Acting in Anaesthesia (Lb. Engleză) PDF

Acting in Anaesthesia: Ethnographic Encounters with
Patients, Practitioners and Medical Technologies

In recent years, evidence-based medicine (EBM), clinical governance
and professional accountability have become increasingly significant
in shaping the organization and delivery of health care. However,
these notions all build upon and exemplify the idea of humancentred, individual action. In this book, Dawn Goodwin suggests
that such models of practice exaggerate the extent to which
practitioners are able to predict and control the circumstances and
contingencies of health care. Drawing on ethnographic material,
Goodwin explores the way that action unfolds in a series of
empirical cases of anaesthetic and intensive care practice. Anaesthesia
configures a relationship between humans, machines and devices that
transforms and redistributes capacities for action and thereby
challenges the figure of a rational, intentional acting individual.
This book elucidates the ways in which various entities (machines,
tools, devices and unconscious patients, as well as health care
practitioners) participate, and how actions become legitimate and
accountable.
Dawn Goodwin is a social science lecturer in medical education and
director of problem-based learning. She teaches courses on various
aspects of science, technology and medicine to both medical and social
science students. Her current research interests focus on the
development of embodied knowledge, its place in clinical practice,
and the processes of learning involved. Her doctoral and postdoctoral
research centred on the notions of participation and accountability in
health care practice. Along with colleagues Dr Buscher and
Dr Mesman, Dawn Goodwin is currently editing a book of
ethnographic studies of diagnostic work drawn from a range of
disciplines.
Acting in Anaesthesia
Ethnographic Encounters with Patients,
Practitioners and Medical Technologies
DAWN GOODWIN
Lancaster University
Contents
Series Foreword
Acknowledgements
1 Understanding Anaesthesia: Theory and Practice
page ix
xi
1
2 Refashioning Bodies, Reshaping Agency
33
3 Accounting for Incoherent Bodies
61
4 Teamwork, Participation and Boundaries
105
5 Embodied Knowledge: Coordinating Spaces, Bodies

and Tools
139
6 Recognising Agency, Legitimating Participation

and Acting Accountably in Anaesthesia
167
References
Index
177
185
vii
Series Foreword
This series for Cambridge University Press is widely known as

an international forum for studies of situated learning and
cognition.
Innovative contributions are being made by anthropology; by
cognitive, developmental, and cultural psychology; by computer
science; by education; and by social theory. These contributions
are providing the basis for new ways of understanding the social,
historical, and contextual nature of learning, thinking, and
practice that emerges from human activity. The empirical
settings of these research inquiries range from the classroom
to the workplace, to the high-technology office, and to learning
in the streets and in other communities of practice. The situated
nature of learning and remembering through activity is a central
fact. It may appear obvious that human minds develop in social
situations and extend their sphere of activity and communicative
competencies. But cognitive theories of knowledge representation and learning alone have not provided sufficient insight into
these relationships.
This series was born of the conviction that new and exciting
interdisciplinary syntheses are underway as scholars and
practitioners from diverse fields seek to develop theory and
empirical investigations adequate for characterizing the complex relations of social and mental life, and for understanding
ix
Series Foreword
successful learning wherever it occurs. The series invites

contributions that advance our understanding of these seminal
issues.
Roy Pea
Christian Heath
Lucy Suchman
Acknowledgements
I would like to express my sincere thanks to all the people who

have both made this book possible and helped me through it: to
all the participants patients and staff of the expertise project;
to the NHS North West R&D Fund (grant number RDO/28/3/
05) for funding the expertise project and for contributing
towards the finance of my doctoral studies; to the ESRC/MRC
for funding my postdoctoral work (grant number PTA-037-270050). I also owe a debt of gratitude to Andrew Smith for having
such confidence in me; to Catherine Pope for her unfailing
encouragement and guidance and most especially to Maggie
Mort, who is responsible for initiating my interest in STS, whose
enthusiastic and critical commentary helped to shape this work,
and whose kindness, understanding and friendship have
extended beyond the realms of a supervisor. This work has
also benefited from being presented to and discussed with the
Lancaster STS community. In particular, I would like to thank
Lucy Suchman and Maureen McNeil for being such sources of
inspiration and without whose encouragement and critical
insight this work would be far poorer.
xi
Acting in Anaesthesia: Ethnographic Encounters with

Patients, Practitioners and Medical Technologies
Understanding Anaesthesia: Theory

and Practice
After changing into my theatre blues I walk down the corridor

and check the work allocation Theatre 1, General Surgery.
I begin by checking the anaesthetic machines, both in the anaesthetic room and in theatre. I turn the gases on and disconnect the
pipeline supply the alarms sound. Turn on the cylinders to check
the back-up supply turn them off and reconnect the pipelines.
Next, the breathing circuit and ventilator: Any leaks? Leave it
functioning but disconnected and wait for the low-pressure alarm,
occlude the end and listen for the high-pressure alarm. Check the
suction clean, connected and working? Finally, top up the volatile agents. This work is quiet, constant and regular; there is no
need to talk, the familiar routine is comforting first thing in the
morning, and the solid and tangible machines are a reassuring
presence.
These are some of the general checks. I then need to think about
the specifics: Which surgeon, which anaesthetist and what procedures are on the operating list? Mindful of their preferences,
I begin to set up for the first case. Patients are always talked about
like this in operating theatres, as cases or procedures such as a
mastectomy or a hip replacement. It might also be depersonalising, but for me, its utility is as a specific way to think about the
mornings workload, to anticipate the likely requirements of the
morning. First on the list is a right hemicolectomy; an ET tube
will be needed to secure the patients airway, size 8.5 for a male, a
1
size 5 face mask, a size 14 or 16 naso-gastric tube, intravenous

cannula a large grey one, 16 gauge, intravenous fluids and a fluid
warmer, the warming blanket to go over the patients upper half
during surgery, flowtron leggings to prevent deep vein thromboses
and a diathermy plate to earth the electrical current used to cauterise bleeding vessels. Provided that the anaesthetist doesnt want
to do anything fancy, he or she will require a combination of
drugs: an induction agent, propofol is now almost ubiquitous, but
it could be thiopentone if the anaesthetist is conscious of the drug
budget; a muscle relaxant, usually atracurium; opiate analgesics,
probably fentanyl and morphine; may be a sedative, a little midazolam; and some intravenous antibiotics. If the anticipated surgery is going to be quite extensive, they may also want to do an
epidural; I get the kit together just in case.
The anaesthetic room is over-run with a kit such as this
drugs, syringes, needles, cannulae, tubes and connective devices,
all in five or six different sizes. Working as a nurse in anaesthetics,
you develop an affinity for these devices. There is something satisfying about being able to lay your hand on just the right device
for almost every eventuality, and at being adept at assembling the
intricate constructions required for invasive monitoring, for
example. You develop personal routines, the efficiency of which
rely on having the relevant item strategically placed for use.
Working so closely with the anaesthetists is interesting; it is
fascinating to learn about management of an unconscious patient
both holistically and in terms of the articulated systems of the
body: for example, learning how to take care of a patients airways
and respiratory system, understanding the precise combination
and volume of gases the respiratory system needs at a given point
during anaesthesia and how to provide for this, appreciating the
concatenated effects this has on the rest of the body, and following how control for this system passes back and forth between
the patient, anaesthetic machine and anaesthetist. Engaging in
Understanding Anaesthesia
these dynamics in knowing, doing, acting and intervening can be

totally absorbing.
It is intriguing how so much can be gleaned from a reading
and a trace on the monitor. As a patient exhales, he or she will
expire carbon dioxide; therefore, when controlling a persons
respiratory system measuring the carbon dioxide levels becomes
crucial. First of all, do you have a reading? If the monitor is
connected and is functioning correctly and there isnt a carbon
dioxide reading, then either the patient isnt breathing or the
breathing tube (the endotracheal tube) is in the wrong place the
oesophagus rather than the trachea. Then there is the reading to
consider: the normal range of measurements, for an adult, is
between 4.5 and 6. For measurements outside this range, it is
possible to read into those figures an array of potential meanings;
for example, is the patient being underventilated (in which case
the respiratory rate and volume of gases supplied is insufficient to
adequately ventilate the patient)? Is the patient developing septicaemia? The increased metabolic rate which results from the
patient becoming overwhelmed by an infection means that an
elevated level of carbon dioxide is produced. Or is the reading
significant in indicating malignant hyperthermia (a rare inherited
metabolic disorder triggered by anaesthetics)? Again, in this, the
excessive level of carbon dioxide relates to an increased metabolic
rate. Further interpretations can be garnered from the shape of
the trace. As the patient exhales, the measurements are displayed
on the monitor in the form of a line graph. If the line rises only
gradually as the patient exhales, one possible interpretation is
that the patient has chronic lung disease, the gradual climb of
the carbon dioxide reading corresponding to the rigid noncompliant cells irregular release of carbon dioxide. In this sense,
physical manifestations of an individuals life testify to the specificity of unconscious bodies. The persons habits, preferences,
perhaps even occupational history connect an unconscious body,
here and now in the operating theatre, to a life and history

elsewhere.
Patients play a curious role in the operating theatres; they arrive
as relatively independent individuals, and I meet the person briefly
before he or she is anaesthetised. Patients are then rapidly transformed, connected to electronic monitoring, attached to drips and
infusions and rendered unconscious, and responsibility for this
vulnerable body is redistributed amongst doctors, nurses, technicians, auxiliaries, computerised technology and mundane artefacts.
Once anaesthetised, however, patients do not become passive and
homogeneous; they continue to exert their particularity in their
bodily condition and the interventions he or she requires. A simple
example of this is how an extremely nervous patient may require
significantly more anaesthetic to induce unconsciousness; more
complex examples come in the form of lengthy and intricate
medical histories of chronic disease in multiple systems, requiring a
vast range of adjuncts and specifications to routine care.
Following surgery, patients gradually reclaim their independence on a piecemeal basis, first breathing, then consciousness,
speech and so on; this process may continue long after the patient
has been discharged from hospital. As a nurse in Recovery, one can
witness this initial re-emergence of the person. For me, working in
Recovery also has the advantage of greater autonomy, by working
closely with the anaesthetists but not under their direct supervision. The patient is in a state of intense transition, reclaiming their
ability to breathe unaided, regaining their protective reflexes,
moving quickly from unconsciousness to consciousness, having
been cardiovascularly destabilised by surgery and their awareness
of pain changing rapidly with their level of consciousness. This
short period of instability requires concentrated nursing support:
the Recovery nurse must ensure that the patients blood loss has
been controlled and compensated for, their level of consciousness
is adequate and not overly affected by the sedative effects of
pain-relieving drugs and indeed that the measures taken for pain
relief are adequate. Then there are the specific complications
related to every surgical procedure for which the recovery nurse
must be aware and vigilant; vascular surgery, for example, carries
an elevated risk of dislodging a fat embolism and incurring a
stroke. However, by taking primary responsibility for a patient in
this brief period of time, the nurse is in a position to specify the
interventions required an ability denied to the anaesthetic nurse
because the anaesthetist is virtually always present and assumes
principal responsibility. So in Recovery I can act, I can say this
patient requires more pain relief, I can obtain a prescription and
administer it, if I think the prescribed drug inappropriate I can
request a different one. In anaesthesia, the anaesthetist decides and
administers I can only assist and suggest, but this rarely causes a
problem.
I find it interesting how the distribution of roles and
responsibilities has developed in theatres; how the boundaries of
ones practice are formed, maintained, challenged, extended and
yet remain both relatively constant and always susceptible to
change. How is it that the anaesthetic nurse, in addition to
assisting the anaesthetist, also takes responsibility for the diathermy, operating table attachments, the operating lights, pressurerelieving devices, warming aids and additional surgical devices
such as insufflators, cameras and screens used during laparoscopic surgery? At least in the hospital where I worked, scrub
nurses relinquished all claim to these duties. Instead, in addition
to their core duty of preparing and accounting for the surgical
instruments, they complete the operating theatre register, coordinate the pace of the operating list by sending for the patients
and undertake the majority of the theatre cleaning. Sometimes
these roles overlap, and there is certainly scope for much greater
fluidity here, yet these role divisions, whilst they rarely receive
explicit attention, seem curiously constant.
My work as an anaesthetic and recovery nurse left me wondering about the relationships between these elements I mention:
the patients, the anaesthetic machines and the monitoring, the kit
and equipment, the team of practitioners and the ways in which
work is distributed amongst them. How do these elements intersect with knowledge and with action? How is knowledge generated, by whom and how does this shape actions? And, conversely,
what are the limits, the restrictions, those factors that inhibit
knowledge production and action? How do these questions relate
to such descriptions of practice contained with the prescriptions of
evidence-based medicine (EBM)?
An opportunity to pursue and develop these questions came in
the form of an invitation to join a team of researchers concerned
with understanding the learning processes involved in an anaesthetists development of expertise.1 Briefly, the motivation for the
research project stemmed from the increasing emphasis, in the
training of anaesthetists, on formalised learning on tutorials,
the recall of theories and techniques of anaesthesia and on the
demonstration of observable and measurable competencies.
This emphasis, however, served to undermine the value of the
traditional apprenticeship form of learning. How exactly
learning in practice learning in doing contributed to the
development of anaesthetic expertise remained unarticulated,
and its significance continued to be implicitly and practically
diminished by policy changes that reduced junior doctors
working hours and the service-delivery elements of their work.2
1
The research project was entitled The problem of expertise in anaesthesia. It was
financed by the NHS North West R & D Fund (project grant number RDO/28/3/
05). My colleagues in this project were Dr Andrew Smith, a consultant anaesthetist,
Dr Maggie Mort and Dr Catherine Pope, both social scientists.
2
The New Deal for Junior Doctors restricted the amount of time trainees spent in
hospital, therefore reducing both the training and the service delivery elements of
their work (Simpson, 2004). The implementation of the European Working Time
Directive, which introduced a 58-hour working week for all hospital employees in
August 2004 (http://www.dh.gov.uk, 2004), further reduced the working hours of
Fieldwork Identities and Local Knowledge
The study adopted an ethnographic approach grounded in

detailed real-time observation along with a series of in-depth
interviews. The emphasis of the observation was to capture the
details, particularities and demands of anaesthetic work that tend
to be missed in textbook accounts of anaesthesia for example,
the ways in which anaesthetists develop personal routines and
practices, and their particular ways of performing a certain
technique. The interviews were similarly focussed on practice
sometimes being quite general and exploratory in nature, and
sometimes being focussed on a recent period of practice or a
specific critical incident. With a remit to observe anaesthetic
practice in its various forms and environments, and to discuss the
processes by which anaesthetists have developed their styles, it
was my responsibility to organise and engage in the fieldwork.
The first hurdle was to secure access to the clinical environment primarily, the operating theatres. Formal approaches were
made to the Department of Anaesthesia, the hospital ethics committee and the theatre management and staff. These formal access
negotiations were eased significantly by Dr Smith, a consultant
anaesthetist and member of both the department of anaesthesia
and the research team. The anaesthetists we approached were
unaccustomed to, and sceptical of, the research methods we proposed. Therefore, having a consultant anaesthetist initiate and
support both the aims and methods of the research assuaged some
fears and countered some scepticism.
However, in spite of having attained departmental and hospital clearance, there was also a more subtle, ongoing process of
junior doctors. In addition, the structure of anaesthetic training programmes moved
away from the traditional apprenticeship-style training that incorporates a service
delivery element (Ellis, 1995), and became focussed around observable and measurable competencies (Royal College of Anaesthetists, 2000).
negotiating access, on an individual level. Each time I observed in

the clinical areas, I had to secure the consent of the individuals
concerned. I began with those anaesthetists who looked favourably on the project and who were enthusiastic to share their
knowledge and expertise. These tended to be practitioners with
whom I had enjoyed working as a nurse, with whom I had an easy
rapport, and who were less likely to be concerned by my presence. After a while I began to receive invitations to observe from
some anaesthetists who were initially less forthcoming. By this
time, the novelty of the project had worn off slightly and the
suspected ominous presence of the observer in the anaesthetic
room had never materialised, tempered by my familiarity with the
environment. It seemed almost as though these anaesthetists
were a little affronted they hadnt attracted my research attention
through which the banal and ordinary activities of the working
day are transformed into the mysterious and correspondingly
interesting (Suchman, 2000a: 2).
The clinical side of anaesthesia, that is, life in the operating
theatres, was familiar to me; it was my territory. I had a natives
knowledge of the environment; I could move about the hospital
and its departments relatively unquestioned, unchallenged in my
right to be there. What was unfamiliar to me, hidden from view,
was the work required of anaesthetists once the operating lists
were finished and they left the theatre department. To demystify
this aspect of anaesthesia, I negotiated office space in the department of anaesthesia to use as my working base. Office space in the
department was enormously beneficial in that I could observe how
the department of anaesthesia functioned as a body within the
hospital, and how individuals managers, consultants, secretaries,
clinical nurse specialists, anaesthetic trainees functioned within
this. I was able to follow how managerial, bureaucratic and
organisational decisions were made, inscribed into documents and
presented to the department, and also the clinical ramifications of
these decisions. I was able to observe how the department organises, maintains and polices itself, and how personal narratives of
clinical practice were brought back to the department, discussed
informally, infused with theories, contrasted with anecdotes and
solidified into learning experiences.
Therefore, all these issues shaped the boundaries of my
empirical field: the growth of the project from concerns about
the training of anaesthetists, the relative ease of access, my
familiarity with the operating theatres and the strangeness of the
anaesthetic department. These early influences and factors gave
the study certain characteristics, which I did not wholly
appreciate at the time, characteristics that in some ways are
contrary to my personal understanding of anaesthetic practice.
By locating myself in the anaesthetic department, my focus was
both broadened and narrowed. It was broadened in that I became
aware of how the practice of anaesthesia was not solely a clinical
endeavour; I was introduced to the professional, political,
bureaucratic and educational duties that also constitute the work
of anaesthesia. It was narrowed in that my focus centred on
anaesthesia as the work of anaesthetists. This is somewhat at
odds with my experience of anaesthesia as something that is
produced in practice by an array of actors such as nurses, operating department practitioners, medical devices and technologies
and local routines, and includes but is not reducible to the
activities of anaesthetists.
My identity and its legacy, therefore, brought some very
particular qualities to the research, and as Peshkin (1985)
observes, these qualities will be simultaneously enabling and
disabling, opening some research possibilities whilst closing
others. One such aspect is my local knowledge of the setting. The
merits of this are uncertain and have a long history of debate
within methodological literatures. As Garfinkel (1972) points
out, for background expectancies to become visible, one must
10
either be a stranger to the life as usual character of everyday

scenes or become estranged from them. Potentially, then, my
familiarity with anaesthetic practice may blind me to the significance of members knowledge. Given that one of the interests of
the team project was the development of tacit knowledge, this
served as a useful heuristic for thinking about my own. When
typing up and elaborating upon my field notes, therefore, I was
conscious to include detailed descriptions of the physical settings
(even though the layout of the anaesthetic rooms and what each
cupboard contained was as familiar to me as my kitchen cupboards at home), and although I would use the nomenclature of
anaesthesia in my field note transcripts, I was mindful to add a
translation, and where I added my own interpretation of an event
I would take care to explain what had informed my interpretation. There was also a practical need for this level of specificity in
the transcripts, in that they were to be shared amongst the
research team, two members of which were social scientists. In
addition to the attention granted to making my local knowledge
visible, we also conducted seven joint observation sessions, in
which I was accompanied by one of the two social scientists.
Perhaps, not surprisingly, these accounts were different, but only
insofar as the level of detail I was able to incorporate. Hess (2001:
239) sees this level of near-native competence as a marker of
good ethnography:
the standard of near-native competence means that good ethnographers are able to understand the content and language of the field
its terminology, theories, findings, methods, and controversies and
they are able to analyse the content competently with respect to social
relations, power structures, cultural meanings and history of the field.
This criteria laid out by Hess placed me at an advantage, and in

terms of writing field notes and asking questions, I certainly
found my familiarity with the abbreviations, terminology,
abundance of conditions, drugs and technological devices a
11
useful resource. During the fieldwork, then, I sought to utilise

and advance my knowledge of anaesthesia, and stepping out of
my role as a nurse, being relieved of the need to act as a nurse,
afforded the opportunity to note and examine that which is taken
for granted.
Watching Anaesthetic Work
Guided by the expertise study design, the clinical observation was

organised around the aim of appreciating the variation encompassed in anaesthetic work and exploring how experience of these
different settings informs an anaesthetists development. I
observed anaesthetic practice approximately once a week over a
12-month period, joining a morning or afternoon operating list,
evening or weekend on-call period. This observation covered each
of the surgical specialties, particularly those that necessitate specific anaesthetic techniques, and the various environments in
which anaesthesia is practiced, in order to gain insights into how
different theatre layouts and equipment might affect the practice
of anaesthesia. I also chose operating lists to which a combination
of anaesthetists were assigned, such as a lone consultant, a consultant and trainee, experienced trainee and novice anaesthetist, a
lone trainee. This not only captured some of the variation of
anaesthetic practice but also rendered visible some of the differences between anaesthetists at varying stages of experience. The
sessions with two anaesthetists were particularly illuminating, as
the need for anaesthetists to articulate their actions to a greater
degree resulted in their practice being more amenable to scrutiny.
In these observation periods I took running field notes; my
mandate was to record as much detail as possible, not only of what
was said but also of actions, features of the environment and the
role of anaesthetic technology. I attended to those taken-forgranted practices, the body of assumptions and conventions on
12
which everyday anaesthetic practice proceeds. And, as I suggested

