps. The physician in his or her trajectory scheme visualizes what
rnight be termed an arc of work, that is, the overail work that needs to be
done to control the illness course and get the patient back into good
enough shape to go home. The arc of work rnay not be cornpletely
visualized by the physician, and, indeed, the physician may hold in
abeyance precisely what further work is required until after initial steps
are done, until Wc see how things work outuntil the actual phases
are known. Under those conditions, the total arc of work wilf evolve
more siowly, as the trajectory manager senses or calculates what necds
to be done next. And in problernatic trajectories that go quite awry,
even temporarily out of control, the total sequencing of work rnay be
known only after the case is finished. (The case of Mrs. Price exem
plifies the evolution of unanticipated phases, unanticipated sequences
of work, and an arc of work that could only be known post hoc.)
At any rate, during each phase it will be decided that certan things
need to he done: monitor cardiac output, get another X ray, continue
30
Illness Trajectories
the dialysis sessions, monitor the postsurgical condition, and so on. Any
point at which it is decided to do those things we cali a trajectort sequence
point. ihe term is apt because at each point a different cluster of tasks is
required; they will change partially or totally at the next sequence
pornt. But the terrn is less important than our recognition that the
cluster of tasks (E. C. Hughes [1971] calis thern bundles of tasks) have
both a sequential ordering and an organizational base that allows their
being carried out.
The physician ordinarily does not concern himselfwith the organi
zational and operational details of carrying out the orders, the supervi
son and articulation of those tasks fail under the province of various
technicians and nurses and, where specialized tasks are done, such as X
ray or brain scanning, other medical specialists. If there is sorne defect
in organizational arrangements, then there will be difficulty in adher
ing to the sequence and its tirning, as will be illustrated beiow. The
resource base includes the proper skills, a sufficient work force,
appropriate equipment, necessary drugs, enough tirije, and so on.
Sorne of the resources will be allocated to and found on the ward itself;
others rnust be drawn frorn other departrnents and sornetimes frorn
outside the hospital itself, like repair services for equipment or the
electricity to run equipment.
To give sorne concreteness to the foregoing abstract staternents
and to convey additional points that pertain to organizationai function
ing, we present four short case histories with an accornpanying corn
rnentary. They will bring out sorne of the diverse and interlocking
types of work involved in trajectory work.
1. Cardiac Recovery Ward. In the cardiac recovery ward, there are
eight roorns, one patient per room, one highly skilled nurse per pa
tient. Backup support is provided by readily available house staff
(residents and interns) and attending physicians on cali. Ail rooms are
equipped with multiple machines. Machines are for sustaning life
(IVs, respirators), for rnonitoring (TV screen and recording of cardiac
functioning), for comfort care and prevention (mobile rnattress, cooi
ing rnachine for rnattress), for therapy (postoperative blood purifier),
and so on. There are ample supplies of rnedications on the ward as well
as various kinds of supplies for imrnediate use. A bioengineer cali
brates machines each day and is on cali for emergencies. Ihere is
regular servicing of machines both in-house and by rnachine company
representatives. Extra equipment is stockpled in case a machine
breaks down.
The rnjor function of work en this ward is te get the patients
through the critical three to four post-op days, keeping their poten
tially hazardous trajectories on course. The trajectorv phasing has
31
 Uhapter 2
mniphases to which the nurses are sensitively cued. Patients are mostly
unconscious, and so patient reactions to the work and their participa
tion in it are absent. Also biographical work, taking into account their
lfe histories and concerns, is at a mnimum for the staff. Km are
scarcely in evidence except at short visiting hours, so their participation
in patient care is also minirnal at this phase of the trajectory.
Comfort care is important but subordinate to survival tasks.
Psychological care is also subordinate but somewhat visible in and
around the more medical tasks. The nurse does a great deal of machine
monitoring, too, making certain that the machines are working cor
rectly, that connections are secure, and so on. Body monitoring s done
with the rnonitoring machines, but a major part of body monitoring is
done by the nurses through their own observations and perceptions.
1 watched nurse T. working today for about an hour with a
patient who was only four hours post-op. In general the
work was mixed. She changed the blood transfusion bag.