earlier, my knowledge of the setting in some ways facilitated this
process; in describing a scene, I could quickly focus on its significance for a practitioner, the object of a practitioners attention or
recognise an unusual or novel circumstance. And, in working from
the anaesthetic department when transcribing these field notes,
I was able to elaborate and clarify my understandings, discussing
issues with, for example, the anaesthetist at the next desk.
Supporting and informing this body of clinical field notes are
my notes of what I alluded to above as the non-clinical side of
anaesthesia. In using the anaesthetic department as my working
base, I was initiated into the busy informal networks of anaesthetic
learning, where difficult cases were talked about in an opportunistic manner, over a sandwich at lunch, viva practice and tutorials
for the trainees were carried out, journal clubs took place, and
where the departmental meetings occurred in which policies are
discussed and anaesthetists are invited to share their recent critical experiences. Again, wherever possible, I would take overt field
notes, which for the examination and viva practice and the
departmental meetings was straightforward but it was more difficult for the opportunistic occasions. These unprompted, spontaneous conversations in which experiences and concerns were
shared with colleagues would occur unexpectedly around
me, often the significance of which I would only appreciate in
retrospect.
However, I realised that in noting these conversations my
fieldwork had inadvertently developed a duplicitous quality. I was
concerned about whether I might be abusing my position in the
department, exploiting the relationships I had established before
the research began. I was most concerned about this with my key
informants. These were the individuals I found it particularly
fruitful to talk to and question, although these relationships
stemmed from friendships and alliances I developed as a nurse.
13
Paradoxically, then, where rapport was at its best, and my identity

most enabling, was also the point at which it was most disabling.
Whilst this may be a familiar scenario when using observational methods (see, for example, Dingwall, 1980), it nevertheless
enhanced my awareness of the ethical implications of undertaking research in a familiar environment with familiar people.
Hence, I was charged with practically resolving this issue in such
a way that allowed me to capitalise on the insights I gained
through working from the department but without this undercurrent of duplicity. My response was to reiterate my identity as a
researcher regularly and to negotiate consent every time I formally observed anaesthetists. Incidents and issues that came to
my attention informally I would try to follow up during the
formal data collection where the ambiguous status of the data,
whether on or off the record, was clarified. For example, over
lunch, a conversation developed between three consultant
anaesthetists in which they chatted about their opinions of the
clinical abilities of some new trainees the ones they knew would
be all right and the ones about whom they had concerns. When
I subsequently formally observed one of the consultant anaesthetists involved in this conversation, I brought up the subject of
trainee assessment and how he personally approached this topic.
Feeding the informal data through these formal channels both
enhanced the candour of the fieldwork and improved the quality
of the data.
In the paper Ethics and Ethnography: An Experiential
Account (Goodwin et al., 2003), I explore the ethical implications of my position in more depth. In discussing this and other
situations in which the ethics of observation concerned me,
I came to appreciate, first-hand, that although I might try to
alleviate the duplicitous quality of my fieldwork, I alone could not
control the situations I was included in and excluded from and
the information that participants revealed or withheld. The
14
participants also exert their agency and in doing so contribute to

the shape and character of the data.
Talking Common Sense
My remit to ascertain and elucidate the tacit aspects of practice,

what counts as common sense for anaesthetic practitioners
proved challenging to attain when it came to the interviews. The
difficulty was that my interest lay in the mundane routines of
everyday practices the things that people had become so
accomplished at that it no longer took a great deal of concerted
effort; how then to encourage people to articulate the deeply
embedded practices they no longer have to think about? I found
that the most successful approach was to anchor the discussion to
personal practice, how their practice developed, how it came to
look the way it does. I also asked respondents to take me through
their last clinical session and any problems or issues it raised, or
we might discuss a specific critical incident they had recently
experienced. Towards the end of my fieldwork, the opportunity
for a different kind of interview a debrief arose. I had been
observing in intensive care, following a routine ward round when,
in the process of modifying a patients treatment, the patients
condition deteriorated and became critical. After several hours of
intense work, the patients condition was stabilised. The anaesthetist suggested that he would find it valuable to look at a copy of
my observation transcript, as a form of self-assessment. I readily
agreed and proposed we debrief afterwards: to use the transcript
as a resource to guide reflection. The subsequent interview lasted
more than 2 hours and was replete with detail: the anaesthetist
was able to contribute features that I had missed or to which I did
not have access; for example, what he had seen down the bronchoscope or the pressure he had felt when ventilating the patient.
He also talked of the interactions between the different members
15
of staff and the role that X-rays, ventilators and chest drains
played in this situation.
This technique has much to offer both analytically and methodologically. In terms of the quality and depth of the primary
data the transcript of the field notes a debrief provides the
opportunity to compare accounts, to clarify misunderstandings, to
elaborate the description. It also presents an interesting analytical
position, a layering of researchers and participants experiences,
accounts and reflections. On this occasion, debriefing offered
benefits for both participant and researcher; however, this process
was extremely time-consuming for the practitioner. Despite the
potential of this technique, the demands it places on the practitioner, coupled with the impending conclusion of the fieldwork,
meant that it was only possible to debrief, in this way, on one
further occasion.
Standardising Health Care Work and Accounting for Practice:
Knowledges Made Visible and Invisible
This book utilises the fieldwork I undertook for the expertise

study, and whilst it draws on our collective theorising in the team
project, it is primarily a development of those personal curiosities
I acquired working as a nurse, presented in the opening account of
my work in anaesthesia. The point to note is that, being funded by
the National Health Service (NHS), the team research project had,
at the end of 2 years, to produce policy-relevant findings and
recommendations that could feed into the debates around the
training of anaesthetists (see, for example, Smith et al., 2003a,
2003b, 2006a, 2006b; Pope et al., 2003), whereas this book presents a broader, and yet more personal, reworking of the learning
in doing topic.
My involvement in the expertise study taught me about how
knowledge changes in content and form as it passes from person
16
to person, gets embedded into personal and local routines, is

written into research papers or books, becomes incorporated in
the design of machines or devices or is formalised as a standard,
guideline or protocol. I came to understand how knowledge is
thoroughly embodied and situated in practices; a particular technique performed by one anaesthetist may yield entirely different
results as the same technique in the hands of another anaesthetist.
And I began to appreciate how knowledge and expertise can be
seen as an effect of a particular configuration of persons, routines,
environments, machines, tools and devices.
However, for me, questions remained around learning,
knowing and doing: Which participants act, in that they contribute to shaping the trajectory of anaesthetic care? How do they
do so and how do they learn about doing so? How are these
actions recognised and rendered accountable? These are questions of increasing significance in the light of growing efforts in
the United Kingdom in recent years to regulate and standardise
medical practices. EBM, patient safety initiatives, clinical governance and professional accountability have all become progressively more important in shaping the organisation and
delivery of health care around standardised practices. McDonald
and colleagues identify how the use of clinical guidelines aims to
reduce the opportunity for individuals to apply their own judgements about what constitutes best and safe practice, thus
limiting the variability of clinical work and increasing overall
quality of care (McDonald et al., 2006). May et al. (2006) propose
that, collectively, EBM, clinical guidelines, protocols and
decision-making tools, along with new practices and technologies that distribute accountability beyond the clinical encounter,
bring into play a new form of governance. Technogovernance
refers to the way that informatics interventions discipline
and frame the individual subjectivities of both patient and
doctor (for example, as EBM divorces patient experience from
17
knowledge about the effectiveness of treatments) and have

embedded in them means of adjudicating and reporting on those
decisions to others. Such surveillance, May et al. argue, introduces a much wider network of accountabilities.
As McDonald et al. point out, these movements in health care
all utilise the notion of standardisation as an inherent good, one
that limits the potential for error and results in safer practice.
Standards, it seems, are so ubiquitous that they frequently
become invisible (Bowker and Star, 2000). They are often
deployed in the aim of making things work together, frequently
need to be legally or professionally enforced and, once established, have an inertia that renders them exceedingly resistant to
change (Bowker and Star, 2000). Indeed, standards are pervasive
in health care; from the size of the connections that enable
syringes to be attached to intravenous cannulae, to the dosages of
drug administration, to the policies and guidelines that set out
the practices of health care practitioners, standards coordinate,
orchestrate and regulate the practice of health care. Bowker and
Star (2000) point out that in forming boundaries around objects
and activities, standards impose a classification system and
furthermore, that:
Classifications are powerful technologies. Embedded in working
infrastructures, they become relatively invisible without losing any of
that power. Classifications should be recognized as the significant site
of political and ethical work that they are. (Bowker and Star, 2000: 147)
EBM is emblematic of such a standardising logic: it is the

principle that the selection of health care interventions be based
on research findings that testify as to their effectiveness; a principle that is now endorsed in NHS policy (Harrison, 1998). It
builds on a classification system known as a hierarchy of evidence that ranks evidence according to the reliability and validity
of the study design, from randomised controlled trials at the top to
expert opinion and case studies at the bottom (Lambert, 2006).
18
The political and ethical dimensions of this classification system

relate to the evidence it valorises and that which it renders invisible, and accordingly unimportant; here, epidemiological research
evidence is strongly promoted as the most reasonable, rational
basis for making decisions about health care interventions, whereas
factors such as the patients wishes (drawing on their knowledge
about what is preferable, practical and manageable in their particular lives), the availability and accessibility of treatments (given
that some treatments may only be accessed by travelling considerable distance to centralised facilities), the experiential knowledge
of the practitioner (what practices work best in their hands), the
knowledge embedded in local routines (that can accommodate the
demands of some interventions and not others) and situational
knowledge (ideas about what would work best in this instance,
rather than a universal best) are all eradicated from the decisionmaking framework.
At least in the United Kingdom, Western Europe and the
United States, basing medical practices on proven diagnostic and
therapeutic knowledge has meant an attempt to standardise
medical practices through the increasing use of clinical practice
guidelines:
Under the recently emerged banner of evidence-based medicine,
guidelines have become the tool of choice to weed out unwarranted
variation in diagnostic or therapeutic practice and to enhance the scientific nature of the medical care delivered. (Berg et al., 2000: 766)
However, Berg (1997a) notes that guidelines do not confine

themselves to carrying rational knowledge; rather, the construction process will interweave a wide, heterogeneous range of
elements. Take, for example, a National Institute for Clinical
Excellence (NICE) technology appraisal: in line with EBM these
guidelines rely heavily on the RCT as the preferred source of
evidence for the critical review. However, in tackling somewhat
less than glamorous subjects such as wound care, which
19
command less publicity, and research interest and funding than

perhaps new surgical techniques or new drugs, NICE are compelled to work with other forms of evidence, those lower down,
or even off the bottom of, the hierarchy. In the case of difficult to
heal surgical wounds there exists no RCT evidence to support
any particular debriding agent (products that breakdown and
absorb dead tissue). In the absence of such evidence, NICE advise
that the choice of debriding agent should be based on comfort,
odour control and other aspects relevant to patient acceptability;
type and location of wound; and total costs (NICE, 2002: 128).
The way these tools are presented, however, largely hides these
negotiations from view (Berg, 1997b).
Moreover, the interweaving of many different logics, rationalities, evidences and knowledges that characterises the construction
process of clinical practice guidelines continues when the tool
becomes part of the local work routines. Berg identifies how, for
example, nurses tinker with the tools prescriptions so that blood
tests can be done on time whilst, seemingly simultaneously, the
patient is wheeled to the X-ray department. However, Berg
insists:
This is not a deplorable and preventable outcome of the corrupting
processes of getting a tool to work: it is the only way for the tools to
work in the first place. Delegating the task of producing the tools
demands in real time to medical personnel requires leaving them the
leeway to digress from the tools prescribed steps, to skip or skew input,
or to sometimes just avoid the tool completely. . . . It requires allowing
medical personnel to adjust the tool to their ongoing work. It requires
that the tools become part and parcel of local work routines. It
requires, thus, a further localisation of the tool: a moving away from its
ideal-typed universality and uniformity. (Berg, 1997a: 152, original
emphasis)
Accordingly, EBM and clinical guidelines are just one of the

elements that gets worked into clinical practice alongside the
other, perhaps less visible but no less relevant, elements.
20
In this sense, Timmermans and Berg (1997) argue that universality is always local universality. Only when studying how a
guideline works in practice does it become clear what is not
explicitly mentioned, how the guideline both relies upon and
changes pre-existing practices and routines, and the knowledge
and expertise of practitioners. Somewhat paradoxically, then,
allowing the practitioners some discretion in how they articulate
the demands of the guideline seems to be the only way to achieve
standardisation:
Tinkering, having the leeway to adjust the protocol to unforeseen events
and repair unworkable prescriptions is a prerequisite for the protocols
functioning: in these practices, the overall stability of the network is at
the same time challenged and dependent upon the instabilities within its
configuration. (Timmermans and Berg, 2007: 293)3
Suchman (2007: 200) elaborates this point in respect of the

general nature of plans: it is the inherent underspecification of
the formal plan that affords the space of action needed for its
realization. Standards, plans and guidelines work, therefore, by
presupposing a vast array of unspecified knowledges and practices, and incorporating a discretionary space for the accomplishment of these contingent labours.
Consequently, and in contrast to the well-articulated fear that
EBM and guidelines stifle decision making, denigrate medical
expertise and deplete skills, Timmermans and Berg propose that
these tools transform and redistribute existing knowledge,
responsibilities and expertise, making some skills obsolete and
requiring others. These new competencies involve not only
bringing together new and old ways of doing the work, but also
creatively accounting for the work (Suchman, 2007: 204) so that
it both accords with the demands of the guideline whilst providing a reasonably accurate description of events.
3
This insight follows from the work of Vicky Singleton on the instabilities of the
Cervical Screening Programme.
21
Suchmans observation about creative accounting draws

attention to the implications of tinkering and rearticulating the
guidelines prescriptions. Although the tools functioning may
depend on this, often tinkering will require health care practitioners (nurses in particular) to operate outside their official
responsibilities and, if interpreted literally, to contravene the
formal prescriptions which, in turn, renders them vulnerable to
disciplinary action. In sum, technologies of coordination and
control (Suchman, 2007: 277), such as procedural instructions
and guidelines, prescribe courses of action designed to be reliably
reproduced, and serve as a measure for comparative assessment.
The problem, as pointed out earlier, is that these tools rely on a
discretionary space a space for judgement and action. So rather
than guidelines limiting the scope for the application of individual judgement, as is their aim (McDonald et al., 2006), it is
more that the need for individual judgement is obscured. So my
concern echoes that of Bowker and Star: it is a concern for the
political and ethical implications of what is rendered visible and
invisible. Guidelines underscore the scientific basis of the proposed treatments and interventions, whereas the necessity for the
subtle use of judgement in the deployment of guidelines is erased.
The implementation of clinical governance is a further way
in which the standardisation of practice and the accountability of
health care practitioners are being prioritised in the United
Kingdom. Clinical governance is a framework through which
NHS organisations are accountable for continually improving
the quality of their services and safeguarding high standards of
care (Department of Health, 1998: para 3.2). By harnessing
movements such as EBM and tools already in use, such as
guidelines, audit and incident reporting, clinical governance aims
to create a systematic set of mechanisms to specify quality standards and to guide and monitor the delivery of health care. These
tools of clinical governance all share the aim of clarifying and
22
documenting clinical practice, which, in conjunction with the

emphasis on regulation and monitoring of performance, results
in a concentration on the explication and reporting of, and
accounting for, health care work. Clinical governance is a means
of performing accountability; it works, not only to specify duties
but also to construct the means through which clinical practice is
judged:
Accountability is more than, indeed systematically different from,
responsibility. The latter entails, literally, being liable to answer for
duties defined as yours. . . . Accountability, on the other hand, is in its
operation and scope more total and insistent. Not only are duties
specified, but the means of evaluating the level of their performance is
already prescribed, in implicit or explicit norms, standards and targets
of performance; wherefore surveillance over and judgement of performance is vastly widened and deepened. (Hoskin, 1996: 265)
So as indicated in this discussion, where practice is formalised,

standardised and prescribed, as in the tools of clinical governance, it serves as an (idealised) version of practice against which
everyday practice is measured. Moreover, clinical governance has
been seen as a challenge to professional autonomy and medicalmanagerial relationships (Gray, 2004), tethering, as it does,
improvements in quality to stronger mechanisms of professional
regulation and requiring that clinicians engage in self-surveillance
(Flynn, 2002): modern professional self-regulation, for example,
will play a fuller part in the early identification of possible lapses
in clinical quality (Department of Health, 1998: para 1.16). The
mechanisms of clinical governance, therefore, multiply and
extend the lines of accountability.
Codes of practice are the primary tool through which professional bodies achieve the self-regulation and accountability of
doctors and nurses. Again, these codes are normative descriptions
of professional conduct that set out the standards that practitioners must demonstrate. A major problem with these codes,
23
however, is the model of practice on which they are based. For

example, doctors must:
Prescribe drugs or treatment, including repeat prescriptions, only
where you have adequate knowledge of the patients health and medical
needs. (General Medical Council, 2001: 3)
This assumes that it is always possible to know the cause of the

patients health problems before acting. However, often doctors
need to perform an activity in order to learn something about the
patients condition. The model of practice embedded in these
statements inverts this cycle of learning, presuming it is always
possible to learn first and then act. Decisions are conceived of as
carefully thought out rationalisations cost/benefit analyses of
known and predictable consequences that can be isolated to
discrete moments of cognition from which actions follow. In this,
medical practice is characterised by clarity and certainty, grossly
underestimating the level of ambiguity and uncertainty that has
long been recognised as a feature of clinical practice (Fox,
1957, 2000).
Furthermore, these codes stress the autonomy of the practitioner:
When working as a member of a team, you remain accountable for
your professional conduct, any care you provide and any omission on
your part. (Nursing and Midwifery Council 2004: 8)
And:
Working in a team does not change your personal accountability for
your professional conduct and the care you provide. (GMC,2001: 12)
These statements reify a model of practice in which practitioners

act individually, with actions and omissions being clearly bounded
entities. Collaboration with other professionals does not detract
from the personal accountability of the nurse. However, it is difficult to ascertain the degree to which one practitioners actions
are informed by anothers. For example, nurses have considerable
24
influence over doctors diagnoses and prescriptions, perhaps by

describing a patients condition in such a way that the doctors
response is the one the nurse desired, or by making direct
requests for a specific prescription (Hughes, 1988; Prowse and
Allen, 2002).
For the GMC, good teamworking specifically depends on the
clarity of roles and responsibilities between participants. Doctors
must:
Make sure that your patients and colleagues understand your professional status and specialty, your role and responsibilities in the team and
who is responsible for each aspect of patients care. (GMC, 2001: 12)
Here, the composition of teams is implicitly taken to be regular

and deliberate. However, often team members might be rather
more ad hoc, their responsibilities being less distinct and overlapping. An operating team, for example, will include a surgeon, a
scrub nurse, a circulating nurse, an anaesthetist and an anaesthetic assistant either a nurse or operating department practitioner. In addition, the surgeon may have an assistant, there may
be more than one anaesthetist, more than one circulating nurse,
the recovery nurse may attend and there may be all manner of
learners and students present. Whilst practitioners will have their
own specified duties, they will also share tasks that need to be
shared, fill in for one another where necessary, and generally
participate flexibly as their skill, knowledge and experience
allows. Codes of practice focus on the individual within a team
rather than reflecting how collaborative work is achieved.
The codes emphasise the accounting for actions:
Whatever decisions or judgements registrants make, they must be able
to justify their actions. (NMC, 2006: 1)
And doctors must:

Keep clear, accurate, legible and contemporaneous patient records
which report the relevant clinical findings, the decisions made, the
25
information given to patients and any drugs or other treatment prescribed. (GMC, 2001: 3)
Practitioners must be able to give an adequate account of their

actions, but as Hoskin points out, the terms of accounting are
already specified implicitly and explicitly. An adequate account is
necessarily one that draws on the same notions of practice as the
codes: an autonomously acting individual that consciously evaluates the likely outcomes of a proposed intervention and then acts
accordingly. As Suchman (2007) identifies, this leaves practitioners to reconcile the differences between the way they practice
and the way these codes insist they should practice.
To summarise, these codes build upon and exemplify the idea
of human-centred, individual action; professional conduct is
premised upon an individual, cognitive mode of decision making
and activity that negates the collaborative nature of health care
work, and in which the contingent and distributed nature of
decision making is completely absent. Decisions are supposed to
be made prospectively, on the basis of knowns and certainties,
and actions follow. In these documents, professional accountabilities crystallise on certain actions and particular actors, they
exaggerate the authority and autonomy of practitioners and the
degree to which they can predict and control the circumstances
and contingencies of health care.
An alternative view of practice is developed in this book, one
in which clinicians and patients act in concert with each other and
various medical technologies, machines and devices. Activity,
decisions and participation are fluid, relational, and collaborative.
I explore the way that action unfolds in a series of empirical
cases of anaesthetic and intensive care practice. I follow how
capacities for action are produced in the interactions of practitioners and patients together with technologies, machines and
devices and address the tensions that arise for practitioners in
attempting to reconcile the differences between the way practice
26
unfolds and the way that formal descriptions of practice insist it

should happen. Anaesthesia provides a particularly interesting
position from which to interrogate the relationships between
evidence or other formalisms such as policies and guidelines,
with patients, machines and practitioners and the capacities for
action these relationships produce. By inducing unconsciousness,
disabling speech and intervening in the ability of the body to
autonomously regulate itself, anaesthesia plays with the characteristics usually assigned to an actor. Anaesthesia configures a
relationship among humans, machines and devices that transforms and redistributes knowledge and agency, and stands in
contrast to the figure of a rational, intentional agent. This juxtaposition enables one to question the assumptions a rational
position invokes and to scrutinise the conditions necessary for
action. This relational nature of agency, however, escapes formal
methods of allocating accountability, and in codes of professional
conduct, individual clinicians become responsible and accountable for actions authored by many participants, both human and
non-human.
Unfolding Anaesthetic Work
In the next chapter I begin this examination of acting in anaesthesia by exploring the role of the patient and the anaesthetic
machines. I begin here because the patient, being unconscious
and rendered speechless, can easily be overlooked, or considered
absent, construed as the object of knowledge rather than an active
participant in events. For example, Atkinson (2002) analyses the
relationship between medical technologies and patients bodies,
conceptualising the machines as technologies of inspection,
interrogating the body and disaggregating it into signs and
representations to be read by competent observers. Whilst this
usefully elucidates how technology mediates knowledge of the
27
body, in this configuration, the patient as a unique individual is

almost deleted, rendered passive, and stripped of agency. In some
cases it may be that this construction of the patient as a passive
object actually enables certain health care practices. Hogle (1999)
has argued that organ transplantation practices mandate
mechanisms that change the conception of the patient, that
depersonalise the patient. She suggests that in attending to the
medical technology a donor requires in intensive care, personhood and identity are progressively filtered out. In anaesthetic
practice, however, I contend that the patient as an individual is
very present, and a very active agent in the unfolding performance of anaesthesia. In this chapter I grapple with how to
conceptualise and articulate the contribution to anaesthetic
practice the patient makes.
The interface between human and non-human agencies provides an interesting vantage point from which to investigate
actors differentiated capacity for action. And given that here, the
unconscious patient is conceptualised as a vigorously acting
entity, albeit acting in some rather ambiguous ways, how the
anaesthetist is seen to plan, prescribe and execute a course of
anaesthetic care is a process that requires some elaboration.
Frequently, in medical practice, there will be multiple,
incompatible explanations of a patients condition, prompting
numerous and different possible courses of action. Chapter 3
focuses on the work of the anaesthetist in constructing a situated
and dynamic account of a clinical situation that renders the situation intelligible and in doing so indicates an appropriate course
of action. Decision making, in these circumstances, has been
analysed as a process of alignment by bringing together various
sources of knowledge a coherent narrative that explains the
majority of the patients signs, symptoms readings, and measurements is produced, a narrative that also organises prospective
actions by indicating an appropriate response on the part of the
28
practitioner. More recently in Science and Technology Studies

(STS), attention has turned from looking at methods of closure
how, of all the paths that might possibly be taken, options are
reduced and a single path emerges to exploring the multiplicities,
disunities and incoherences of bodies, objects and knowledges (see,
for example, Berg and Mol, 1998, and Mol, 2002). Here, analyses
have highlighted how, despite there being tensions, differences are
not necessarily resolved, they endure. However, in health care
settings the notion of professional accountability has become
increasingly significant, consequently, the existence of unresolved differences can sometimes be deeply problematic. Health
care practitioners work in a culture in which certainty of
knowledge, diagnoses and actions is highly valued and, on one
level, enacted as a prerequisite for interventions, and yet on
another level, it is frequently, if implicitly, enacted as an unattainable ideal. In this chapter, I explore how accountability can be
achieved both in circumstances where a coherent narrative may
be drawn and where, despite concerted efforts at alignment, the
disunity of the patients body persists.
The activities of nurses and operating department practitioners (ODPs)4 also contribute to the particular shape and
quality of anaesthetic care. The distribution of work between
4
ODPs and nurses work in the United Kingdom is now reasonably interchangeable
with the exception of a few professional and historical distinctions: First, as there is no
mandatory register for ODPs, only qualified nurses are supposed to hold the keys for
the controlled drug cupboards. Second and historically, nurses tended to perform the
scrub role (which seemed to be held in greater esteem) whilst technicians or
operating department assistants (as they used to be known) assisted the anaesthetist.
This distinction is still discernable with the majority of scrub practitioners being
nurses and the majority of anaesthetic assistants being ODPs, however, as anaesthesia
as a specialty has developed so has the role of the assistant, ODAs have become ODPs
now with a 3-year diploma/degree course, and it is largely impractical for the keys to
be held by anyone other than the anaesthetic assistant, as it is the anaesthetist, rather
than the operating surgeon, who administers the controlled drugs. In the hospital at
which I worked, a local policy was devised that acknowledged that the keys could be
held by the anaesthetic assistant, regardless of their professional background.
29
anaesthetist and nurse or ODP, the level of energy these practitioners exert in shaping the course of anaesthesia varies from
person to person, and the way professional boundaries of practice
are enacted also affects the unfolding course of anaesthesia.
Chapter 4 concentrates largely on challenges to these boundaries
so as to elucidate the consequences they have for the generation
and distribution of anaesthetic knowledge, and how the form and
character of knowledge a practitioner develops affords particular
levels of involvement. The continual negotiation of the distribution of work and knowledge between doctors and nurses means
that the issue of professional boundaries has remained a current
and controversial subject for sociological analysis. I discuss some
of the ways these boundaries have been theorised: as ecologies of
knowledge in which the character of knowledge each professional group develops and utilises is a consequence of their daily
work experiences (Anspach, 1987), as a negotiated order
(Svensson, 1996) in which nurses are in a unique position with
knowledge that doctors depend on, and as the boundaryspanning activities that nurses perform, making decisions using
doctors tools, coordinating the movement and activities of doctors, and engaging in activity that resembles medical diagnosis
(Tjora, 2000).
This discussion outlines how the knowledge and practices of
nurses are shaped and defined by disputes and constraints on
practice, and tacit arrangements as to the boundaries of their
responsibilities. I explore this theme using Lave and Wengers
(1991) concepts of legitimate peripheral participation in communities of practice. One of the most important learning
resources that Lave and Wenger identify is the legitimacy of the
learner to participate, and they suggest that the level of legitimacy
conferred is strongly related to the degree to which the different
identities are forged. This draws attention to the integral role
access plays in the generation of knowledge. This chapter
30
addresses the tensions that develop when practitioners stray

outside accepted boundaries, and the consequences for practitioners learning, the resources they have for influencing the care
of a patient and the accountability of their actions.
As I indicated earlier, work as an anaesthetic nurse involves
developing an intimate knowledge and awareness of the kit: the
specific features, characteristics, purposes, possible uses, techniques of handling and availability of the devices used in anaesthesia. The availability of a piece of equipment, and the skill of
the user, could radically change the path an anaesthetic trajectory
might follow. The possibilities for action afforded by artefacts
and devices, therefore, also have a bearing on how anaesthetic
practice unfolds. In Chapter 5, I examine the spatial dimensions
of the workplace, the arrangement of material resources and the
development of embodied knowledge. I explore how the
accomplishment of anaesthetic techniques depends on the precise
alignment of practitioners bodies, tools and the patients body.
Developing an awareness of the specificities of anaesthetic
practice, an anaesthetist cultivates a body of normal appearances
(Sacks, 1972). I discuss how the form, position and configuration
of both humans and devices are significant elements in constituting this body of expectations. Moreover, set against this body
of expectations, any departures from the normal are more
immediately visible; in becoming accustomed to the normal
appearance of a given situation one can recognise more readily
the abnormal or missing. By following disruptions to customary
configurations of teamwork, I explore the utility of these
arrangements and how disruptions function as learning opportunities vital to the development of expertise.
It is this intersection of humans, technology and devices, with
learning, knowing and doing that interests me, and it is how
these relationships are enacted that I examine in this book. In this
study of the relationships between patients, machines, devices,
31
teams of practitioners and the hospital environment, along with

formalisations such as policies, procedures and the prescriptions
of EBM, this book draws heavily on the field of STS and ethnomethodology but also brings the fields of medical sociology
and medical anthropology to bear on these topics. The importance of this study of agencies comes into focus when posing the
question of how situated actions, with their variously recognised
actors and agencies, relate to the configurations of actors and
agencies implicit in professional codes of conduct. Such codes
tend to tether accountability to discrete and precise actions, and
to particular practitioners, which means that specific participants
are held to be responsible for events authored by multiple actors.
This, in turn, indicates certain tensions between practice and
accounts of practice.
Showing how practice in anaesthesia unfolds, that it is not
only made up of the contributions of practitioners, but also of
machines, unconscious patients, as well as tools, devices and
organisational routines disrupts the deterministic sense in which
medicine has been practiced and interpreted. Within the medical
profession itself, the concept of an autonomously acting clinician
is highly valued, and the need to control diagnosis, treatment and
the evaluation of care strongly informs professional ideology
(Harrison, 2004). Importantly, the dominance of medicine, in
terms of the ability of doctors to determine a patients state of
health and command compliance with treatment regimes, has
itself come under scrutiny by medical sociology and by feminist
studies of medicine. These critiques have raised awareness of the
manifold ways in which patients participation in decision making
has been systematically diminished, patients are thus constructed as
passive objects of medical treatment rather than as active agents in
the healing of their bodies. Indeed, Cussins (1998: 169) observes
that we have become accustomed to thinking of patients as
disciplined subjects par excellence. Without denying the dominance
32
of medicine, however, this book will delineate the limits of this

critique by highlighting the obstacles and difficulties individual
practitioners face when trying to determine the course of events,
for example, it will show how patients participate in shaping the
course of their anaesthetic even when unconscious. Consequently, this book traces the tensions individual practitioners
work with when held accountable for actions that are distributed
amongst many participants, especially those assumed not to act.
Following Suchmans (1987, 2007) analyses of humanmachine relations, this book argues for the primacy of the
immediate context of action in understanding how trajectories of
care are shaped. Most particularly, the analysis of the interactions
between the patient, the anaesthetic technologies and the
anaesthetist demonstrates the intractably contingent character of
action, elucidating the ways in which entities that lack the traditional characteristics of an agent (machines, tools, devices and
unconscious patients) can and do act. The conclusion discusses
the consequences that erasure of these actors incurs for professionals when they have to account for their actions, and how
the emphasis on specifying and formalising the delivery of care
works to undermine the grounds on which action is based; it
diminishes the legitimacy of the patients and situational contingencies to inform treatment decisions and obscures the expertise and knowledges that have contributed to such decisions.
Refashioning Bodies, Reshaping Agency*
The purpose of anaesthesia is to temporarily insulate a patients

senses from the trauma of surgery. This necessitates a reconfiguration of bodily boundaries and a redistribution of bodily functions. Anaesthetic machines are called upon to assume some of
these responsibilities, for example, frequently patients are paralysed in the process of anaesthesia thus disabling their capacity to
breathe, and the anaesthetic machine, once programmed, will then
assume this responsibility. Furthermore, in rendering the patient
unconscious, anaesthesia incurs a silencing of the patient. Here,
anaesthetic machines are again enrolled to provide an alternative
route of expression with monitoring devices displaying readings,
diagrammatic traces and measurements. An anaesthetised patient,
therefore, is heavily reliant on the relationship that is forged with
the anaesthetic machine. Indeed, the patient is technologically
extended and augmented through this relationship. In a very
practical and material sense, the patient becomes a mix of organic
and technological components, in other words, a cyborg.
Cyborgs: Fact, Fiction and Social Reality
The word cyborg was coined in 1960 by Clynes and Kline,

as short for cybernetic organism. It referred to a living
* This work was first published as Goodwin, D (2008) Refashioning bodies, reshaping
agency. Science, Technology and Human Values, 33:3 (34563).
33
34
creature enhanced by computer-controlled bio-feedback systems,

developed in the aim of liberating the human from environmental
constraints:
The Cyborg deliberately incorporates exogenous components
extending the self-regulatory control function of the organism in order
to adapt it to new environments. (Clynes and Kline, [1960] 1995: 31)
Space travel, according to Clynes and Kline, would be better

facilitated by modifying the body in partial adaptation to space
conditions rather than persisting in carrying the earths environment into space. Importantly, the technological components
of the cyborg should function unconsciously, to prevent the
space traveller from becoming a slave to the machine:
The purpose of the Cyborg, as well as his own homeostatic systems, is
to provide an organizational system in which such robot-like problems are taken care of automatically and unconsciously, leaving man
free to explore, to create, to think, and to feel. (Clynes and Kline,
[1960] 1995: 31)
The technological components of the cyborg, therefore, are

necessary only insofar as they support the vitality, ingenuity and
imagination of the human.
This idea that humans need not be tethered to their environment but may be technologically augmented so as to enable super
new capabilities is an enticing imaginative resource. Cyborgs have
proliferated in fiction; they have become a projection of our fantasies about ourselves (Hacking, 1998: 211). And, in doing so, the
definition has loosened, the emphasis centring more on new
capabilities than on bio-feedback systems:
(science fiction) cyborgs tend to be big, sort of mechanical but also sort
of organic; there is seldom the organic being upon which or in which a
bio-feedback mechanism has been implanted. They are, however,
correctly described as alive, living. (Hacking, 1998: 212)
Again, the defining feature of the cyborg is his/her vigour and

liveliness.
Refashioning Bodies, Reshaping Agency
35
The cyborgs of fiction have increased in imaginary complexity

from humans who, when adorning a special suit, are endowed
with special powers to humans whose bodies have been permanently modified to take advantage of the latest technological
innovations that engender such new capacities as incredible
strength, speed and intelligence. And, latterly, cyborgs have taken
the form of mutants whose altered genetic code allows them to
spontaneously change their shape and biological structure as
circumstances require (Oehlert, 1995). These heroes increasingly demonstrate an ambiguous and uneasy double-edge: they
deal with violence by violence, their powers may be used for good
or evil and the interventions that gave them their powers may also
destroy them (Oehlert, 1995). The unease with such imaginary
cyborgs seems to revolve not around the question of whether the
machine will take over the human but around what the human
chooses to make of his/her new abilities (Oehlert, 1995).
Haraway reminds us that the cyborg is also a creature of
social reality as well as a creature of fiction (1991: 149). The
cyborg, she suggests, takes a material form in ones lived social
relations, and particularly those of modern medicine (Haraway,
1991: 150). Medicine excels at creating cyborgs; Gray, Mentor
and Figueroa-Sarriera (1995: 2) argue that there are many
actual cyborgs among us in society and those they cite are the
products of medical interventions persons with artificial
organs, limbs or supplements (such as a pacemaker), immunized
persons reprogrammed to resist disease and those pharmacologically reordered to behave differently. These cyborgs are not
necessarily augmented with homeostatic feedback mechanisms,
but they are humans supplemented with technological innovations designed to support, and perhaps transform, their capacities, vitality and their life. Lock (2002) argues that advances in
medical science have brought about a confusion of body
boundaries and mingling of body parts never before possible
36
(Lock, 2002: 1406). Medical sociologists, Nettleton and Gustafsson

(2002: 13) explain:
As we develop our knowledge, expertise, technologies and activities
associated with the body, the more uncertain we become as to what the
body actually is. The boundaries between the biological, social and
technological become less clear. Boundaries, such as the distinction
between life and death, that once appeared immutable, are no longer
clear-cut.
Distinctions that had previously been made with confidence and

clarity, including that of human/machine, are now clouded and
uncertain. In this sense, cyborgs epitomise the mix of technological and organic necessary to extend and enhance life, and to
generate new capacities, but they also represent a powerful
blurring of boundaries, they are provocative in their subversion
of easy distinctions, and in conveying a sense of unpredictability
they invite caution and wariness. This is instructive when
thinking about both medical and technological innovations and
existing practices. Natural boundaries are transgressed, new
entities with different capacities are created, requiring reconsideration of existing responsibilities and accountabilities. It is as
Haraway (1991: 150) argues: for pleasure in the confusion of
boundaries and for responsibility in their construction.
The Cyborg: An Analytical Resource for Thinking
about Agency
The confusion of bodily boundaries and the evermore intimate

connections and relationships forged between bodies and technologies have encouraged, and are deeply implicated in, debates
about the forms and locations of agency. Such debates have
figured prominently in STS, which, through symmetrical analyses of humans, technologies and materials, sought to recover
the agency of things. The product of this body of work is
frequently summarised by the proposition that humans and
37
artefacts are mutually constituted (Suchman, 2007). However,

as Suchman (2007: 269) points out: mutualities . . . are not
necessarily symmetries and within assemblages or networks of
humans, machines and materials, there are important questions
of difference in terms of the forms of agency to which different
actors have access. Nevertheless, Gray, Mentor and FigueroaSarriera (1995) note that the traditional allocation of agency,
which casts humans as intentional agents and machines, technologies and materials as inert, is tenacious. Callon and Law
(1995: 490) identify the characteristics usually attributed to an
agent:
agents are those entities able to choose, to attribute significance to their
choices, to rank or otherwise attribute preference to those choices;
(. . .) agents are able to intervene to act in order to (re)create links
between their goals and the actions that they cover.
The analysis of cyborg relationships in anaesthesia offers a

particularly focussed opportunity to reconsider this traditional
view of agency as it allows me to analyse the capacity and
character of agency that can be demonstrated when both patient
and machine elements lack intentionality. Taken together with
the other cases discussed in this book, this project is an attempt
to acknowledge the agency of things and to study the asymmetries between things and humans without falling back to the
default position that Gray et al. indicate. Delineating some of
the different forms and locations of agency found in the dense
sociotechnical arrangements that make up much of contemporary health care, and how these agencies intersect and are
effected in interactions, is urgently required in order to better
understand, and allocate, appropriate accountabilities. Currently, codes of professional conduct attribute agencies and their
associated accountabilities much as Gray et al. describe with
practitioners (note: not humans as that would include patients)
being the intentional agents, and all other elements of health
38
care practice as inert. Analysing the union between an unconscious patient and anaesthetic machine as a cyborg a living,
vital, communicating entity opens a window on the constraints
and elements shaping practitioners actions, sensitivity to which
is almost completely absent in current attributions of accountabilities.
In keeping with the desire to recognise the agency of things,
Latour (1999) suggests that we must learn to redistribute actions
among many more agents, a suggestion that prompts the question of where to draw the boundaries of anaesthesias cyborgs; is
the anaesthetist part of the cyborg? What of the nurses and
ODPs? Where should the dispersement of agency end? My
response to these questions is to reiterate that the patientanaesthetic machine cyborg is an analytical unit, purposely
chosen to elucidate the form agency might take when both
human and technological components lack intentionality. To
add conscious, intentional actors into this unit would only serve
to cloud this analysis. The cyborg figure focuses attention on the
intense human-machine interdependencies necessary for current
anaesthetic practice, an emphasis that the term anaesthetised
patient does not convey. It is not a natural bounded category,
on the contrary, the cyborg invokes ideas about the disruption
of seemingly natural bodily boundaries, and the redistribution of
some bodily functions necessary for life, in a way that other
analytical terms, such as hybrid, does not. Hence, my aim is not
to delineate what capacities for action belong to the human or
the machine, but to explore what agencies this dynamic relationship demonstrates.
Haraway (1991) has argued that those human-machine relationships that are forged, and the boundaries that are drawn
within, around and between entities are issues that matter. She
contends that the cyborg figure can be used to question the
political and ethical effects related to which human-machine
39
unions are promoted, and where and how their boundaries are
drawn. For Haraway, the cyborg figure is instrumental in resisting
the easy invocation of technological determinism when analysing
sociotechnical relations: we are not dealing with a technological
determinism, but with a historical system depending upon
structured relations among people (1991: 165). Likewise, the
cyborg figure I outline here demonstrates that an alliance between
human and machine need not necessarily be seen as one that
bolsters the powers of doctors to interrogate the bodies of
patients, such an alliance may also amplify the expressions of
patients so that their contributions are more readily recognised
by both doctors and analysts of medical practices. The intention
here is not to suggest that becoming a cyborg can liberate patients
from medical dominance, rather, it is an attempt to explore the
specificities of one of the layers of the dense sociotechnical
arrangements of health care, and to trace how these enactments of
agency are implicated in other layers and other enactments of
agency. My intention is to demonstrate how an entity that lacks
consciousness and intentionality may still provide a dynamic
contribution to the shaping of events, which, although not
equivalent to, can be counted against the ability of doctors to
define, determine and control events.
Unconscious Bodies in Medicine
It seems, however, that the circumstances in which bodies and

technologies are at their most intertwined in medical practice,
are also the points at which the person can least be described as an
agent, having been silenced, rendered passive, depersonalised or anonymised by the technological practices of health
care personnel. Hogle (1999) suggests that in organ transplantation practice, managing the ambiguities of the living cadaver
(Hogle, 1999: 149) mandates a reconceptualisation of the human
40
body as existing in an altered, brain-dead state. She contends

that depersonalisation is achieved by attending to the body
through the technology that sustains it by observing monitor
changes, administering medications and fluids, inserting arterial
lines, suctioning lungs and withdrawing blood for testing.
Consequently, the body, as a patients body seemed to disappear (Hogle, 1999: 148), an impression aided by the visual
dominance of medical devices and equipment. Hogle describes
how the body is dispossessed of its identity: by collecting personal and bodily information, manipulating the body, and recreating the person and her body on paper (1999: 148), the
donors identity is displaced into the medical records. What
remains, according to Hogle, is an identity without a body, and,
presumably, a body without an identity.
Depersonalisation practices have also been noted by
Hirshauer (1991) in the preparation of bodies for surgery. He
observed how the handling and manipulation of the patients
body, necessitated by anaesthesia, reduce the patient to a body.
After inducing anaesthesia the body is further reduced to its focal
part, the remainder being obscured by sterile drapes. He concludes that The disappearance of everyday bodies also implies
the persons anonymity (Hirshauer, 1991: 289).
Within the sociology of health and illness, debate about
bodies and technologies has tended to focus on how medical
knowledge of the body is produced (Nettleton and Gustaffson,
2002). Atkinsons (1995: 62) study of haematology is exemplary
in this respect; he argues that the body is interrogated by a
powerful armamentarium of investigative machinery that disaggregates the body into numerous traces and fragments to be
read by competent observers. Here, Atkinson usefully elucidates
how practitioners use medical technologies to interrogate the
body of the patient, but this does, however, position the patient
as a passive object of knowledge. Furthermore, the focus on the
41
interactions between doctors and medical technologies obscures