She milked it down, and took out an air bubble. Later she
changed it again. Later got the bottle part fihled through
mechanical motion. She drew blood and immediately put
back new blood into the tube. She milked the urine tube
once. She took a temperature. She put a drug injection into
the tube leading to the patients neck. She added potassiurn
solution to the nonautomated IV. But all the whule she had
in focus, though not necessarily glancing directly at, the
TV, which registered EKG and blood pressure readings.
Once she punched the computer button to get the flfteen
minute readout on cardiac functioning. And once she
milked the infection-purifier tube leading from the patients
belly. And periodically she marked down both readings and
sorne of what she had done. Once the patient stirred as she
was touching his arm: she said quite nicely then that she
was about to give hirn an injection that would relax hm.
He indicated that he heard. Another time she noticed him
stirring and switched off the light aboye his head, saying to
him, thats better, isnt it? At one point she decided that
hs blood pressure was not dropping rapidly enough and
toid the resident, suggesting they should do something; he
hesitated, she kept nudging, until he went into action; said
he did not like the drug she liad suggested. So he narned
another with which she was not familiar. He brought in a
medical reference book, consulted it, neither knew whether
the drug involved an injection or an IV, but then he discov
ered it has a ten-minute acton, so it cant be an IV. She
got the drug, injected it. The resident gazed at the TV
32
Itlne.s Trajectoner
screen for ahout hve minutes, then announced to the
nurse, its workng. Meanwhule, she liad been doing her
series of tasks again around and with the patient.
Notable in the nurses work is that there are clusters of tasks, done
perhaps in flexible sequence but repeated serially every halfhour nr so.
And depending on the rniniphase and the nurses judgments, her work
can be slowed or speeded up. lhe intervais between the series of task
sequences are important since they allow her to confer with the charge
nurse and with the house staff and to get sorne relief from the other
wise conti000us intense work.
During these postsurgical phases, the staffs most salient work with
these patients is that of clinical safety. The intense monitoring of the
patients condition during each minipliase of the trajectory, the almost
cOfltinUOUs focus on the TV screen, and the constant alertness to any
difficultv with the respiratorv machine, which is breathing for the
patient, ah speak volumes ahout the centrality of clinical safety tasks
(see chap. 4).
in doing these tasks, the nurse or physician is implicitly as much
focused on trajectory considerations as with the more obvious work
itself. Albeit at particular moments a specific task mav aborb attention.
the patients location on a hazardous trajectory is never quite forgotten.
Unlike an X ray or an EKG technician, who may see a patient only once
and who prohably is not much concerned with trajectory considera
tions but only with the immedate tasks at hand, the cardiac recovery
unit personnel are nvolv ecl in a work situatio n wherei n tasks and
trajectorv consid eration s are fused. To quote one nurse: You are
thinking about a lot of things,
making stire they ah come otit right and
00 time. Things means tasks, and time means trajecto
ry mini
phase.
2. Catheterization Laborator. Catheterization of the heart, a highlv
complex diagnostic procedure, seeks detailed information about car
diac darnage. lo the catheterization laboratory there is a massing of
1 resources: equipment, medications, skilled personnel. and the like.
Equipmen includes an electronc monitor, a computer, an X-rav
camper with control machines, video monitors, tape recorders, a
power dye injector, machines to measure cardiac output, machinerv
For processing the film from the monitoring equiprnent. and so on.
Supplies for ah this rnachinery are kept nearby and are purchased by
the department itself; the technicians share the responsibility of keep
ing the shelves stocked. The phsicians ernplov a wide range of skills
during the catheterization. The technicians have a years training and
33
 ttlness Trajectones
additional training on the job; their work require s close attenti on, ears Another machine is rolled up to measure intracardiac
and eyes attuned to the constant beeping of the monito rs and the EKG pressure; they give the patient another pilI.