the relationship between patients and medical technologies, and
how this relationship may enable patients to convey their needs as
well as assisting doctors to interpret them.
The contributions of the patient and machine as crucial
components of anaesthetic practice are easily overlooked by
virtue of their silence. The subtlety and ambiguity that surrounds the cyborgs expressions can too readily lead to the denial
of agency and the overestimation of medical practitioners
abilities to determine a patients care. Since Freidson (1970)
characterised medicine as a dominant profession, exploring the
various manifestations of such dominance the manifold ways
in which patients are rendered passive recipients of health
care and their participation in decision making systematically
diminished has been an important line of critique in medical
sociology and feminist research (Nettleton and Gustafsson, 2002).
However, there is a sense in which dominance can be read as
determinism, by which I mean that doctors are assumed to be
able to determine a persons state of health and the treatment they
require. Even within the medical profession notions of control
have currency: the highly valued concept of autonomy emphasises
the need to control diagnosis, treatment and the evaluation of
care (Harrison, 2004). Without disputing the dominance of the
medical profession, there are constraints on the degree to which
a doctor can define, determine and control a situation and the
course and outcome of events, and these constraints come in the
subtle forms of agency that so often go unrecognised.
Cussins (1998) makes an important contribution towards
articulating the subtle forms of agency patients may demonstrate. She notes that much critical work in medical sociology
and feminist studies cast the infertility patient as an exemplary
objectified patient who is either saved or victimised by the
technology and medical practices. From this position, the
42
patient is entirely lacking of agency, all virtue or criticism

therefore is attributed to the doctors and the technology. In
contrast, Cussins suggests that the woman actively engages in
her objectification where it is instrumental to her cause (of
becoming pregnant). The patient is called upon to participate in
various forms of objectification in order to render her body
compatible with instruments, drugs and procedures, a process
Cussins (1998: 192) calls ontological choreography: the coordinated action of many ontologically heterogeneous actors in the
service of the long range self. The infertility patient is locally
and temporarily reduced to a series of bodily functions and parts.
The failure of cycles of infertility treatment can indeed lead
women to portray their objectification as dehumanising; however, where medical activities have led back to, and transformed,
the long-range subject then the heterogeneous ontology of the
treatment zone becomes irrelevant.
Such subtleties in the different forms of agency are easily
missed, and relationships between patients and technologies are
far from uniform or straightforward. In anaesthetic practice, it is
in large part a result of technological developments that unconscious patients expressions have been amplified. My suggestion is
that these expressions should be recognised as being agential.
However, Pooveys study of an early form of anaesthetic
practice the administration of chloroform to women to ease
the pain of labour during the Victorian period indicates the
vulnerability of an anaesthetised body to doctors explanations of
its behaviour:
the silenced female body can be made the vehicle for any medical mans
assumptions and practice because its very silence opens up a space in
which meanings can proliferate. (Poovey, 1987: 152)
Poovey argues that an anaesthetised body is a silent body dispossessed of the resources to resist the interpretations of doctors.
43
During the Victorian period, physiological responses to anaesthesia were interpreted as uninhibited sexual desires mandating
some form of control. These responses have long been recognised
as the excitation phase of induction, a phase now greatly diminished due to the rapidity with which modern anaesthetic drugs
work. Therefore, much has changed in anaesthetic practice since
the Victorian period, and the anaesthetised patient, I suggest, is no
longer quite silent. Rather than being disabled, the anaesthetised
patients ability to communicate is transformed, as is the language
and matter that can be conveyed. The technological augmentation
of the body engenders different forms of expression, which in some
ways compensate for the loss of language. Therefore, unlike the
situation of the Victorian physicians described by Poovey, in my
observation of recent anaesthetic practice, the anaesthetists could
not impose just any explanation on a given situation; the interpretation had to fit with what the patient expressed. Tracing the
ways in which the expressions of anaesthesias cyborgs contribute
to the shaping of their trajectories through anaesthesia enables one
to reconsider the characteristics of agency, of what may qualify as
action. This focus recognises the cyborgs participation in his/her
care and demonstrates the limits to which anaesthetists can be said
to determine and control the process and outcome of anaesthesia.
It also enables me to suggest a notion of how agency without
intentionality might look.
Cyborg Agency: Expression, Participation and the Shaping
of Events
The production of the patient-anaesthetic machine union

depends on the concerted work of anaesthetists, nurses and
ODPs who, with the participation of the patient, construct
certain pathways and connections between the patient and
anaesthetic machine. Discussing this induction phase I first
44
illustrate how the boundaries of both patient and machine are

transformed and how capacities are changed in this process. I then
focus on the operative phase of anaesthesia, when work on
producing a cyborg has ceased and emphasis turns to the functioning of this patient-machine union. Here I follow how the
cyborg expresses his/her needs during surgery, questioning what
new capacities this merger engenders and in what ways the cyborg
can act. Finally, I look at the dissolution of the cyborg in
the recovery phase, how this is achieved, and the work that is
necessary to re-establish the human and to shed the technological.
Fashioning Anaesthesias Cyborgs
The anaesthetic room is a small anteroom attached to the

operating theatre specifically for the purpose of inducing
anaesthesia. In the scene below it is 8.20 am, the first patient on
the operating list has just arrived in the anaesthetic room and the
ODP and the consultant anaesthetist (in the United Kingdom,
anaesthetists are medically qualified doctors. Consultants will
have completed a further 7-year training programme in anaesthesia) immediately begin work on forging those pathways that
connect the patient and the anaesthetic machine.1
ODP: Just sort your pillows out. He removes two pillows then sits
the patient forward and unfastens the back of the patients gown.
Dr Butler: Needle in the back of your hand. Can you just clench
and unclench your hand. He fastens the tourniquet around the
patients left arm.
1 Pseudonyms are used throughout this book. Where possible I have referred to
practitioners by their role (nurse, ODP) in an attempt to convey the scene with
clarity. This is, however, at the expense of imposing a clear formality and hierarchy on
the data that was, in practice, far more subtle with most anaesthetic practitioners
being on first name terms. I have used . . . to indicate missing talk as I was only able
to record fragments of verbatim quotes. Edits, in the form of summarised data, and
explanations are indicated in italics.
45
The ODP applies monitoring to the patient a blood pressure cuff

around the patients arm, electrocardiogram leads on his chest, and
a pulse oximeter probe to a finger. He works quickly and efficiently.
Dr Butler taps the patients forearm. Local anaesthetic he says as
he injects. He then smoothly inserts a cannula.
Meanwhile the ODP has moved round the room to the left hand
side of the patient and connects the cannula to the prepared fluid
infusion. He then secures the cannula with a dressing. The ODP
takes an endotracheal tube (a tube that is inserted through the vocal
cords and into the trachea to facilitate ventilation) out of the cupboard, opens the packet, cuts about 2 inches off the end of the
tube, removes the blue plastic connector from the discarded end
and inserts this to the now shorter ET tube.
Dr Butler injects from a syringe with an orange label (an orange
label signifies an opiate, I presume it is the fentanyl which he asked for
earlier). Dr Butler addresses the patient: A gin to go with the
tonic. (Then to the ODP) Have we seen a surgeon yet?
ODP: Ill go and have a quick look. He leaves the anaesthetic
room.
Dr Butler: Need to see the whites of the surgeons eyes before we
start.
The patient points to the screen: What are these figures up there?
Dr Butler runs through all the readings on the monitor explaining
which readings refer to his heart rate, oxygen saturation and
blood pressure.
We wait.
The anaesthetic machine beeps 3 times, no-one responds. A few
moments later Dr Butler takes a drug box out of the cupboard
labelled Glycopyrolate (used to increase the heart rate) draws some
up and injects into the cannula. The drip runs very quickly. The
monitor shows the measurements: pulse 42, oxygen saturation
91%, blood pressure 153/81.
From the moment the patient enters the anaesthetic room, the
ODP and anaesthetist immediately begin work on transforming
46
the body of the patient: the ODP attaches the monitoring

thereby enabling the expression of various parameters and diagrammatic representations. This mode of communication can be
seen when the cyborg emits three beeps, signifying a heart rate of
42 beats per minute and below the monitors preset alarm limits.
The anaesthetist responds by administering glycopyrolate, a
drug that increases the heart rate. So these expressions are nonverbal, they consist of numbers and diagrammatic traces, and are
supplemented with auditory and visual alarms.
The ODP prepares for a further connection between the
patient and anaesthetic machine when he removes two pillows.
Of the boundary transformations detailed here, this is the most
difficult to achieve; it connects the patient and anaesthetic
machine by the placement of an endotracheal tube that runs
from the patients trachea to just beyond the patients lips
where it is attached to the breathing circuit of the anaesthetic
machine. He positions the patients head and neck to allow for
the optimal view of the vocal cords through which the tip of the
tube will be placed. The ODP then shortens the endotracheal
tube to the requisite length. This tube fortifies the pathway
between the patients lungs and mouth, providing an uninterrupted route for gases to travel from the anaesthetic circuit
to the patients lungs. Below the ODP returns to the anaesthetic room wherein work commences on establishing this
connection.
ODP enters and addresses the patient: Weve found a surgeon now so
were going to get started now.
Dr Butler: Going to give you some oxygen. He stands at the head
and holds the black mask gently over the patients face. Your job
is to keep your eyes open as long as you can. Dr Butler injects
propofol (a white substance from a 20 ml syringe a drug for
inducing anaesthesia) into the cannula slowly, as he speaks. The
patient is still talking.
47
Dr Butler: Youll wake up about a minute after they have finished.

(The patients feet are still moving. It is quiet.) Open your eyes.
No response, the patient has now stopped moving and talking.
Dr Butler ventilates squeezing the reservoir bag with his right
hand whilst holding the mask on the patients face with his left.
Dr Butler lifts the mask off and inserts an orange (size 3) guedal
airway (this is a white plastic oval shaped tube, about 3 inches long,
which lies horizontally along the tongue then drops down into the
pharynx, this prevents the tongue from falling back and occluding the
airway).
Dr Butler: Classic tooth right at the front, perfect intubating
tooth. He replaces the mask and ventilates, there is a slight leak
where the mask does not quite fit the shape of the patients face.
The ODP presses the patients face up to meet the face mask, the
leak stops. Dr Butler injects atracurium (a muscle relaxant). The
ODP moves to uncross the patients legs.
Dr Butler: Quite useful, that finger, Mark. He repositions the face
mask and the ODP returns to pressing the face of the patient to
meet it. Dr Butler chats socially to the ODP, about the ODPs
son playing cricket.
Pulse 44, oxygen saturation 98%, blood pressure 143/70. The
drip runs more slowly now. Dr Butler looks at the clock and
continues ventilating. The anaesthetic machine beeps pulse 38.
ODP: Slow, isnt he? (gesturing towards the monitor)
Dr Butler: Hes on betablockers. Ive given him some glycopyrolate already, good blood pressure though.
The anaesthetic machine beeps heart rate 40. The ODP picks
up the laryngoscope. They both seem to be waiting for the blood
pressure reading before intubating. Dr Butler takes the laryngoscope and inserts it, the ODP pulls the right side of the
patients mouth further to the right. Dr Butler inserts the
endotracheal tube and replaces the guedal. The ODP inflates
the cuff on the endotracheal tube and then places a piece of tape
over each closed eye.
Dr Butler: If I only had one tooth left, Id be inclined to whip it
out. The ODP ties in the tube. Dr Butler sets the ventilator.
48
As anaesthesia disables the protective reflexes of the body,

connecting the patients and the machines airways must be tied
as closely as possible to the commencement of anaesthesia. After
injecting the induction agent, Dr Butler confirms he is able to
ventilate the patient then paralyses him using a muscle-relaxant
drug, this generally takes 3 minutes to have an effect. Dr Butler
and the ODP work with the airway devices inserting a guedel
airway and pressing the patients cheek to the mask to prevent
gases leaking out to support the patients breathing until the
airway connection has been accomplished and the anaesthetic
machine can assume responsibility for ventilation.
The cyborgs expressions are acknowledged when the heart
rate of thirty eight beats per minute again triggers an alarm on
the monitor leading the ODP to comment: Slow, isnt he? The
anaesthetist explains that the patient takes betablockers (drugs
that slow and regulate the heart rate) and adds that he has given
glycopyrolate to increase the rate. In spite of this action, however, the patients heart rate remains stubbornly low, so to
qualify the lack of further action by the anaesthetist, he balances
the low heart rate against the good blood pressure. Instances
such as this, where borderline measurements remain borderline
despite action to return them to within a normal range, are
barely noteworthy in anaesthesia. Such measurements are to be
cautiously observed in the knowledge that, as in this case, the
impending surgical stimulation is likely to have the desired effect
of raising the heart rate. Practice is premised on the understanding that circumstances are subject to rapid change, activities tend to be fluid, responsive and conservative so as not to
foreclose subsequent possibilities for action.
As the required 3 minutes pass, attention returns to securing
the airway connection. Dr Butler inserts the laryngoscope, and
visualises the vocal cords through which he places the tip of the
endotracheal tube. A balloon at the tip of the tube is inflated,
49
sealing the connection and preventing movement of the tube

back through the vocal cords. The tube is then securely tied in
place. Once the tube is connected to the anaesthetic machine,
gases can be delivered from the machine directly into the
patients lungs, a task to which Dr Butler attends when he
programmes the ventilator. Dr Butler then verifies the placement of the tube using a stethoscope to listen to the air entry
into each lung. In addition to ventilating the patient, the
accomplishment of the airway connection provides another
communicative resource the content and concentrations of
inspired and expired gases can now be clearly articulated.
This scenario details the routine ways in which connections
between the patient and anaesthetic machine are forged in the
event of anaesthesia. Monitoring devices are not just attached to
the surface of the patient but also are fitted inside the body
organic and technological components are dovetailed together.
These links provide the cyborg with various means of expression.
In rendering the patient unconscious, the use of language and
gestures are disabled. But a silent body is not necessarily a
passive, uncommunicative body; indeed, the patient must still
communicate, to signal to the anaesthetist as he did when his low
pulse rate warranted attention. It is, I suggest, the alliance
between the patient and the anaesthetic machine that enhances
the ability of an unconscious patient to convey his/her status.
There are, of course, expressions that are not technologically
mediated, for example, the colour of the skin, whether it feels dry
or clammy, the size of the pupils, and so on. The point is that, in
all but critical situations, these expressions are relatively subtle,
whereas being technologically augmented, the cyborgs expressions are amplified.
Moreover, the need for the ODP to press the patients cheek
against the face mask to achieve a seal demonstrates the specificity of such connections and how both skill and improvisation
50
are involved in the marriage of standardised pieces of equipment

with the infinite variation of human anatomy. Hence, unconscious
patients are not homogeneous but retain their individuality in the
specificity of their bodily condition, the particularities of the
human-machine union and the different interventions each
cyborg demands. That the unconscious body does not necessarily
respond in the desired way to pharmaceutical manipulation is
neither surprising nor particularly troubling to the (experienced)
anaesthetist; rather, it exemplifies the entangled state of agencies
(Barad, 2007: 23) that constitute anaesthetic practice.
Cyborgs Speaking
The scene in this section demonstrates how the cyborgs

expressions may inform the course of anaesthesia. Here, in a
different observation session, the pathways and links between the
patient and anaesthetic machine have already been established,
and surgery has been ongoing for some time. Dr Smith is the
consultant anaesthetist.
Three beeps from the anaesthetic machine.
Dr Smith looks at the anaesthetic machine: Oh, what now? (He
then looks at the surgeon.) Youre hurting him, his block has
worn off . . . lets give him something . . . (he turns to the ODP)
50 of tramadol . . .
The ODP enters the anaesthetic room and returns with an ampoule
and syringe. Dr Smith cracks the ampoule open and draws the
contents up into the syringe, he labels it and injects half of it.
Blood pressure 131/78, pulse 59, oxygen saturation 98%, carbon
dioxide 4.4, Isoflurane (anaesthetic gas) on 5%, VE flashing 6.2.
(Later, as I typed these field notes in the anaesthetic department, I asked
another anaesthetist, who was sitting next to me, what VE flashing
6.2 means. She said that it stands for Volume Expired and 6.2 is a
fairly normal measurement. The anaesthetic machine will measure the
volume expired and then flash to alert you to changes from that norm.
For example, a painful stimulus will increase the patients respiration
51
rate, the volume expired will increase, and the reading will flash. Or,
after administration of a strong analgesic the respiration rate will fall as
will the volume expired and again it will flash to alert you. These are
normal responses.)
Dr Smith turns the Isoflurane back down to 1.5%. Blood pressure 160/98. He injects the rest of the syringe and throws it in the
yellow bin bag and then writes on the anaesthetic chart. I ask
Dr Smith about why the isoflurane was on 5%. He said it was just to
dampen the bp until the tramadol (a pain killer) worked. He said
the respiratory rate was back to 14 now as well. Dr Smith continues writing on the anaesthetic chart. Blood pressure 144/87.
The greater the depth of anaesthesia, the less sensitive the patient
is to pain. The body responds to pain in various ways, often by an
increase in heart rate, blood pressure, respiration rate or changes
in other bodily parameters. If, however, some form of pain relief is
incorporated into the anaesthetic, this allows the anaesthetist to
reduce the amount of anaesthetic used and therefore the associated side effects. Hence, anaesthetists will generally give a combination of anaesthesia and analgesia, aiming to achieve a lighter
anaesthetic (with fewer side effects) whilst maintaining the
patients insensitivity to pain. Here, three beeps from the cyborg
is followed by Dr Smiths comment that the surgeon is hurting
him (the patient) and the assumption that the block (a procedure
in which local anaesthetic is injected around a nerve pathway
preventing the conduction of nerve impulses) has worn off. The
cessation of pain relief provided by the peripheral nerve block
necessitates the administration of further analgesics. The blood
pressure and pulse are initially within normal parameters and it is
by triggering the volume expired alarm that the cyborg indicates
the presence of pain. Subsequent raised blood pressure measurements further support the anaesthetists interpretation that
the cyborg requires further analgesia.
The anaesthetists response is twofold. First, he injects 50 of
tramadol (an ampoule contains 100 mg) and following the
52
subsequent blood pressure reading of 160/98 he administers the

remaining 50 mg. Concurrently, he increases the concentration
of the anaesthetic gas with the intention of deepening the level of
anaesthesia and so lessening the awareness of pain. The depth of
anaesthesia and corresponding level of unconsciousness are far
from stable and distinct entities, rather the depth of anaesthesia
achieved is dynamic, changing in response to the level of surgical
stimulation, efficacy of analgesia and amount and type of
anaesthetic administered. Consequently, sensitivity to pain and
capacities to respond fluctuate in tandem with the level of
unconsciousness. The excerpt ends with a lower blood pressure
reading of 144/87 indicating that the cyborgs expressions have
successfully conveyed his status, in that the anaesthetist interprets and responds appropriately, and that the anaesthetists
strategy is beginning to combat the pain incurred by surgery.
As discussed in the previous chapter, May et al. (2006)
suggest that although debates about EBM have often been
framed as a political contest between clinical autonomy versus
managerialism, there is more at play than these two notions.
Debates about EBM also represent struggles over what kinds of
experiences and knowledge patients are authorised to bring to the
clinical encounter, and how these are made to count (May et al.,
2006: 1023). Notwithstanding the unconscious status of these
patients, the issue of what knowledges are brought to bear on
practice, by whom and how these are legitimated is still a salient
one. This episode shows how anaesthetic practice is comprised
of a complex interweaving of contributions from the cyborg,
interpretations, assumptions and anticipations of the anaesthetist, in response to an intensely dynamic situation informed by
the activities of surgeons, scrub nurses, ODPs and auxiliary staff,
all of which is ordered, framed and regulated by local routinised
practices and organisational and professional codes of conduct.
The authority and legitimacy of these different forms of
53
participation is, of course, not equivalent, and the ways in

which participation is made to matter how it is legitimated
is an issue that will be pursued in the various scenarios
throughout the book. Here, my first priority is to establish how
the anaesthetised patient the cyborg can indeed be said to be
a participant.
Cyborgs in Transition: Reclaiming the Ability to Breathe
The recovery phase of anaesthesia is a state of gradual transition

with consciousness returning and dependence on the technological augmentation of the body slowly diminishing. It is here that
movement through different levels of unconsciousness, and the
redistribution of capacities that accompanies this movement, is
most visible. Recovery begins in the operating theatre with the
cessation of anaesthesia and the relocation of the responsibility to
breathe from the ventilator to the patient. Retaining the monitoring connections, the patient will then be transferred to the
recovery room for a period of close observation. A description of
the beginning of this transition follows, wherein the patient
regains control of her breathing. The operation has finished, the
patient has been moved from the operating table to a trolley, and
positioned on her side in preparation for removal of the endotracheal tube. As the patient has been undergoing ear, nose and
throat surgery, her head is at the opposite end to the anaesthetic
machine to allow the surgeon access and space to operate. This
necessitates some manoeuvring so that the anaesthetist can reach
both the head of the patient and the anaesthetic machine.
Dr Woods: Can we have her feet to the door and her head to the
anaesthetic machine, that way I can reach the anaesthetic
machine. The patient trolley is wheeled so it is at a right angle to
the operating table. Dr Woods opens another suction tube, turns
the suction on.
54
Dr Woods: Shes not quite on her side is she? (to a nurse). The
nurse and Dr Woods reposition the patients shoulders.
The nurse is then called away to prepare for the next operation.
The anaesthetic machine beeps.
Dr Woods talks to a medical student: We might have to wait for
the CO2 to rise before . . . Dr Woods ventilates. She then takes
the tape off the endotracheal tube. Machine beeps (a single beep
signifying it has just recorded the blood pressure). The patient
moves, the carbon dioxide trace is now undulating.
Dr Woods says to the patient: Claire, deep breaths. The recovery
nurse prepares the oxygen mask.
Dr Woods: Claire. (Then to the medical student) Ill take the tube
out when Im happy that she is breathing regularly, not quite yet.
Patient is still again, the carbon dioxide trace is now flat.
Dr Woods: Claire. The patient gags on the tube, she begins to
chew it then stops and rubs her eye. The carbon dioxide trace
goes up and down again.
Dr Woods: Deep breath in. She squeezes the reservoir bag and
pulls the tube out. The recovery nurse puts the oxygen mask on
the patient. Dr Woods addresses the medical student: So we
know she is breathing because the mask is steaming up and you
can feel her abdomen moving. The recovery nurse and
Dr Woods disconnect the monitoring and wheel the patient to
the recovery room.
Although there are signs that the patient is beginning to emerge

from anaesthesia, these signs are capricious: one moment she is
breathing spontaneous movement accompanied by an undulating carbon dioxide trace on the monitor, the next she is not
the patient becomes still again and the carbon dioxide trace flat.
The anaesthetist cannot remove the tube until these signs have
stabilised and the ability to breathe can be firmly identified within
the patient. Removing the breathing tube means the cyborg loses
a communicative resource and the anaesthetist must be vigilant
for other expressions which confirm that the patient is breathing
55
independently: the anaesthetist watches the oxygen mask steam up

and feels the patients abdomen rise and fall with each inhalation.
Monitoring will continue in the recovery room for a short period
but, as the patient regains consciousness, she is less reliant on
the monitoring for expression, some forms of electronic monitoring being exchanged for modes of communication such as
language use.
Adjudicating on when to begin this dissolution of patient and
machine, the anaesthetist must carefully consider the signs: have
they settled sufficiently to indicate a stabilised relocation of
responsibilities within the patient? The skill of the anaesthetist
lies in interpreting this language: the anaesthetist cannot fabricate just any account their accounts are constrained by the
expressions of the cyborg. The anaesthetists interpretation of a
clinical situation, then, is achieved by considering the cyborgs
contribution alongside elements such as the patients medical
history, contingencies of the surgery, other practitioners contributions, routine organisational practices and the possibilities
for action afforded by anaesthetic tools and devices. Taking
these elements together, the anaesthetist constructs an account
that lends the situation some intelligibility and indicates a
direction for ensuing action a process examined in detail in the
next chapter. However, the point I would like to press here is
that, unlike the situation Poovey described with patients unable
to resist the anaesthetists account of the situation, present-day
cyborgs in anaesthesia have some resources at their disposal to
assist the anaesthetist in understanding their needs. Much rests
on an account that accords with the cyborgs expressions. In this
scenario, misinterpretation would have resulted in a patient that
was unable to breathe independently and dislocated from the
resources to facilitate this. In response to the way that discourses
are often said to have material effects (see, in particular, Barads
[2007] critique of Butlers Bodies That Matter), Barad (2007: 225)
56
questions: Is there any sense in which materiality might be said

to constrain discourses? This example shows how the anaesthetists options are structured by the materiality of the cyborg.
The anaesthetist talks of having to wait for the carbon dioxide to
build up, and being sure that the patient is breathing regularly.
As discussed earlier, this form of agency does not rely on consciousness and intentionality; rather, it is a material and technological form of agency, but one that is still vital, energetic, and
dynamic. It is both active and responsive.
Resistance: A Cyborgs Contribution
The fusion of patient and machine necessitated by present-day

anaesthesia realigns the boundaries of both patient and machine
and transforms modes of expression: monitoring devices convey
such details as heart rate, blood pressure, oxygen saturation, a
diagrammatic representation of the heart rhythm, and more.
However, anaesthesia also silences the patient, disabling the
capacity to speak verbally. Inducing unconsciousness necessitates
a further merger of patient and machine a secure pathway
between the patients lungs and the ventilator must be established. The responsibility for breathing can then be relocated
from human to machine, and presenting the volumes and concentrations of gases delivered to and retrieved from the patient
further expands the expressive resources of the cyborg.
These boundary transgressions and the expressions they
enable enhance the anaesthetised patients contribution to the
course of their anaesthetic, they are the means through which
unconscious patients can convey their needs. The technological
augmentation of the body allows for the construction, by the
anaesthetist, of a reasonably sophisticated account of the
unconscious patients needs. Sophisticated, that is, in relation to
the situation Poovey describes of anaesthesia without current
57
monitoring practices but an impoverished account, perhaps, in

comparison to actors that demonstrate intentionality and language use. This is an attempt to recognise the distinctive form of
agency of a particular cyborg relation within a collective. Callon
and Law (1995) argue for agency to be distributed amongst a
hybrid collectif but concede that it tends to be attributed to
certain parts of the collectif, significantly those that demonstrate
intentionality: The agents we tend to recognize are those which
perform intentions . . . but it does not have to be so . . . (Callon
and Law, 1995: 502). Despret (2004) describes how bodies
communicate in spite of themselves; she refers to the way a horse
may read a persons body language. The body, therefore, may
talk outside the frame of the persons consciousness. Anaesthesias cyborgs provide a further example of how bodies can
communicate outside a persons consciousness, and of the shape
agency without intentionality might take.
However, it is important to acknowledge the specificities of
this form of agency. My efforts to illustrate the agency of an
unconscious body connected to a machine is not a levelling
device designed to obscure human authorship of actions. The
cyborgs expressions technologically mediated and organic
(the colour and feel of the patients skin, the size of the pupils
and so forth) must be taken together with situational knowledge of, for example, the contingencies of surgery and the
patients medical history, for the anaesthetist to assess the needs
of the cyborg. Agency is not contained within the body, or
within the machines it is enacted in relations. So when those
expressions of the cyborg are coupled with appropriate actions
on the part of the anaesthetist an elevated respiration rate and
blood pressure being followed by the administration of analgesia this indicates that the cyborgs expressions have been
recognised and have successfully informed the course of his/her
anaesthetic care.
58
Furthermore, an uneventful reversal of the human-machine

union is not only important for anaesthesia but a measurement
of its success. My conceptualisation of the combination of the
patient and machine as a dynamic, vigorous, acting entity casts
some light on why the attainment, maintenance and reversal of
this particular cyborg state is precarious and easily disturbed,
and therefore closely marshalled by a team of practitioners.
Hogle (1995) questions whether bodies can phase in and out of
cyborgism and the possibility for transience in cyborg states
(Hogle, 1995: 213). In anaesthesia the aim is for transformations
to be affected and reversed all in the period of a few hours.
Studying anaesthesias cyborgs, then, provides an opportunity to
concentrate on this transience, how the transformation processes
are accomplished, what capacities are gained and lost and the
work entailed in reanimating the human. So, in answer to Hogle
(1995: 213): yes, bodies can phase in and out of cyborgism but
accomplishing such transience requires the support of human
facilitators and technological devices, in short, it depends on a
connection with a network of humans and technologies.
The argument I want to make is that even when the patient is
unconscious, the clinician has to work with the patient rather
than impose a trajectory. Unconscious patients do act, but in
very limited and distinct ways, and this form of agency can be
recognised in the ways it constrains and directs an anaesthetists
actions. Isolating the patient and machine as my unit of analysis
has enabled me to clearly illustrate how the cyborgs expressions
inform an anaesthetic trajectory. The subtle ways unconscious
patients may act has tended to be overlooked with the focus on
depersonalisation, the anonymity of surgical bodies (Hirshauer,
1991), and the dispossession of patients identities (Hogle,
1999). My description of anaesthesias cyborgs suggests that to
be unconscious is not necessarily to be passive or considered
homogeneous, rather, unconscious patients retain their specificity
59
in their embodied form, in the expressions their bodies and the

technology produce, in their medical histories and in the interventions their unconscious bodies require.
Consequently, the boundary reconfigurations I describe
provide the conditions for resistance, in that the cyborg may
contribute to and shape a doctors interpretation. Whilst the
cyborg figure is not without limitations (see Currier, 2003), like
Haraway, I find cyborg imagery to be a convincing tool to
undermine both human and technological determinism. Poovey
(1987) describes how anaesthesia denied Victorian women of the
resources to contest the interpretations of physicians. Physiological responses to anaesthetics were articulated as uninhibited
sexual desires and fantasies mandating some form of control. In
my observation of anaesthetic practice, the patient, technologically extended and transformed, can resist, their expressions
being one of the factors that shape how anaesthetic practice may
proceed.
It is worth attending to the differences between these two
situations. Pooveys claim is situated in the mid-Victorian
medical professions treatment of women during childbirth. My
argument addresses current anaesthetic practice and is not
gender-specific. The particularities of the different practices we
studied and the sources of data to which we have access may
explain the disparity in our arguments. Consequently, I have
taken Pooveys claims as my starting point but my argument is
directed towards contemporary conceptualisations of agency,
towards our relations as humans with technologies and to add
further nuance to the debates surrounding the dominance of
medical practitioners. This argument to recognise the subtle
forms of agency patients even unconscious ones and
machines may demonstrate is also deeply implicated in debates
around the ways in which medicine and health care is practiced
and who may be held accountable for what. Decision support
60
systems, such as clinical practice guidelines, now widely used in

hospitals (Webster, 2007) and the tool of choice for implementing EBM (Berg et al., 2000: 766), presume decision making
to be an individual affair rather than a jointly produced outcome
(Webster, 2007). This is hardly surprising given the extent to
which this figure of an autonomous, rational agent is embedded
in Euro-American imaginaries and how technological projects
seek to reiterate that image (Suchman, 2007). However, my
suggestion is not that managerial attempts to codify and standardise expert practice will be of limited use as has been argued
elsewhere (Greatbatch, 2005), rather, my concern is more about
the difficulties posed by this conception of autonomous, rational
agency, which erases other agencies or at least severely limits
their relevance, when courses of action must be accounted for. It
is to the anaesthetists management of these tensions, and more
broadly to the details of his/her participation that I now turn.
Accounting for Incoherent Bodies
Frequently, in medical practice, there will be multiple,

incompatible explanations of a patients condition, prompting
numerous and different possible courses of action. Decision
making, in these circumstances, has been analysed as a process of
alignment by bringing together various sources of knowledge,
and weighing one against the other, a narrative is produced,
which explains the majority of the patients signs, symptoms,
readings and measurements. More recently in STS, attention has
turned from looking at methods of closure how, of all the paths
that might possibly be taken, options are reduced and a single
path emerges to exploring the multiplicities, disunities and incoherences of bodies, objects and knowledges (see, in particular,
Berg and Mol, 1998, and Mol, 2002). Here, analyses have
highlighted how, despite there being tensions, differences are not
necessarily resolved, they endure.
In the last chapter I sought to disturb the view that anaesthetised patients are passive, stripped of agency and seemingly
absent from proceedings in which they are central. In this chapter
I seek to explore the anaesthetists role in the organisation and
delivery of anaesthetic care and how accountability is achieved
both in circumstances where the messages conveyed by the
anaesthetised patient and anaesthetic technologies the cyborg
are relatively coherent, and circumstances where they are not. In
the case of the latter, I examine the ways in which anaesthetic
61
62
practice is shaped and accountability is achieved where, despite

concerted efforts at alignment, the disunity of the patients body
persists. The subtle forms of agency that the cyborg demonstrates,
however, do not figure prominently (if at all) in the normative
descriptions of practice contained within codes of professional
conduct, clinical guidelines and other such formal articulations of
clinical practice. Furthermore, in health care settings the notion
of professional accountability has become increasingly significant;
hence, the existence of unresolved differences can sometimes be
deeply problematic. Health care practitioners work in a culture in
which certainty of knowledge, diagnoses and actions is highly
valued and, on one level, enacted as a prerequisite for interventions, and yet on another level, it is frequently, if implicitly,
enacted as an unattainable ideal. Therefore, these claims for the
agency of unconscious patients, coupled with recent theorising
in STS around the incoherences of medical practices and the
increasing prominence of professional accountability, give rise to
the question and focus of this chapter: How are course of action
shaped and accounted for in situations in which the expressions
of the cyborg do not readily lend themselves to explanation?
Medical Practice: The Work of Making Meanings
and Establishing Their Legitimacy
Berg (1992) has suggested that medical sociology would benefit

from employing the insights of social studies of science, and in
particular, the laboratory studies. Medical sociology, he argued,
had tended to separate the content of medical action from the
social aspects with the former constituting a domain inaccessible to sociological investigation. Casper and Berg have said
that the sociological investigator has tended to stand with his or
her back to the heart of medicine and studied the social phenomenon surrounding it (1995: 397). Atkinson (1995) has
63
made a similar argument suggesting that STS and medical

sociology have developed largely in isolation from one another
and that they might fruitfully be brought together. Medical
sociology, Atkinson contends, has treated medicine as the
medium for other issues gender, class, race, power but rarely
addressed the content of medical knowledge and practice.
Moreover, the almost exclusive attention on the doctor-patient
relationship has led to neglect of how doctors relate to one
another and to medical science in the organisation of their work.
Accordingly, in Atkinsons (1995) study of haematologists, he
focussed on how medical knowledge is distributed, represented,
legitimated and, in short, produced in and through medical work.
He describes how a heterogeneous range of resources are drawn
together in the construction of a case which serves to explain
the patients condition. A case is:
a device whereby the diverse types and sources of knowledge and
actions derived from different time-frames, are brought together under
the auspices of a single discursive organization and made available for
the collective gaze of medical colleagues. (Atkinson, 1995: 149)
This is not simply the recitation of the patients story, or a series

of facts and findings; rather, the case should provide a clear
chronology of reported events, weaving together information
from different sources and of different types into a single, moreor-less coherent account (Atkinson, 1995: 95).
A case, then, constructs a coherent body, but not only this, it
simultaneously constructs the appropriate medical practices,
treatments, and interventions. Berg (1992: 156) explains: what
matters is that the physician makes a patient problem solvable by
reducing the infinite array of possible actions to just one disposal. A solvable problem inherently contains a disposal; physicians do not diagnose first, then decide upon a therapy
(although this staging may be applied in retrospect); rather,
accounts and disposals are constructed together (Berg, 1992).
64
However, rather than tracing how bodies and medical practices are made to cohere, the multiplicities of bodies, objects, and
knowledges have begun to be opened up to inspection. Dugdale
(1999) describes how an object the IUD that is talked about
in different ways constitutes different, multiple, IUDs rather
than describing different perspectives on the same object.
Attending to the talk, Dugdale exposes how the IUD is a system that can be analysed in terms of its human and non-human
parts; it is a device to be managed by its registration, marketing,
addressing of adverse reactions; it is an array of expert knowledge to be read in the medical literature; and it is one of a
range of contraceptives. In one committee meeting the IUD was
constituted as a series of different IUDs. Dugdale points out,
however, that possibly this dispels singularity too quickly, for the
talk is also predicated on the assumption that all its participants are
talking about a single IUD (1999: 125, original emphasis). So
instead of converging, objects oscillate between multiplicity
and singularity: if decisions, subjects, or indeed objects, cohere
then this is because they are both singular and multiple (Dugdale, 1999: 131).
Perhaps the most comprehensive exploration of multiplicity
is Mols (2002) influential text the body multiple. Her starting
point is that: objects come into being and disappear with the
practices in which they are manipulated (Mol, 2002: 5). Mol
explains how atherosclerosis in the out-patient clinic, in the
operating theatre, and in the pathology laboratory, are all different atheroscleroses rather than different perspectives on the
same disease. In the out-patient clinic, atherosclerosis is a
complaint of pain on walking. In the operating theatre, atherosclerosis is the accumulated debris atherosclerotic plaques
inside a vessel to be stripped out and discarded. And in the
pathology laboratory, atherosclerosis is something seen under a
microscope a thickened intima, the lining of the vessel wall.
65
These different atheroscleroses may cohere pain on walking is

caused by reduced blood flow to the lower limbs because of the
build-up of atherosclerotic plaques. However, this is not necessarily the case. Mol argues that bodies arent always coherent,
and she cites examples in which pressure measurements and
clinical examinations are poorly aligned. In these cases some
work is required to coordinate them:
In the specificities of the practicalities of enacting a disease, an explanation may be found for the inconsistency of two diagnoses. One of
them wins. The other is discarded. Thus a single patient ends up with a
single atherosclerosis. (Mol, 2002: 66)
The disease to be treated, then, is composed of such elements

as the numbers that come out of the vascular laboratory, the
complaints of the patient, and the bodys supporting evidence
ascertained on clinical examination. Mol makes it clear, however,
that coordination work does not reflect a pre-existing singular
body, rather, it is a task. Designing treatment entails that, in one
way or another, the various realities of atherosclerosis are fused
into a composite whole.
Whilst acknowledging the various ways in which bodies may
be made to cohere when treatment decisions are required, she
goes on to elaborate how practices also resist the reduction of
multiplicity by means of distribution. The atherosclerosis of the
clinic, and that of the laboratory, can be different and yet exist
quite unproblematically so long as they are kept separate, and are
therefore in no position to contest one another. Incompatibility,
of the different atheroscleroses, is not necessarily a problem:
Incompatibilities dont stop patients getting diagnosed and treated.
Work may go on so long as the different parties do not seek to occupy
the same spot. So long as they are separated between sites in some sort
of distribution. (Mol, 2002: 88, original emphasis)
Mol suggests that a bodys lack of cohesion is unremarkable;

apparent incompatibilities do not make life more difficult, on the
66
contrary, they make it easier. Atherosclerosis is both pain and a

clogged-up artery but not both in the same site. It is pain in
diagnosis and a clogged-up artery in treatment. In this way, the
possible tensions between variants of a disease disappear into the
background when distributed over different sites.
Mols argument, however, presumes a body that is amenable
to either coordination work or distribution. Consequently, for
Mol, this means that:
Bodies enacted are being done, which means that they cannot answer the
question of what to do. However uncomfortable this may be, this question,
what to do, is a question we have to face. Not in circumstances where
anything is possible, but still. (Mol, 2002: 16465, original emphasis).
But perhaps this account deprives the body of some agency, and
bestows a little too much on the practitioner? Possibly the body
may be less compliant? In the last chapter, I argued for greater
recognition of the contribution made by the unconscious patient
and the anaesthetic machine towards the shaping of events. Such
participation will not always align with the anaesthetists projections. I wonder, then, about those occasions when incompatibilities do not stay contained in their respective sites, for example,
when they need to be temporarily drawn together for treatment
decisions but resist practitioners attempts to align them.
Hirshauer (1991) hints at the work involved in interpreting
the needs of an unconscious body and observes that the anaesthetised body is able to convey some very limited information
about his/her condition. According to Hirshauer, the patients
signs of life are externalised in the form of digital signs and
readings, audible and visual alarms, and clinical signs. In this
way, the unconscious patient provides some information with
which the anaesthetist must work:
To the anaesthetists, the signs of life indicate a patients state, which has to
be continually controlled to maintain the delicate equilibrium of various
circulations. Compared with the evidence of verbal exchanges, which may
67
begin with, say, how are you feeling?, the bodys dumbness presents a
problem. The evidence of machine-produced values takes their place,
supported by the evidence of clinical signs. (Hirshauer, 1991: 291)
Hirshauer identifies how machine-produced values coupled with

clinical signs replaces verbal communication, an observation that
resonates with the argument in the previous chapter.
Introducing the work of the anaesthetist, he goes on:
One must read all these values to see how the patient is feeling, what
s/he needs. (Hirshauer, 1991: 291, original italics)
However, Hirshauer concentrates on the visualisation of these

signs. He comments that regular blood analyses are presented on
computer print outs, the monitor shows the pulse rate, the ECG
trace, respiratory rate and so on. This implies that the meaning of
these signs of life are relatively self-evident and unproblematic.
So in this sense, the work of making meaning rendering the signs
of life intelligible is glossed. This is also the case when Hirshauer discusses the significance of the alarms. When machine
produced values fall outside the preset limits and trigger the
alarm, he offers two common interpretations for his example:
The (ventilator) alarm signal indicates not only a threat to a vital
function but also the fading of narcosis. It alerts the vigilant anaesthetist
to restore the intermediate state of narcosis. (Hirshauer, 1991: 292)
However, this overlooks the contingency of these alarms and how

their meaning is constructed in relation to other situational and
communicative resources. Pasveers (1989) study of the introduction of X-ray imaging clearly illustrates how technological data
must be considered with regard to current patterns of knowledge
and practice, rather than having an intrinsic, unambiguous meaning. In contrast to the idea that X-ray images instantly provided a
new, visual way of rendering the world, Pasveer demonstrates how
the images became progressively significant, their use and diagnostic significance evolving over some time. What could be argued
68
to be inside the images from the beginning actually had to be

shaped by the X-ray workers. Hirshauer hints at this meaning
making work when he states that clinical signs complement the
machine produced values and are assessed in the light of anamnestic data collected before the operation (1991: 292). He lists
some of these clinical signs listening with a stethoscope, registering a tear and checking the pupils but does not elaborate on the
processes through which they are allied to the signs of life and
how, of the multiple possibilities, the legitimacy of an interpretation and course of action is accomplished. It is this work that
interests me in this chapter: how the anaesthetist works to establish
the salience of the cyborgs expressions and in doing so legitimates
one possibility over another.
As discussed in the Introduction, movements such as clinical
governance, EBM and their tools of implementation, such as
clinical practice guidelines, seek to clarify, standardise and
document the roles and responsibilities of practitioners, and to
regulate the manner in which they practice. Increased standardisation is promoted on the assumption that it will reduce, or at
least limit, the potential for wrong-doing or human error,
thereby resulting in safer health care systems (McDonald et al.,
2006). Guidelines, however, also serve a bureaucratic function,
they provide non-medical managers with a legitimate resource
with which to challenge medical practice:
The attraction of a rule-based approach, particularly give its
endorsement by scientific researchers, Government, the evidencebased medicine movement and the NPSA [National Patient Safety
Agency] is that it provides some legitimate basis from which otherwise
powerless managers can attempt to exercise control over powerful
medical professionals. (McDonald et al., 2006: 197)
In contrast to this representation as powerful professionals,