images on the oscilloscope. Their work is tense, stressf ul. Besides
running the equipment, adjusting it, and consta ntly calibra ting it, they A word about the sequence of the tasks: in general there
also prepare the catheterization room and prepar e the is a rough
patients, re sequence of things to be done, beginnng before the patient is actuall
cording on clipboards during the procedure the time of y
each injection in the catheterization room, for example, the physician readying the
or drug dose, its amount, and so on. They also assist the physic ians medical records, the technicians readying the machinery,
during the procedure. They develop film that has record the ward
ed the pa nurses scheduling the catheterization and perhaps preparing the
tents responses on a monitoring machine. For ah the staff, pa
there is a tient psychologicahly, the patient doing lkewise, the transport person
high risk from scattered radiation, so ah are consci entiou s about nel taking the patient down for catheterization. During
proper protection. There is also maximal attenti on to keepin the diagno stic
g every session itself, there is a sequence of tasks, but these are somew
thing sterile since the risks of the catheterizatio n to the patient hat
are very flexible depending on which tests are done and in what order. More
high. Speed of procedure is important because of the risk
factor and, over, the staffis prepared for machine breakdown, which does
of course, so is accuracy. happen
sometimes. There are not only delays but sorne shifting of task sequen
Utilitization of the total set of proced ures differs , depend c
ing on ing and additional clusters of tasks to be performed (see chap. 3).
the patients condition. Decisions are made individ ually for each pa Unlike the cardiac recovery unit, with its intense focus
tient. If a patient appears to be having difficu lty, one on surviv al
or more of the medical and nursing care, the work here is aif in the service of diagno
multiple tests may be eliminated. During the sequen ce of s
compl icated, ing precisely the location of cardiac damage. Since risk to
risky procedures, the patient does much work: lying the patient of
still, holding the diagnostic procedures is high, there is quite literally embedded
breath, not coughing, coughing on instruc tion to eject in
dye from the the medical and technical work the demanding requirement that carry
heart. The patients composure work (see chap. 6) may be consider ing out those tasks be clinically as safe as possible. We cali this latter,
able; for nstance, sometimes a piece of equipm ent fails to work for a ctinicatsafety work, and, of course, it involves tasks,
while, and procedures are then delaye d. The staff too (see chap. 4). Bits
does composure and pieces of those tasks can be seen in the description aboye:
work, too, in an effort to remain calm and project an the
image of effl physicians decision to omit certain tests or to
ciency and trustworthiness. If something goes wrong, delay slightf y certain
they try to keep procedures untl he is certain of the patients immediate physio
the patient unaware of that fact. logicai
reactions, the tense attention of physician and technic ians to many
Here is a bit of interaction exemplifying the division tasks, reftecting not just their concern for diagnostic accuracy but
of labor, the for
patients part in it, and composure work. The interaction upcomng danger, and, of course, the careful monito
also reflects ring of the
something of the sequence of tasks. patients physiological condition. The other salient type of work, of
They were now doing the angiography, cadi time telling course, is composure workeverybody is working very hard to make
the patient to certain that no breakdown of composure occurs, for that would
take a deep breath and hold, now breathe inter
and cough. (A physician explained to me later that this fere with the primary diagnostic work (see chap. 6).
is As in the post-op work of the preceding case, focus is very much
when the patient can go into cardiac arrest; there is only
dye in the heart, no blood; momentarily the vessel is
1 the immediate tasks, on the work to be done, but again, the patient
on
s
1
occiuded. The cough pushes out the dye each trajectory is very much in the foreground of attention. For one thing,
time that a
picture is taken.) It is necessary to rotate the patient the diagnostic focus is on locating precise ly the kind of trajecto
for ry this
different shots. . The proced
. ure was continu ing: X-ray patient is on and where he or she is on it; for another, the potenti
.
shots controlled by the technician from two big machin al
es, danger of catheterization itself is related to the patients cardiac condi
the physician controliing the injections and the timing tion. So, again, work and trajectory are tightiy iinked.
of
the shots. Each time a technician or physician says breath 3. Misorganization of a Spinat Scan. In contrast to the two smoothly
e
and cough. Next they gaye the patient nitrogl ycerin, functioning and organizationally successful types of activities depicte
asking the patient which strength he was used to. Anothe d
r aboye, the next situation, which also involves diagnosis, exemp
technician reports 87, stable, pressure looks good. hifies
fauhy organization in sequencing the tasks. The result is a setback
in
34
35
 Ittness Trajectone.
the patients trajectory. Previous therapeutic action
is at least partly
undone, and the patient would have faced even worse filled in that organization, preventing still worse darnage to the patient.