McDonald et al. (2006: 197) found that doctors portrayed
themselves as competent professionals who struggle to achieve
69
success in the context of factors which they are powerless to

influence. Doctors, it seems, accept that there are elements over
which they have no control, such as inadequate equipment,
excessive workloads, inexperienced support staff, patients arriving late or patients with abnormal anatomies. Moreover, doctors appear to accept that these factors are quite simply part of
health care work in the NHS (McDonald et al., 2006).
This discrepancy between how medical practice is deemed to
occur in formal documents (doctors, being at perfect liberty to
control his/her own actions, simply implement the specified
processes) and how it is talked about by doctors (as a complex
amalgam of many different factors throughout which the locus
of control is distributed) is exacerbated by codes of professional
accountability. In articulating a professions agreed standards,
they serve a normative function by reifying a preferred manner
of professional activity. However, being premised on an individual, cognitive mode of decision making and activity, such
codes of conduct downplay the complexity of real-world, situated decision making and the extent of involvement of other
human, technological, environmental and material factors. In
these documents, therefore, professional accountabilities crystallise on certain actions and particular actors.
The contradictions between these two versions of medical
practice a distributed sociomaterial one articulated by doctors,
and an individual, autonomous, cognitive one that is inscribed
into texts that describe or direct health care broaches questions
around how the legitimacy and accountability of actions are
achieved, and on those occasions when this discrepancy between
the two, sharply contrasting, modes of action does, and does not,
become problematic. In what follows, I explore three scenarios
from anaesthetic practice that demonstrate a range of approaches to working with unconscious bodies and the sometimes
difficult task of establishing the legitimacy of actions.
70
More or Less Coherent Bodies
It is Saturday morning, an 8-year-old child is having an Open

reduction and internal fixation of his broken arm under general
anaesthetic. This involves surgically exposing the fracture, realigning the bones, bridging the fracture with a metal plate
secured by metal screws and then closing the wound. The
anaesthetist, Dr Wilkins, is a trainee. He is relatively new to the
specialty having practiced anaesthesia for 6 months, mostly
under supervision. This is one of the first occasions he has
worked independently. The excerpt begins in the operating
theatre with the surgery already under way.
The pulse rate, displayed on the monitor, goes back up to 130.
Dr Wilkins peels back the tape covering the patients eyes, lifts the
eyelid and looks at the pupil, he then administers more morphine.
He has given 5 ml so far.
Pulse 147, blood pressure 147/51.
Dr Wilkins turns to me, he says he had given 5 of morphine and the
patients pupils were pinpoint, now the pupils are really wide again
and the patient is also taking on a lot of isoflurane. (This indicates
that the patient is responding to pain as he has insufficient analgesia to
counter the effects of surgery.)
Pulse slowing to 103. Dr Wilkins records on the anaesthetic chart
some measurements from the list on the screen.
Pulse 86. He stands leaning on the drip stand, watching the monitor.
Blood pressure 120/44. He turns the volume down on the pulse
oximeter. High end tidal CO2 (measurement of expired carbon
dioxide) flashes on the screen, the numbers in white read 8.7. Dr
Wilkins presses some buttons on the monitor and scrolls through
some screens. (I think he is changing the alarm limits on the end
tidal carbon dioxide measurements as one of the screens he scrolled
onto was called Airway Gases, and following this the number stops
flashing.)
Dr Wilkins feels the patients forehead. An ODP enters with the
controlled drug book. Dr Wilkins asks the ODP for 50 mg of
71
voltarol (a pain killer). End tidal carbon dioxide now reading 9.2 and
not flashing. The ODP enters, hands Dr Wilkins a glove and a
voltarol suppository. Dr Wilkins administers the voltarol suppository, then looks at the pupils again and gives more morphine (about
8 ml given in total).
I ask about the end tidal carbon dioxide readings, he says he did
change the limits. He says: its probably because he is hypoventilating, its quite high but its all right.
End tidal CO2 now flashing again and reading 10, pulse 80,
blood pressure 108/48. Dr Wilkins watches the surgery.
This scene tells of an inexperienced anaesthetist learning to

distinguish the boundaries of routine practice. He takes the
raised pulse rate as a sign that the patient is experiencing pain,
the appearance of the patients pupils, going from pinpoint to
wide, and the raised blood pressure (147/51 is high for an
8-year-old) adds weight to this account. Further affirmation is
provided by the amount of isoflurane, an anaesthetic vapour, the
patient inhales. Not all patients undergoing general anaesthesia
are paralysed and their breathing regulated by a ventilator, and
as this patient still regulates his own breathing he can take on
more isoflurane by increasing the depth and rate of inhalation.
The more anaesthetic inhaled, the deeper the level of anaesthesia, thus countering the painful effects of surgery.
Drawing together these measurements and signs with situational details such as the surgical manipulation of the fracture
produces a relatively coherent account of a body in pain. In
weaving together information from different sources and of
different types, the anaesthetist creates a single, more-or-less
coherent account, through which events themselves unfold
(Atkinson, 1995: 95). Events unfold through this narrative, as its
construction simultaneously produces the appropriate medical
practices, treatments and interventions. As outlined here, a
solvable problem inherently contains a disposal: a patient in pain
requires analgesia. Here, the anaesthetist administers morphine
72
for immediate effect and voltarol to cover the next few hours.
Subsequent signals from the patient, the pulse slowing to 86 and
the blood pressure reading falling to 120/44, suggest that the
analgesia has had the desired effect of counteracting the pain of
surgery, and thus confirms that the problem was indeed one
of pain.
Nevertheless, even in this most straightforward of cases, the
patients body is not entirely coherent. The carbon dioxide
readings, for instance, do not fit within this explanation
and suggest a slightly different bodily state one that has been
over-analgesed. Exhaled carbon dioxide is primarily measured as
an indication of the adequacy of ventilation. However, given that
one characteristic of morphine is to act as a respiratory depressant, if the anaesthetist overestimates the amount of morphine
required this will result in insufficient ventilation (in a patient
regulating their own breathing) and a corresponding rise in the
amount of exhaled carbon dioxide. Therefore, the end tidal
carbon dioxide reading can also serve as an indirect measure of
the sufficiency of analgesia. The anaesthetists actions may have
not only relieved the pain but also depressed the patients ability
to breathe.
So the anaesthetist seeks to ascertain whether he has given the
appropriate amount of analgesia. After giving the first 5 ml of
morphine, he feels the patients forehead, as a clammy or sweaty
forehead serves as another indication that the patient is
experiencing pain. However, this appears to discredit the possibility of an over-analgesed patient, as the anaesthetist continues to
administer more analgesia: first, a voltarol suppository and, on
checking the pupils again, some more morphine.
Even in routine situations such as this, bodies arent entirely
unified; here, producing a coherent body means disregarding the
carbon dioxide measurements. This is not to say that the carbon
dioxide readings are incorrect; the anaesthetist clearly accepts
73
the veracity of the readings, acknowledging that the patient is

hypoventilating. Rather, it is that the anaesthetist needs to be
confident that his actions are warranted, and the more the signs
align the more coherent the account the more secure the
anaesthetist is in his reading of the patients body. Coherent
bodies provide a good basis for action.
Connecting Coherent Bodies: Certainty,
Legitimacy and Accountability
Nevertheless, the evidence of the readings and measurements

cannot be disregarded lightly. Actions, treatments, interventions
and omissions must be legitimate, reasonable responses, and
doctors should be confident about this. There are cultural
expectations in medicine that doctors achieve a degree of certainty in their practice (Atkinson, 1984; Adamson, 1997). In this
respect, Adamson (1997: 135) points to the role played by hospital rules, regulations, rituals and routines:
Certainty is a moral ideal to be achieved through measures such as
routinely checking patients arm bracelets before administering drugs,
regularly monitoring their vital signs, their IV drips, and the machines
to which they are attached, continuously forming images of their
bodies, and constantly analysing their bodily fluids and tissues. In many
situations, expressions of uncertainty by medical professionals would
violate norms and invite punitive sanctions.
So although doctors may stress the unpredictability of their work

and the need to respond flexibly as a reason for the inappropriateness of guidelines, this does not necessarily mean that
doctors entirely reject the notion of routine work. On the contrary, personal routines, established though experience, are
employed as a way of maintaining safety, and disruption to these
routines is invoked as a reason for why errors occur (McDonald
et al., 2006). Adamson adds that when there is some ambiguity,
physicians will typically resolve the problem of what to do in
74
favour of the norm. The scene here shows the anaesthetist tentatively constructing the carbon dioxide readings as within the
limits of normal, albeit perhaps marginally so: its quite high but
its all right. This view is supported by the checking of the
pupils, the feel of the skin and the continual monitoring of the
vital signs. These activities bolster the anaesthetists confidence
and legitimate his understanding of the situation.
The routine checking, and the need for certainty, draws
attention to the context of accountability in which 20th-century
Western medicine is practiced. For ethnomethodology, accountability is considered to be an ever-present background feature of
all social and practical action. Accountability refers to the ways
in which actions are organized: that is, put together as publicly
observable reportable occurrences. They are not only done, they
are done so that they can be seen to have been done (Button and
Sharrock, 1998: 75, my emphasis). This draws attention to the
ways in which participants might have in mind the possibility
that their actions can be inspected and that they might later be
held to account (Neyland and Woolgar, 2002). In the interests of
conceptual clarity, therefore, I use the term legitimacy to refer
to the reasonableness and appropriateness of an understanding
or course of action, and accountability to refer to the recognition
of that legitimacy. There is overlap between these two notions
and the processes through which an action becomes legitimate
also may be the same as those through which it becomes
accountable. Here then, not only are these routine checks publicly observable procedures that serve to establish, amongst those
present, a degree of certainty that the patient is in pain and
further analgesia is warranted but, further, these checks also may
indicate the doctors awareness that his actions may be questioned subsequently by unspecified others.
Moreover, a routine situation, itself, confers some security:
the safety of the norm (Konner, 1988: 366). A routine situation
75
constitutes a frame of reference that delineates what are appropriate actions and what are not. Within this frame of reference, sets
of actions are repetitively and habitually carried out without
explicitly needing to reflect on or legitimate the actions involved
(Berg, 1992). Konner, an anthropologist undertaking a medical
degree programme, suggests that practicing medicine according to
the norm has not only legal benefits but also moral and psychological ones you feel safe. He reflects: the comfort the practitioner derives from keeping to ritualistic routines, held firmly in
common with other practitioners, is difficult to exaggerate
(Konner, 1988: 366). If the carbon dioxide readings can be
regarded as within normal limits, then administering more
analgesia to a patient in pain is an appropriate and legitimate
action.
The checks and monitoring activities become part of routine practice, an effect of the culture of certainty in which
doctors practice, they constitute legitimate and accountable
action. Routine practices incorporate sets of accountable actions,
they build into normal practice activities that support and
confirm the ongoing action. Learning the routines, and learning what constitutes normal, means learning to practice
accountably. The anaesthetist here is learning to define the
boundaries of normal practice and, given that he had to change
the limits on the anaesthetic machine to prevent it from
alarming, this indicates that the patients carbon dioxide readings fall outside at least one construction of normal. So the
anaesthetists checking is cautious and explicit, and his articulation of normal perhaps provisional pending the outcome of
this episode: the phrase its quite high but its all right
implicitly carries with it the proviso for now. Its all right,
insofar as it resolves shortly, once the need for such a degree of
pain relief has passed and the effects of the analgesia have begun
to wane.
76
Incoherent Bodies and the Routine
The following scenario takes place in the operating theatre, the

patients operation has finished, and she has been transferred
from the operating table onto her bed. The anaesthetist is
waiting for the opportune moment to extubate to remove the
endotracheal tube through which she has been ventilated. As
seen in the previous chapter, extubation requires that the patient
must have recovered the ability to breathe independently and
there must be signs that consciousness is returning.
Dr Hughes: Hello, operations finished. Time to wake up. He speaks
loudly and with a deep voice. He walks to the anaesthetic machine,
squeezes the grey reservoir bag (manually ventilating the patient)
and repositions the pulse oximeter. He continues ventilating, oxygen saturation flashing 74%, increases to 86%, still flashing.
There are 12 people (including me) in theatre. Its very noisy.
Only Dr Hughes, the ODP and I look at the patient.
Oxygen saturation 89%.
Dr Hughes: She desaturates very quickly. He is stood by the
anaesthetic machine, ventilating. What length is the tube in at?
ODP: 24, 22 at the teeth.
Dr Hughes: Hmmm. Maybe its just shifted.
Saturation now 93%.
Dr Hughes: Mrs M, time to wake up, operations finished, are you
comfortable? (Deep voice again.) There is a change in the tone
of beeps.
Desaturating again. Saturation 91%. He walks back to anaesthetic machine, ventilates, oxygen saturation 89%.
ODP stands by the patients head.
Dr Hughes: As soon as the sats drop she starts looking dark.
Saturation 89%.
ODP and two others move the operating table away.
77
Dr Hughes ventilates, saturation 88%. Come on Mrs M. Mrs M,

operations finished. He suctions around the patients mouth and
throat. Patient coughs. Thats better. Mrs M, big deep breaths,
operations finished, open your eyes. Dr Hughes ventilates,
saturation 89%.
Another ODP enters and looks at the patient: What have you
done to her?
Dr Hughes: Shes only had 6 of morphine. He changes the position of the pulse oximeter, saturation 82%, then continues ventilating. Patient coughs again, saturation dropping to 79%.
Dr Hughes turns the valve by the ventilator bellows then asks: Is
there a stethoscope?
ODP: Dozens of them. He hands Dr Hughes a stethoscope that
had been hanging on the anaesthetic machine.
Dr Hughes presses the stethoscope to the patients chest, by her
armpits and listens as he ventilates, the same on the other side.
Patient coughs. Dr Hughes continues ventilating, saturation
87%: Sounds all right. Have you got any suction catheters?
ODP: What size?
Dr Hughes: Nothing too brutal. He ventilates, frowning at the
patient. Mrs M, wee tickle in the back of your throat. He feeds
the catheter down the ET tube, the ODP occludes the hole at the
top and Dr Hughes pulls the catheter out. Nothing to speak of.
(Looking at the catheter.)
A nurse enters to ask Dr Hughes about the next patient
Dr Hughes: Mrs M time to wake up. Patient still coughing. OK
Mrs M, tickle in the back of your throat (suctions). Big deep
breath, another tickle. He moves the tube fractionally, saturation
falls from 8176, ventilates, the cuff on the tube is down. . . .sats
a little bit higher before I extubate. Another wee tickle . . .. He
reinflates the cuff. Just dont understand why.
ODP: Member of staff, always trouble.
Dr Hughes: Lets work on the assumption its the tube thats upsetting her. (Then loudly to the patient.) Big cough on 3. 1 . . .
2 . . . 3. (Extubates.) Big deep breaths Mrs M. He places the black
78
mask over her face. Saturation climbs immediately to 96%.
Happier without the tube, anyway pain doesnt seem to be a
problem, thankful for small mercies. He changes the black mask
for a clear plastic oxygen mask. Look! He points to saturation
it reads 99%. Shall we go into Recovery, Mrs M, finished now.
Anaesthetists tailor their anaesthetic so that extubation can take

place in the first few minutes after surgery has been completed,
ordinarily within 5 or certainly 10 minutes. The excerpt here has
been edited but does in fact span 30 minutes. The anaesthetist
hesitates because the patient doesnt display the usual configuration of signs that suggest extubation is warranted. The signs
are mixed the patient coughs indicating that the level of
anaesthesia is now quite light and she is becoming aware of the
tube in her throat but, most significantly, the oxygen saturation
reading is problematic, ranging from 74% to 91% before extubation. Blood, fully saturated with oxygen, would read 100%,
and normal readings range between 96% and 100%. Again, the
accuracy of these measurements is not in doubt, the anaesthetist
verifies the readings by noting the change in the patients colour
when the saturation levels drop she starts looking dark. For
some reason, then, the patients oxygen intake is insufficient.
The anaesthetist first considers the placement of the endotracheal tube questioning its length, perhaps this has shifted
slightly so that it does not fully ventilate both lungs. This
proposition is dismissed when the correct placement of the tube
is confirmed by listening with a stethoscope to the air entry in
each lung. When an ODP asks What have you done to her? the
anaesthetist answers the implied question Have you given her
too much morphine? and thus depressed the patients ability to
breathe. Apparently, the anaesthetist considers this to be an
unlikely explanation having only given 6 mg, and he returns to
concentrate on the tube. He uses a suction catheter to remove
79
excess secretions from the lungs but again there is nothing to

speak of . Assuming that there is no problem with the endotracheal tube (and in this case the tube has been used throughout
surgery to adequately ventilate the patient, it appears to be
correctly positioned and clear of secretions), it would generally
be considered imprudent to remove the tube when oxygen saturation levels are so low, but there seems to be no convincing
way to account for these low readings.
The body, in its alliance with the anaesthetic technology
demonstrates some agency in generating these expressions, but
their meaning is not self evident and must be actively contrived by
the anaesthetist. As indicated earlier, the meanings of these measurements are not stable, nor do they inhere within the readings,
on the contrary, the meaning of the low saturation readings is
elusive and indicates no course of action. So just how does the
anaesthetist proceed? Over-analgesia does not seem to be a credible explanation, problems with the placement and functioning of
the tube cannot be found, and yet still the oxygen saturation levels
are persistently low. All these accounts are unconvincing, they lack
unity and coherence, but time is pressing and some action must be
taken promptly. Low saturation levels are only tolerated transiently and must be resolved. Furthermore, the next patient has
now been waiting in the anaesthetic room for almost half an hour.
The anaesthetist perseveres with his assumption that there is
some, unidentified, problem with the tube. His phrase Lets
work on the assumption its the tube thats upsetting her implies
the agency of the unconscious Mrs M in rejecting the tube.
Enacting the agency of the unconscious body goes some way to
legitimating the removal of the tube, rendering the anaesthetists
actions intelligible. That the reason for Mrs Ms rejection of the
tube is indecipherable to the anaesthetist, and his acceptance of
this, could be read, as another example of the incoherences of
unconscious bodies.
80
Skill, Tacit Knowledge and Accountability
In terms of accountability, however, the anaesthetists

assumption is unsatisfactory, vague and inadequately explains
the elements of the situation. But he must proceed in some
direction, and however tenuous it may be, the anaesthetist must
posit some sort of organising theory on the situation, a thread
through which the bodys presentation can be rendered comprehensible. The anaesthetists assumption possibly is in part
informed by his tacit knowledge, but the intangible, and to
some extent inarticulate, nature of this knowledge, leaves the
anaesthetist vulnerable when accounting for his actions. As
Suchman (2007) points out, human interactions draw on a wide
range of possibly relevant phenomena and therefore invariably
exceed what is made accountable in any direct sense. The difficulty for the practitioner comes when, as in this case, actions
cannot be justified in terms of explicit, externally verifiable
indicators such as blood pressure and oxygen saturation measurements, the remaining relevant phenomena being rather
unconvincing when decontextualised in a written record for
subsequent scrutiny.
Incoherent bodies generate insecurities, and unlike in the last
scenario, the incoherent, unexplained, element in this case (the
low oxygen saturation levels) cannot be ignored because adequate oxygenation is ordinarily a prerequisite for extubation. To
remove the tube in this situation could be considered an unwise
and cavalier action. How is it, then, that this course of action is
treated, by those present, as relatively unremarkable and legitimate? One explanation might be that the decision to extubate is
less of a choice than it is a process of working through possible
options. The anaesthetist is guided by performing the routine
checks verifying the readings, considering the level of analgesia, systematically eliminating the various possible problems
81
with the tube. Even though these checks have proved fruitless,
performing them still provides an element of security.
Failure to identify the cause of the low oxygen saturation levels
through the routine checks and the passage of a relatively lengthy
period of time (30 minutes) meant that some further action was
needed in order to elucidate the situation. This much is obvious to
the other participants, particularly those who share (or at least
have overlapping) professional vision with the anaesthetist,
namely, the ODP. Professional vision is the socially organized
ways of seeing and understanding events that are answerable to
the distinctive interests of a particular social group, it refers to the
process through which practitioners learn to see the objects with
which they work (Goodwin, 1994: 606). At least to the ODP,
removing the tube in spite of the low oxygen saturation levels is an
unremarkable, sensible and appropriate action when all the
routine checks have been completed he neither makes any
comment nor shows any expression of concern. Extubation does,
in fact, resolve the problem but if it had not, this action would at
least simplify the situation, eliminating the question of a problem
with the tube. Whilst an unconscious patient, poorly oxygenated
and without a tube to facilitate ventilation, is far from a desirable
situation, the anaesthetist is able to ventilate the patient using only
basic equipment (a bag and mask), all the requisite equipment for
reintubation is ready to hand, and having already intubated the
patient once, the anaesthetist knows he is able to do so again if
necessary. To a considerable degree, therefore, the anaesthetists
actions are organised and legitimated by undertaking the familiar
checking procedures, even though they failed to conclusively
identify the problem before extubation. This is, however, the
thorny issue: it might seem reasonable and responsible to those
present with whom they share professional vision, and the decision may well be distributed, over time, throughout the routine
checks, and amongst participants, but accountability for this
82
action remains squarely with the anaesthetist. When issues of

professional accountability are questioned, it is often retrospectively, with action decontextualised and scrutinised by various
actors clinicians, managers, patients and relatives who dont
necessarily share professional vision.
In sum, this unconscious incoherent body is, not without
difficulty, nevertheless managed through routine practices.
I have drawn attention to the apparent lack of concern for what
could be considered an unwise action removing the tube whilst
the oxygen saturation levels are low and explained this in terms
of the participants shared professional vision; it simply didnt
need to be remarked upon because the ODP is as aware as the
anaesthetist that the routine checks proved fruitless and some
further action was necessary. And, in spite of the lack of comment, accountability was performed through the routine checks,
and, in this way, removing the tube was legitimated. I would,
however, like to make one further point. Although removing the
tube resolved the practical problem (in that the oxygen saturation measurements immediately climbed to an acceptable level),
it didnt actually solve the cognitive problem exactly how the
tube had been upsetting the patient was still a mystery.
Adamson (1997: 135) highlights how notions of medical
uncertainty are premised on the assumption that the problem
which is the source of the uncertainty can, in principle, be solved
either by the proper application of existing knowledge or by
clinical and scientific progress. Medical uncertainty, therefore,
presumes a coherent body in which a disease process unfolds in a
reasonably uniform manner. Problems for clinicians arise either
from missing information or around the interpretation of clinical
signs and symptoms and the application of scientific knowledge.
Drawing on recent expositions of multiplicity, however, leads
me to suggest that bodies do not always express themselves in a
coherent manner, which casts the problems that arise for
83
practitioners in a rather different light. It is not that there is an

integrated organized process unfolding within the body that
clinicians do not yet fully understand; it is more simply that
bodies arent always coherent. This, in turn, means that problems are not always reducible.
However, accepting that bodies may be incoherent does not
help the analyst to understand how this might be problematic for
clinicians. When incoherent bodies are not distributed but collected at one time and in one location and some action, treatment, or intervention is necessary, then clinicians must at least
try to reduce the conflict, and produce a body amenable to a
particular course of action. Furthermore, they must be confident
that their actions are warranted and will not harm the patient,
and they also must try to meet cultural expectations of certainty.
So this is the intersection I would now like to open up and
explore: how, in situations in which the body doesnt present
itself as a unified whole, and does not respond to routine care, do
clinicians organise and legitimate their actions. The next scenario lacks the overall organisation provided by the routine, and
instead practice is pieced together step by step. This, in turn,
promotes the visibility and prominence of the ways in which
practices are legitimated.
Incoherent Bodies and the Critical
The following scenario takes place in the intensive care unit. It

describes a critical period of a patients care. The patient is
reviewed during the morning ward round in which a consultant
anaesthetist, two junior doctors and several nurses discuss his
condition. The staff are aware that the patients condition is
deteriorating but are unable to identify precisely why. The
scenario spans approximately 2 hours, necessitating some editing
of the field notes, and this is indicated in italics, as are the
84
explanations that I have added. After intense work to isolate and

address the problems, and to stabilise the patients condition, the
consultant conveys the course of events to the family. These
scenes show how a team of practitioners work to align the
patients signs, symptoms, histories and measurements into a
convincing and coherent story, and it also shows how the
patients body resists such unifying logics.
The first scene begins with the nurses, student nurses, two
junior doctors (one surgical trainee and one anaesthetic trainee)
and a consultant anaesthetist, all scrutinising the patients chest
X-ray before reviewing the patient himself. They discuss
whether he might have a pneumothorax, a term used to describe
a leak in the lungs through which air escapes but remains trapped within the chest cavity, compressing the lung and preventing
proper inhalation.
Dr Williams (consultant anaesthetist) puts up some chest films and
discusses with the two junior doctors whether it shows a pneumothorax they conclude it does. Dr Davis (surgical trainee)
hands them another X-ray that they look at. A further two nurses
and one student nurse also gather around the X-rays. The consultant questions the nurses: If you saw this what would you
think? One of the nurses mentions that the trachy (tracheostomy
a surgical opening in the throat through which the patient is intubated
and ventilated) tube is pointing the wrong way.
Dr Williams: The trachy looks like it is in the wrong place. . . . Is
there anything we need to do in a rush because of this X-ray?
Dr Chatterji (anaesthetic trainee): No.
When first appraising the X-rays, two explanations for the

patients condition are discussed: Is the tracheostomy tube
wrongly positioned, and is there a pneumothorax present?
Crucially, however, whilst the X-ray may hint at these possibilities, the X-ray alone is not considered definitive enough to
85
warrant such invasive action. In a study about medical imaging,

Joyce (2005) explains that physicians integrate information from
a variety of sources, seldom relying on a single source to warrant
action. To do so means that they might treat a patient for a
disease that exists only in that particular source in this case, the
doctors might treat the patient for a pneumothorax that only
exists in the X-ray. Attention, therefore, turns from the X-ray to
the patient himself. The more elements that can be aligned, the
more persuasive the account.
At the patients bedside:
Dr Williams briefly recounts the patients history of care in the
ICU: . . . attempted tracheostomy . . . bleeding . . . Charlie (Dr
Davis surgical trainee) saved the day . . .
The nurse who answered the question about the trachy (I see from
her name badge she is called Lucy) gives a history of the last days
care: . . . CO2 keeps going up and up, it doesnt seem to matter
what you do to the ventilator . . . tachycardic (raised heart rate) . . .
Dr Williams: Why?
Lucy: Hes struggling. She continues with the history mentioning
the patients urine output, potassium levels, on TPN feeds (liquid
nutrition administered intravenously), no bowel sounds . . .
Dr Williams: Anyone examined him?
Dr Davis (surgical trainee) responds: Very quiet breath sounds,
CO2 retaining. I dont think hes getting rid of . . . (he turns to the
ventilator and points to the trace) . . . little notch there.
Dr Williams: Why is he . . . quick listen to his chest. He puts the
stethoscope to the patients chest then disconnects the ventilator.
Lucy: Did you mean to do that?
Dr Williams: Yes. What can you hear? (He listens by the tracheostomy.) . . . Big wheeze . . . basically his chest is full of gas . . .
chest is so full, cant get . . . (he feels the patients tummy) . . .
distended but . . . dont want any air trapping (in which the expiratory phase of respiration is not completed before the ventilator delivers
86
another breath, consequently air is trapped within the lungs) . . . 200
ml plus . . . chest getting bigger and bigger no matter what
pressures . . . expiratory wheeze . . . blood cultures . . .
Dr Williams and the two junior doctors discuss various aspects of the
patients condition and decide they need to change the pattern of ventilation.
In this scene, the team quickly focus on a problem with the

ventilation: high and climbing levels of carbon dioxide is the first
element mentioned both by the nurse and the junior doctor.
Aligning the carbon dioxide levels with an expiratory wheeze and
an expanded chest, Dr Williams, the consultant anaesthetist,
suggests air trapping may be the problem. Air trapping is a
common problem for ventilated intensive care patients. Accordingly, it seems the nurse has already considered this, pointing out
that the carbon dioxide levels remained high in spite of adjustments to the ventilator. In the first instance, then, uncertainty
over the patients condition is resolved in favour of a problem
routinely encountered. Practical and epistemological reasons for
this are entwined. As Atkinson (1984) points out, medical education promotes the conceptualisation of diagnosis as puzzles
with definitive solutions, a notion supported by the concentration,
during the training of student doctors, on hospital medicine in
which the ambiguity and diffuseness of health and illness in
general practice has already been filtered out. Consequently, the
nature of medical inference is often reductionist:
Whether the patients on the wards have a common complaint or an
unusual one, the chances are that they have got some well-established
observable and relatively discrete pathology. (Atkinson, 1984: 952)
In this, Atkinson also points to an intrinsically straightforward,

practical reason for focussing on a common problem that is, as
air trapping routinely affects many ventilated patients in
intensive care, it is highly probable that it also may be a problem
for this patient.
87
First, they increase the expiratory period on the ventilator settings then
discuss what to do if this doesnt improve the situation.
Dr Willliams interrupts: I wouldnt get him to breathe himself . . .
air trapping . . .
Dr Chatterji (anaesthetic trainee): You mean paralyse him?
Dr Williams: Yes. Give some atracurium (muscle relaxant drug)
now, just see if it works . . .
Dr Williams alters something on the ventilator. Lucy returns
with some ampoules of atracurium.
Lucy: 50 George (Dr Williams consultant anaesthetist)? She
injects.
Dr Williams: . . . if paralysed, well sedated, I think hes well
sedated . . . infected element, dont know what it is . . . paralyse and
ventilate. . . . Why is that going up and down? (He points to the . . .
screen)
Lucy: Not a smooth expiration.
Dr Williams: . . . just bag him. (He disconnects the ventilator and
connects a manual ventilation circuit.) Suction catheter.
Lucy feeds a catheter down the tracheostomy. Dr Williams disconnects the manual ventilation circuit and listens, head by the
patients throat. He presses with both hands on the patients chest.
Dr Williams: What can you hear?
Lucy: Nothing. She listens, her head by the patients throat.
Dr Williams: Hes still exhaling. (He reconnects the ventilator.)
Are we ventilating?
Dr Chatterji: No.
Dr Williams switches back to the manual ventilation circuit,
Dr Davis ventilates.
Dr Williams moves round to the head of the patient and removes a
pillow. He lifts the patients chin up and holds the tracheostomy
tube and takes over ventilating.
Dr Williams: Quite high pressure . . . do about 6 a minute. He
hands the bag back to Dr Davis who turns the valve on the circuit
and squeezes the bag with both hands.
88
Dr Williams: Air entry very quiet . . . give a nebuliser now.
Lucy: Salbutamol. (A drug inhaled to dilate the airways.)
Dr Williams: 10 ml of 1 in 10 000 adrenaline. Bronchoscope. . . .
Lets have another look at the X-ray, check we are not missing
anything. We all go back to the viewing box.
They decide to paralyse the patient, simplifying the situation by

bringing the patients breathing completely under mechanical
control, but still ventilation is problematic. They change the circuit
and ventilate manually, thereby excluding the machine from the
equation, but the pressure required to transfer oxygen from the
reservoir bag to the patients lungs remains high suggesting that the
difficulty is to be located within the patients body.
Disconnecting the circuit from the tracheostomy, the consultant and the nurse listen. The consultant states that the
patient is still exhaling, again performing a link between prolonged and difficult expiration and high carbon dioxide levels.
That the intensive care nurse is unable to hear anything suggests
that air-trapping although a common problem is not
self-evidently present. Goodwin (1994) describes how making
certain features visible or evident is a facet of professional vision
and achieved through the embodied work of the practitioner.
Thus, air-trapping is a diagnosis that has to be legitimated out
of somewhat ambiguous signs and symptoms.
Singletons (1998) study of the cervical screening programme
highlights how negotiating such ambiguities forms an integral
part of diagnostic work: looking at the laboratory practices
involved in the diagnosis of cervical cell samples, Singleton
identifies how not only do the cells change in ways that do not
easily fit the categories on the report card but that even where
cell changes are clear, the significance of the changes (whether
the changes relate to malignancy or not) is contentious. Furthermore, the diagnosis is not solely made on the appearance of
89
the cells, instead, the appearance of the cells is interpreted differently depending on the age and marital status of the woman
and on the number of children she has born. Singleton suggests
that the ability of the laboratory to detect precancerous changes
depends on its ability to accommodate instability and ambiguity
(1998: 102, my emphasis). This insight, that diagnostic work in
the laboratory demands engagement with uncertainties and
instabilities, also can be said of clinical diagnosis:
Diagnosis is never complete or definitive; it is a process of discovery
which unfolds over time. (Adamson, 1997: 142)
Whilst the notion of discovery might be problematic for an

STS readership,1 this quotation does at least emphasise the way
that a diagnosis does not irrevocably determine the ontology of
the patients body. Although diagnoses might, in part, organise
actions and care, diagnoses are done in ongoing contingent
performances that are always susceptible to change:
Initial diagnosis is regularly falsified by new clinical results or the
appearance of new symptoms. (Adamson, 1997: 149)
At this stage in the scenario, the staff are unable to make a

diagnosis of air-trapping convincing and so work intensively to
legitimate their interventions. Without a diagnosis, there is no
clear organising routine, and working outside a routine invokes
vulnerability, it implies that the correctness of the action needs
to be explicitly renegotiated: the legitimacy which comes as a
matter of course with a routine articulation is now absent (Berg,
1992: 17172). This, in turn, promotes the visibility and
prominence of the ways in which practices are legitimated and
made accountable: reasons for requested drugs are verbalised,
1
Discovery indicates that a patients pre-existing ontological status is revealed by the

doctor, whereas STS scholars might prefer to emphasise the inseparability of being
and knowing; see Barad (2007).
90
the bronchoscope, through which the lungs may be visualised, is

requested and the consultant returns to recheck the X-ray.
Dr Williams: Is there a pneumothorax there? He takes his glasses
off and peers very closely at the X-ray. He follows lines on the
X-ray with his finger.
Dr Davis: You can see a line superimposed. . . . I cant see a
pneumothorax. He points to the X-ray.
Dr Williams: If we cant ventilate him we are going to have to stick
drains in . . . this looks suspicious . . . He compares todays X-ray
to yesterdays. (At one point Dr Williams gets todays and yesterdays X-rays the wrong way round, Dr Davis corrects him.)
Dr Williams: The lung is much more hyperinflated today.
We all follow Dr Williams back to the patient.
The X-ray suggests, but cannot definitively confirm, a pneumothorax. The team are still, at this stage, unable to couple the
possibilities that the X-ray suggests and the symptoms the
patient exhibits tightly together; the mispositioned tracheostomy
tube, the pneumothorax, and the hyperinflated lungs all remain
separate and dissociated entities.
The Problem with Incoherent Bodies: How to Act?
Possibly, this search for a singular patient ontology is misguided.

As discussed earlier, Mol insists that bodies arent always
coherent. When treatment decisions are required, however, Mol
does acknowledges that:
the various realities of atherosclerosis are balanced, added up, subtracted. That, in one way or another, they are fused into a composite
whole. (Mol, 2002: 70)
The body in this scenario resists such coordination, refusing to

be either drawn together or distributed. Here, incompatibilities
are not dispersed between different sites, practices and times, but
91
collected together in one location, at one time, when treatment

decisions must be made urgently. Accordingly, the uncertainty is
such that the staff are still unwilling to act on these possibilities:
they do not want to risk inserting chest drains into a patient for a
pneumothorax that exists only in the X-ray. However, ventilation is now so difficult it may be necessary to take such actions in
spite of these misgivings: If we cant ventilate him we are going
to have to stick drains in. In this instance, certainty of knowledge and in actions, is invoked as something of a luxury an
ideal with the deteriorating condition of the patient forcing the
hand of the medical staff.
Dr Williams taps the patients chest, he asks for a stethoscope,
someone hands him one, and he listens to patients chest.
Dr Williams: 100% oxygen please . . . adrenaline, thats the concentrated stuff. The intensive care sister has just handed him a
syringe, he hands it back.
Sister: What did you ask for?
Dr Williams: 1: 10 000.
The ICU Sister returns with the prepacked syringe of adrenaline
and hands it to Dr Williams. He opens the blue plastic packet
and squirts about 1 ml down the tracheostomy tube. Dr Williams
watches the patient.
Lucy: What is that for?
Dr Williams: Severe bronchospasm . . . it acts directly to break
bronchospasm.
Another diagnosis bronchospasm is briefly considered for

which adrenaline is promptly administered. This is surprising
perhaps given doctors proclivity for acting on a number of
integrated sources; however, this intervention is easily implemented, carries little risk and seems to be undertaken more in an
attempt to eliminate bronchospasm from the frame rather than in
a serious effort to resolve the situation. Diagnosis, therefore, can
92
be seen as a process of delimiting a field of alternatives (Suchman, 2000: 318) rather than simply selecting and confirming a
favoured explanation. For this intervention, accountability, in the
ethnomethodological sense of demand for, and giving of, reasons
for conduct (Garfinkel, 1967) is readily established. The purpose
of adrenaline in this situation is questioned by the nurse and
quickly answered by Dr Williams. Unfortunately, this course of
action proves fruitless and Dr Williams comes back to consider
the insertion of chest drains.
Dr Williams listens again to the patients chest. He feeds the suction catheter down and back again. He ventilates using the
manual ventilation circuit, squeezing hard to empty the whole of
the bag.
Dr Davis brings in a foil tray containing some cannulae and puts a
pair of gloves on. (I think I heard Dr Williams mention cannulae
earlier.)
Dr Williams: Hyperinflated lungs . . . chance to exhale . . . if in
doubt do it.
Dr Davis inserts a cannula into the right side of the patients chest.
He removes the needle.
Dr Williams: Lovely hiss.
Lucy: Setting up for a chest drain
Dr Williams leaves, returning moments later with a syringe of
water, he attaches it to the cannula and removes the plunger I
can now see air bubbling furiously through the water.
Given the considerable ambiguity as to the source of the ventilation problems and the persistence of doubt as to the presence
of a pneumothorax, some further warrant is necessary for the
insertion of chest drains. The increasing difficulty in ventilation
means that this warrant is urgently required, consequently, a
cannula is inserted into the patients chest. The cannula is a
quick and temporary measure, only to determine the presence of
93
a pneumothorax. The comment: lovely hiss confirms the

assumption of a pneumothorax, and is visually reinforced by the
sight of air, which had been trapped within the chest cavity,
bubbling through the water in the syringe. With these events
and interactions, it is obvious to all present that the insertion of
chest drains are necessary interventions as signified by the nurses comment: setting up for a chest drain.
A cannula inserted into the left side of the patients chest confirms the
presence of a further pneumothorax and, under the supervision of Dr
Williams, Dr Davis and Dr Chatterji insert a chest drain in each side.
Following this the bronchoscope arrives:
Dr Williams feeds the bronchoscope down the tracheostomy: No
obstruction in the right main bronchus . . . end of the tube stuck
up against the wall . . . try ventilating now . . . any easier?
Lucy: No.
Dr Williams offers the eyepiece of the bronchoscope to Lucy who
looks down it.
Dr Williams: Youre ventilating against that. . . . Having a bit of a
problem . . . get a tube handy . . .
Dr Davis leaves. Dr Hargreaves (another consultant anaesthetist)
enters.
Lucy: Crash trolley please! She says this loudly, directed outside
curtains. (Crash trolley contains resuscitation equipment)
Dr Williams briefs Dr Hargreaves on their actions this morning
regarding this patient.
Crash trolley wheeled in by the intensive care sister.
Dr Williams: Take the trachy right out . . .
Dr Hargreaves: When the bronchoscope was down what did you
see . . . He continues questioning Dr Williams.
Dr Williams: Ventilation very, very difficult . . . bronchoscope . . .
against the posterior wall . . .
Lucy ventilates. Dr Chatterji stitches in the chest drain.
Dr Hargreaves: Would a tube be easier?
94
Dr Williams: You would know the tube would be pointing straight
down . . . basically disconnect from the ventilator . . . long, long
expiratory . . .
Dr Hargreaves: Not paralysed?
Dr Williams: We paralysed about 40 minutes ago. I think change
the tube . . . just see . . .
Dr Hargreaves: Id be surprised if it makes a difference
Dr Williams stands at the head, holding the patients chin up and
looking down at the patients chest, frowning.
The arrival of the bronchoscope a device that allows internal

visualisation of the lungs enables Dr Williams to see that the
end of the tracheostomy tube is pressed against the wall of the
trachea thereby preventing exhalation. Finally, the X-ray no
longer stands alone in suggesting a mispositioned tracheostomy,
the bronchoscope provides visual affirmation of how it is mispositioned which explains why it is causing a problem: under
positive pressure, air could be forced into the lungs, but with the
end of the tracheostomy tube abutting the wall of the trachea, air
couldnt escape. For Dr Williams, this sight provides sufficient
evidence to convince him to change the tracheostomy tube to an
endotracheal tube. Not being privy to all the previous checks and
attempts to elucidate this situation, some doubt still exists for the
second consultant, Dr Hargreaves. This, again, indicates the
tension between how accountability is interactionally achieved
amongst co-participants, and accountability in the sense of giving an abbreviated, somewhat decontextualised, summary of
events for the judgement of others.
After further discussion with Dr Hargreaves over the type of tube to be
used, Dr Williams decides to change the tracheostomy tube for a normal
endotracheal tube. Before they can do so the X-ray team arrive and take
a chest X-ray of the patient.
95
We all move back over to the bedside. Dr Chatterji listens to the