conseq uences
except for a supplementary factor in the division of labor: lhis hin work was concerned not onhv with clinical safety, but, of course,
a knowl directiy with coinfort care and at ieast impiicitiy with psychological
edgeable and aggressive kinsman.
care. TIc hospital personnel were oni concerned with diagnosis and
An eghtv-year-old woman had been hospitalized for very with what ve cali bodv work (rnoving tIc body to the madhine and back in
severe back pain, eventu allv relieve d bv a combi nation this case), except for the brief flurry of nurses activitv when the patient
of
medication and the use of a cutaneous stimulator. Since returned the hrst time to tIc ward verv much n pain.
she
could not be relatively inobile, a diagnostic scan of her Notable in this case also is an organizational phenomenon
spine was ordere d. The patient was transpo that is
rted hy a gur always potentiallv present: namely, that patient
riey to the radiology departrnent. Unfortunately, there s are in compe tition for
was available resources. TIc clinicai error in aliowi
an unantcipated delay because another patient got higher ng tIc lady to beconi e
prioritv since lis case was an emerge coid anci lcr pain to increase again was due no only to failure
ncy. Watn g there a to
fuil hour, the elderly lady foresee a possibie delay at tIc radiology departm ent lot also
becam e quite coid and develo ped to lcr
severe back pain again. A daughter who had accom being humped to iower prioritv hy anothe r patient s ernerg
panied ency.
lcr to the radiology department finally found an uniden Resources are always finite, and this kind of patient competition
can be
tified hospital worker and reques ted sorne blanke ts. annoying (being made to wait) or destructive (as in this wornan
Coy- s case)
cred with them, tIc mother, now in considerable pain, or sometimes even fatal (nurses fallure to answer a buzzer cali
was by a
transported back to lcr bed. patent). Competition for finite resourc es certain ly does no often
There the nurses rushed into the breech result in fatahity but can resuh in contingencies which affect, whcthe
with pain medica r in
tion and heating pads. Immed smail or large degree, the shape of a trajecto rv.
iately thereaf ter dinner was
served, but the patient being in such paul could 4. The Organization andMisorgan zzation of Comfo rt Work.
not yet eat. In tIc case
Right on the heels of the delivery of the food carne of Mr. Einshtein described at tIc beginn ing of this dhapte
the r, there were
transport man, wheeling his gurney into the roorn. TIc four trajectories involving heart, lungs, anemia , and hack pain. A
claughter asked him to bid off for a while until her couple of days before entering the hospital, Einshtein liad
mother felt better. When a barium
she did, then again covere d with X ray in an attempt to locate tIc source of bis blood
blankets, ah three (patient, daughter, ioss. The night he
transpo rt man) made entered tIc hospital, he vas given a miik of magne sia
the ti-ip to the waiting scanner. After scanning was tahlet to preven t
finished, possible bowel constriction. The foilowing evenin g no tabiet
the radiologist teiepho ned tIc transpo rt departm was given,
ent n whether by design or forgetfulness. TIc
forrning thern that the patent was 10W ready to return next mornin g, tIc patient
to awoke witli constriction anci much pain and
her bed. But the department was too busy; there were could not manag e to pass
no any stooi. He defined this situation as needing mrnediate
transport person nel availab le. So again the patient was attention and
kept asked tIc nurse assigned hm to give hm an enema
waiting. After a few minutes, the daughter pressed . TIc nurses wcre
the
radiologist for action, but the delay continu ah very busy that morning with a number of new
ed. finally a and critical ly iii
radiological technician was pressed into service, so both patients, and so no enema was fortbcoming. No enema
she was forthco m
and the daughter pushed a gurney mot her lying atop ing because the nurses did not hear bis request; that
it is, they defined the
back to tIc patients bed. Once ihere, the lady said, operational contingency differentiy. The head nurse, when
And 1 later sum
was feeling so comfortablenow Im back where 1 started moned by him, spoke of a stool softener but ignored lis
. repiy that he
Thus, tIc mistiming of tasks (transporting the patient needed quick action. finaliv he asked for tIc intern, who
to the scan listened, said
sIc would be hack in twenty minutes, and vanished.
1
ner and the delay in scanning her) and the failure to not to reappear
anticip ate the until tIc next rnorning, not from malevolence or avoida
necessity for another vital task (keeping tIc patient warm) nce, but be-
resulted in cause she too was busy, unusualiv so since she was coverin
untoward consequences for the therapv, which was already g three wards
relativ ely instead of lcr usual single one. Meanwhiie Einshtein
succcessful (relieving her intense pain). The sequen was rnetaph or
ce of expect ed icaily climbing tIc walls of lis room. Finaily, about
tasks took longer than anticipated. New tasks were not four hours after his
foresee n, atid so original request, he convinced tIc head nurse that
the requisite organization kw doing them was lacking an enema was
. Work by km 1
needed, but there was another hotirs delay while this little-u
sed equip
36
37
 Ittness Trafrctories
mcm was brought up frorn another department.
Moments after the
enema, Einshtens pain vanished. discussion in this chapter should have made clear, the organization of
Commentary on this case can be brief, in light of com resources is a matier that involves both a multiplicitv of resources and a
men tarie s on
the preceding cases. Here the patients work was essenti complexity of organization for their utilization.
al to getting
relief (cornfort work) from pain caused by misjudgm A third pOiflt tt)UChed on but not especiaflv emphasized so far is
ent in handling
the anemia trajectory. The delay in getting the enem that work en trajectories can have significant consequences for the
a was due to four
conditions. First, there was a difference in the defin various participants. True, sorne trajectories are relatively uneve ntful,
iton of the nature
of the contingency. Second, the nurses and intern were so thai the experiential and biographical consequences are minimal,
hardly cogn
zant of the anemia condition (Einshtein was iden especially for the personnel. But even with routine trajectories there
tified as a card iac
case). Third, there was intense patient competit can be conseqUenCes for sorne persons since work relationships are
ion for perso nnel s
time, energy, and attention. And fourth, comfort work drectly related tu the illness trajectorv with which they are aH involved.
(for this patie nt)
liad very low priority. After ah, the staff had When trajectories of any kind become problematic, however, then the
been, and was stihl,
working to insure proper monitoring of his blood impact on working relationships can be visihlv great, whetlier delete
press ure and pulse
and proper scheduling of lis medications and vario rioUS or beneficial. And in sorne instances, the impact en staff memhers
us lung treat ments;
they never were particularly concerned with is more Jasting, having consequences for iheir immediate or long-terrn
any com fort care during
his two weeks stay. It was not that they self-regard. The concept of trajectory is especially useful in thinking
were callous ; othe r work,
related to two hazardous trajectories, took about the experiential and identity impaci of work in hospitals because
total prec eden ce over any
concern with discomfort or comfort. They it hrings out the evolving character of thai work and work relatonships
neve
getting the necessary tasks done on time or in
r skip
sequ
ped a beat in
ence, and the
1 over the course of the entire case.
organization was there to see that thos thing
e s were done well. The
patient had no quarrel with any of that, but only resen
ted his battle-of
the-boweh (See chap. 5 for cornfort work.)
Concluding Remarks
In closing this chapter, we shall underline a few poin
ts alrea dy allud ed
to. First, and n relation especially to the cases
just discu ssed , it is
noteworthy that trajectory Work rnay require or
involv e sorne among
several different kinds of work. As later chapters
will clarify further,
they include: cornfort work, clnical safety work,
mach ine work, corn
posure, biographical, and other kinds of psychological 1
work (subtypes
of what will be termed sentimental Work)plus
the work of coordi 1
nating (articulating) all of the many tasks involved
in the total arc of
work. These may have higher or lower prior
ty, depending on the
trajectory and its phasing.
Second, trajectory work of whatever species involves
the organiza
tion of resources. This is why trajectories cann
ot be conceptualized as
pertaining only to the physiological course
of an illness or involving
only medical, nursing, and other teclinical tasks.
Even the construction
of an effective intensive care nursery or inten
sive care unit for adults,
for instance, can involve tlie work of an imag
inatve or at Ieast
compe
tent architect who can, to quote the comments of
one of them, design
an appropriate spatial environment for the perso
nnels work. As the
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39