patients chest with a stethoscope. Dr Williams moves up to the
head of the patient and takes over ventilating, he lays the patient flat.
Dr Williams: Lets just put down a normal tube first of all.
Dr Davis: Do you want sux going in now? (Suxamethonium a
paralysing drug to allow intubation)
Dr Williams: Yes please. He inserts the laryngoscope, then the
tube into the patients mouth but does not yet advance the tube
down to the trachea. Ready to take the trachy out in a minute?
Sister: Tell me when to deflate.
Dr Williams: Is it stitched in?
Sister: Shit.
Dr Williams: Stitch cutter. (Loudly, directed outside the curtains.)
The sister cuts the stitches whilst holding the tracheostomy tube
in place.
I look at the monitor oxygen saturation reading 75%.
Dr Williams intubates then connects the manual circuit and ventilates: That feels better. . . . Aspirate on the NG (nasogastric tube).
Dr Hargreaves: Saturation coming up nicely. Oxygen saturation is
now 86%.
The sister directs Dr Chatterji on how to tape the chest drain
down. (Patient looks pink again now.)
Dr Hargreaves: 89% . . .
Dr Williams: Charlie (Dr Davis surgical trainee), try and ventilate.
Dr Hargreaves: Everything under control from the monitor. He
stands next to me at the bottom end of the bed.
Dr Williams: See what the X-ray shows . . .
Dr Hargreaves: Ill go down (to the X-ray department) and have a
look.
Dr Williams bronchoscopes again, down the tube this time.
Three nurses work at securing everything the endotracheal
tube, chest drains, etc. (The atmosphere is calmer now, around
the time of intubation it felt tense).
96
Whilst this securing work continues Dr Hargreaves (the second consultant anaesthetist) returns to report that the X-ray shows two
pneumothoraces requiring a further two chest drains. These are inserted
by Dr Davis and Dr Chatterji under Dr Williams supervision.
Dr Williams says that he needs to talk to the patients family and asks
Lucy to accompany him.
The critical situation begins to resolve as a result of exchanging

the tracheostomy tube for an endotracheal tube. In a study about
how radiologists construct accountability, Yakel (2001) refers to
the sense in which accountability is commonly taken as something accomplished in, and represented by, a written record.
Instead, and in line with the ethnomethodological sense of
accountability, she suggests that accountability is achieved
through a process of interactions between people and artefacts.
This scene shows the process of accounting for the exchange of
tubes as the correct and appropriate action. Dr Williams comments immediately that ventilation feels better and he invites
Dr Davis to share this observation, Dr Hargreaves attends to the
oxygen saturation readings provided by the monitoring,
highlighting the improvement and acknowledging that the
critical situation is beginning to come under control. Dr Williams visually checks again with the bronchoscope and Dr
Hargreaves checks the X-ray. It is, therefore, a matter of public
consensus, produced through the interactions between the team
and the technologies, that this intervention is legitimated and
becomes accountable as the appropriate action, and the misplaced tracheostomy tube as one of the correct diagnoses.
Tracing the Threads of Accountability
Adamson (1997) points out that diagnosis is a process of trial and

error and that there is no such thing as an incorrect diagnosis in the
present: a diagnosis only becomes wrong with the passing of time
97
(1997: 149). Both this scenario and the earlier one suggest that the
reverse also could be said that a correct diagnosis is something
that can only be established in retrospect. Perhaps it is more
generally that the veracity of a diagnosis whether correct or
not can only be a post-hoc attribution. This is not to say that
doctors are not concerned prospectively with the accuracy of
their diagnoses. This scenario shows the clinicians reluctance to
act without proper warrants especially when care lacks the organisation and security of a routine. Legitimating and accounting
for actions, by explicitly identifying the warrants for interventions
and the recognition of these amongst the team, not only enables
the doctor to be convinced they are acting appropriately but also
renders publicly available the accountability of these actions.
Neyland and Woolgar direct attention to how this distinct
ethnomethodological sense of accountability feeds into the specific
sense of professional accountability:
That actions are rendered recognizable now increasingly means that
they should be tested for the adequacy of their production. (Neyland
and Woolgar, 2002: 263, original italics)
However, some ambiguity persists as to whom accountability is

owed. The particular public to which actions are rendered
accountable is often unspecified and varies considerably in ethnomethodological studies of accountability (Neyland and
Woolgar, 2002). Moreover, Neyland and Woolgar point out
that the nature of the public observation involved also varies:
It is not always clear whether accountability involves the mere recognizability of actions (for example, that it is an answer to a question)
or whether it also involves sanctionable consequences. (Neyland and
Woolgar, 2002: 263)
And this, it seems, is the distinction between the ethnomethodological sense of accountability and the professional one. Thus
far, I have concentrated on how accountability is interactionally
98
achieved amongst participants and have only alluded to the

implications beyond the immediate setting in that participants
may be aware that their actions might later be inspected by yet
unspecified persons in unspecified situations. This scenario,
however, illustrates the connections between different audiences
and how the different senses of accountability are related. When
it became clear that the patients condition was deteriorating
rapidly the consultant, Dr Williams, requested that the nurses
contact the patients relatives and ask them to come in. They
were waiting in the relatives room:
Dr Williams, Lucy and I leave the intensive care unit and walk a short
distance down the corridor to the relatives room. It is a smallish room with
a kitchen area and sitting area. The family a young man, mid-late 20s
(son) and an older woman (wife) are seated drinking tea.
Dr Williams sits in the far corner of the room facing them both,
Lucy sits on the sofa next to the son and I stand behind Lucy
(because there are no more seats). Dr Williams introduces us all, he
tells them that the patient is stable now but earlier on they had had
some difficulties. He begins by going back to the previous day when
the tracheostomy was inserted then talks them through todays
events when they had difficulty ventilating. He explains that this
may have been for two reasons: firstly, the tracheostomy was
pressed against the wall of the trachea, so they have changed from
the tracheostomy back to a tube going in the mouth and down into
the throat. The other reason was a pneumothorax. Dr Williams
explains that a pneumothorax is a small hole in the lung that leaks
out a pocket of air that then compresses the lung. He said at one
point the patients oxygen saturation, which they like to keep at
around 100, went down to about 75% for a period of about 4 or 5
minutes, Dr Williams said they were really struggling during this
period. He continues that they have now changed to an endotracheal tube, which goes into the mouth and down the throat, and put
chest drains in each side, and explains that the patients oxygen
saturation is now back up to 98%.
The relatives express relief, exhale slowly: thank you doctor.
99
Dr Williams goes on: I have to be honest with you, at one point it

was touch and go, and I thought we were going to lose him. The
wife remains silent but is visibly shocked by this news.
Dr Williams describes what the patient now looks like: He has 4
drains in (gestures where they are) and a tube down his throat.
Dr Williams asks the family to wait a few minutes longer whilst they clear
up the equipment after which the relatives could see the patient. Dr
Williams, Lucy and I go back to ICU.
When the consultant anaesthetist talks with the patients

family the account is necessarily simplified so as not to overload the family with superfluous medical details. The consultant conveys only those diagnoses and interventions that have
been retrospectively verified as correct, appropriate and
accountable actions the mispositioned tracheostomy tube and
the pneumothoraces as causes for the patients condition.
Here, then, the search for a unifying ontology is abandoned and
the patient is presented as having two separate diagnoses that coexist but dont cohere. There is no longer any need to unite these
problems, each diagnosis and associated interventions has been
warranted and legitimated separately by a number of different
sources.
The consultants explanations are oriented to giving the
family a reasonable understanding of the events the physiological problem with the patients body (a hole in the lungs), the
difficulties with the technological device (the tracheostomy tube
pressed against the wall of the trachea) and the interventions
incurred (insertion of chest drains and an endotracheal tube).
But, notwithstanding this simplification, Dr Williams takes care
to convey some very specific details: that the oxygen saturation
fell to approximately 75% for a period of 4 or 5 minutes. He
doesnt elaborate on the meaning of this but uses this detail to
emphasise the criticality of this period. It is possible that here he
is oriented to a potential future state of the patient, and potential
100
future discussions with the family in which he may have to

account for any sequelae of this period of desaturation. After
confirming that the ventilation problems are now resolved and
the oxygen saturation levels are now 98%, Dr Williams again
emphasises the severity of the situation: I thought we were
going to lose him. To those present, with experience and
training in critical care, this neednt be verbalised, but
accountability goes beyond those present, and the very real
possibility that the patient might have died has, in Dr Williams
opinion, to be made recognisable to the relatives.2
Incoherence and Accountability in Tension
When issues of professional accountability are questioned, it is

often done retrospectively, with action decontextualised and
scrutinised by various actors clinicians, managers, patients and
relatives who were not necessarily involved in the contested
situation, nor will they necessarily share the professional vision
of those practitioners involved. Therefore, what is visible to the
competent practitioner will not be obvious to the uninitiated,
nor will all the relevant features necessarily be highlighted in
written accounts. In adjudicating on matters of professional
accountability, codes of conduct,3 or technologies of
2
The suggestion that the severity of the situation neednt be verbalised to those
present, all of whom had experience of critical care, stems from a debriefing interview
with Dr Williams, in which he talked through the observation transcript. In this, he
states: I do believe in being honest with people and saying, you know, I thought we
were going to lose him. I thought at one stage he was going to die. I think you did (to
DG). We all thought that at one point, though that was never actually said whilst we
were doing things.
3
For doctors in the United kingdom, the General Medical Council produced a document is known as Good Medical Practice, in addition to which the Royal Colleges
also produce further specialty-specific guidance; for example, the Royal College of
Anaesthetists and Association of Anaesthetists jointly produce Good Practice
guides. Nurses in the United Kingdom are guided by the Nursing and Midwifery
Councils Code of Professional Conduct with additional advice sheets on
accountability.
101
coordination and control as they have been termed (Suchman,

2007: 277), serve as a measure against which practice may be
compared. The argument, following many other critiques, most
notably Suchman (1987, 2007), is that the cognitive model of
decision making and action on which these documents are based
emphasises the control of practitioners and as such does not map
onto practice very well. I suggest that this causes a particular
problem for practitioners where accountability is concerned: by
focussing primarily on the actions of individual practitioners,
other significant elements of practice (such as the agency of
unconscious bodies and technologies) are erased. As Hutchins
suggests, these texts over-attribute knowledge to individual actors:
when the context of cognition is ignored, it is impossible to see the
contribution of structure in the environment, in artifacts, and in other
people to the organization of mental processes. (Hutchins, 1996: 62)
My aim, in this chapter, has been to illustrate, in line with recent

moves in STS, the incoherences that form an integral part of
medical practices. As I have said, the disunity of medical practices, medical knowledge, objects, devices and bodies is a theme
that has come under significant analytical attention in recent
years; however, I have endeavoured to add accountability into
this analytical frame, and to highlight the elements of risk
involved in working in such complex, dynamic, multifaceted
situations, and how these risks are addressed by practitioners.
The first scenario shows how routine practices guide the
anaesthetist into practicing safely and accountably. The skill of
the anaesthetist lies less in the detective work of determining the
diagnosis and more in learning what constitutes the boundaries
of normal. A practitioner is expected to account clearly and
concisely for events, but even in very mundane situations,
patients bodies do not always comply by presenting a clear,
concise, and coherent set of signs and symptoms. Routine checks
102
provide a sense of security here, and as checking becomes a

familiar, regular activity it becomes both ingrained in practice,
and the sense of certainty it provides becomes expected of
practice. Certainty in knowing and doing is highly valued in
health care settings.
The second scenario shows just how recalcitrant bodies and
technologies can be in resisting attempts to align them. In this
scenario, an experienced anaesthetist struggles to account for the
cause of the patients low oxygen saturation. Routine checks in
this case provide security only insofar as they establish further
action is necessary. Here, the anaesthetist must act with considerable uncertainty. He suspects a problem with the endotracheal tube but cannot confirm quite what the problem is, and,
without a cause, he cannot be sure what the appropriate response
should be. Here, accountability can be delineated into its ethnomethodological and professional senses. In the ethnomethodological sense, accountability is achieved in part through shared
professional vision. It is understood by those present that further
action is warranted, and in the light of more favourable options
being exhausted, removing the tube is an intelligible and reasonable response that one way or the other is likely to elucidate
the situation. In the professional sense, accountability is wanting.
There seems to be almost no convincing (objective) reason to
suspect a problem with the tube it is correctly positioned,
ventilating both lungs, clear of secretions, and has adequately
ventilated the patient throughout surgery. Scrutinising this event
retrospectively, it would be easy to construct the removal of the
tube as unwise. How far notions of expertise, tacit knowledge
and professional vision would go to support the anaesthetists
actions would depend in large part on the degree to which they
could be articulated.
In the final scenario, the problem with incoherent bodies
comes into focus: bodies that offer multiple, plausible but
103
incompatible explanations for their presentation do not provide

a lead for action. The lack of an organising script a routine
means that a course of action must be pieced together and
clinicians must work overtly to legitimate and account, as far as
is possible, each step, action or intervention. In the final scenario rationales for action were frequently verbalised, the consultant showed great care to organise the teams actions step by
step, and accountability was explicitly achieved. Events were
observed and commented upon decidedly witnessed. This
scenario demonstrates how the omnipresent sense of accountability in which health care is practiced, relates to a more formal
sense of professional accountability in which actions may be
retrospectively inspected, judged and potentially followed by
professional and legal sanctions. This final scenario showed that
whereas certainty may be highly valued, it is also an ideal, and in
some circumstances, practice, actions and interventions must go
on in spite of intense uncertainty. This creates vulnerabilities for
practitioners in respect of accountability. These vulnerabilities
are in part countered by the more explicit witnessing of events
that goes on between participants in critical circumstances as
compared to routine practice.
Neyland and Woolgar (2002) suggest that ethnomethodological studies of accountability tend to take the relevant public
to be the body of immediately co-present participants and are
often unclear about whether and how different kinds of audiences are implicated. The final scenario shows that health care
professionals operate with a broader notion of accountability,
one that extends beyond the immediate environment. Even
whilst engaged in a critical period of care, the practitioners
demonstrated an awareness of another public the relatives
and in fact asked for them to be called in. Furthermore, in discussions with the relatives, it seems possible that certain details
were conveyed in order to foreground potential future
104
discussions. Without elaborating on the meanings, the anaesthetist plants precise details such as the level of oxygen saturation and the number of minutes. As Garfinkel points out, a
situation is informed by its history and its future: By waiting to
see what will have happened he learns what it was he previously
saw (Garfinkel, 1967: 77). Accordingly, the anaesthetist does not
know, at this time, the consequences of this critical period but is
no doubt aware that there may be some that he will subsequently
have to explain. Finally, then, this suggests that although the
appropriateness of actions, for example the correctness of a
diagnosis, is a post-hoc achievement, this doesnt prevent health
care professionals from being prospectively oriented from
acting in anticipation.
The development of understanding clinical practice as a
process of distributed decision making, with decisions shared
amongst humans, devices and routine practices has been an
incisive analytical resource within STS, but it fails to acknowledge that practice may not necessarily be viewed this way when
questions of professional accountability are raised. In these circumstances, practice is often scrutinised retrospectively, with
actions decontextualised and contrasted against ideal models of
practice inscribed into guidelines and codes of conduct. I have
aimed to highlight the tensions between understanding practice
as something fluid, unstable and multiple and the expectations of
certainty inherent in health care practices and the need to act
sometimes in the absence of such certainty. By tracing the different manifestations of accountability and the links between
them, it is possible to discern how and why disunities must, on
some occasions, be addressed, not necessarily made to cohere,
but in some way be comprehended so that actions can be made
accountable.
Teamwork, Participation and Boundaries*
Anaesthesia is, of course, not accomplished by the anaesthetist

alone. The patient, even when unconscious, can be seen to play an
active role, and in terms of understanding these rather ambiguous
expressions and rendering accountable ensuing actions and interventions, the activities of nurses and ODPs are deeply implicated.
In the previous chapter, however, the participation of nurses and
ODPs passed largely without discussion. In this chapter, I address
this issue directly, focussing closely on the participation of nurses
and ODPs and the scope these practitioners have to inform and
shape anaesthetic care. I am interested to elucidate how anaesthetic practice is partitioned across different workers and how
different agencies, knowledges and practices are imbricated and
interwoven in the organisation and delivery of health care. I am
also interested in the limits to the participation and practice of
nurses and ODPs, how these limits are enacted, supported and
transgressed, and the consequences or effects of doing so.
Knowledge, Work and Multidisciplinary Teams in Health Care
The term multidisciplinary teamwork does not do justice to the

complexities and intricacies of the processes it purports to
* An earlier version of this chapter was published as Goodwin, D, Pope, C, Mort, M
and Smith, A (2005) Access, Boundaries and their effects: legitimate participation in
anaesthesia. Sociology of Health and Illness, 27 (6): 855871.
105
106
describe. DiPalma (2004) points out that the common-sense

notion of teamwork is too simplistic, conveying an overly orderly
and predictable process. And as I indicated in the first chapter,
neither is there anything straightforward about the composition
of multidisciplinary teams; on the contrary, the members of the
team will vary considerably and whilst each participant will have a
given role, there also will be overlaps between the skills and
knowledges of the practitioners, enabling them to flexibly cover
certain tasks as needs and circumstances dictate. Indeed, these
overlaps between the knowledge, skills, abilities and practices of
different health care practitioners (most particularly doctors and
nurses) and the distinctions aimed at discerning the boundaries
between them has been an enduring topic of sociological debate.
Steins (1967) influential account of the doctor-nurse game
draws on his own experience as a physician to describe how
nurses learn to offer advice whilst apparently remaining deferential to the doctors authority. Nurses use both non-verbal and
verbal cues to subtly communicate recommendations, which in
retrospect appear to have been initiated by the doctor. The
game aim is to avoid direct confrontation, with the doctor
gaining from the nurses experience and the nurse gaining satisfaction from her influence on patient care. Whilst elements of
this game are still flourishing according to more contemporary
analyses of health care (Prowse and Allen, 2002), there also have
been important qualifications made on this theme. Hughes
(1988), for example, proposed that doctor-nurse interactions be
understood as a gradient of behaviour. In casualty departments,
Hughes observed that nurses were much less preoccupied with
concealing their suggestions, frequently offering advice in an
open and straightforward way. These breakdowns of deference
(Hughes, 1988: 17), however, almost always involved junior,
relatively inexperienced, overseas doctors. Prowse and Allen
(2002) add a further caveat to the doctor-nurse game, that of
Teamwork, Participation and Boundaries
107
emergency situations. In routine practice, nurses adopted

indirect interactional styles, such as prompting and guiding, that
were respectful of doctors professional turf, whereas in
emergency situations, nurses described interactional styles that
were more challenging and directive. Prowse and Allen (2002)
identify that although doctors are educated to a higher level in
the biological sciences, the social organisation of work in the
PACU (Post-Anaesthesia Care Unit what is referred to in this
book as Recovery) leads to a situation in which nurses have
greater experience giving them a clinical feel not shared by
their medical colleagues. The quality and characteristics of such
experiential knowledge and the potential for it to inform practice
is discussed later in the analysis. The salient point here is the way
that the distribution of work delineates distinct realms of
knowledge a process that Anspach (1987) has termed an
ecology of knowledge.
Anspach proposes that the reason for differentiation between
medical and nursing knowledge lies in the character of work
each group experiences. Doctors and nurses engage in different
sets of daily experiences that define the character of knowledge
available to them. On studying the prognostic decision-making
process in a neonatal intensive care unit Anspach found that
physicians relied heavily on diagnostic technology, placing little
confidence in their intuitive judgements, because of their limited
contact with patients. Nurses, by contrast, relied upon cues that
they gleaned from continuous interactions with infants, characterising them as gut feelings. Anspach points out, however,
that in terms of decision making, there is a disparity in the
influence these forms of knowledge command:
the types of prognostic knowledge used in life-and-death decisions are
not valued equally (. . .) technological cues and interactive cues do not
carry equal weight within the realm of medical discourse. Despite the
fact that nurses have access to certain aspects of an infants behaviour
108
which is not available to the other participants, the interactive cues

noted by the nurses are devalued data. (Anspach, 1987: 229, original
emphasis)
Anspach concludes that through the distribution of work in the

neonatal unit physicians become structurally disengaged from
the infants and their families, and being distanced they rely on
technological diagnostic data in their prognostic decision making. In the interests of more informed and equitable decision
making, Anspach argues for a social structure that facilitates
greater interaction among physicians parents and patients, and
for a more inclusive criteria of certainty (1987: 229) that would
permit the use of intuitive judgements.
Svensson (1996: 384) also recognised that nurses get to know
and observe the patient in an entirely different way from doctors.
However, he argues that this does not disadvantage nurses; on the
contrary, doctors have come to depend on this knowledge.
Changes in the health care context such as the increasing profile
of the social prompted by the prevalence of chronic illness and
the reorganisation of nursing work from task allocation to a form
of team nursing have resulted in nurses cultivating a more comprehensive knowledge of the patient, and instead of the ward sister
acting as an intermediary, nurses and doctors now communicate
directly. Despite these developments, Svensson indicates that
nurses are still wary of encroaching on medical terrain:
Many (nurses) emphasise that they are somewhat careful when it comes
to the purely medical. This is viewed as intruding upon anothers area
of competence, and as calling for some caution against presenting
oneself in a way that appears challenging. (Svensson, 1996: 388)
The boundary between medicine and nursing knowledge may

have shifted, allowing nurses more opportunity for negotiation
and intervention in decision making, but there remains a
reluctance to transgress nursing-medical boundaries without the
(perhaps tacit) invitation or consent of the doctor.
109
Allen (1997) draws out the intricacies of the negotiations

around a nursing-medical boundary, and she found that when
interviewed nurses frequently recounted episodes in which the
boundaries of their practice were contested; however, when
observing the nurses at work, Allen noted that all health care
professionals practiced with minimal inter-occupational negotiation and little explicit conflict (Allen, 1997: 505). Allen
interprets this discrepancy as a reflection of the nurses efforts to
demonstrate control over the boundaries of their work; in an
attempt to establish their autonomy, nurses insisted they could
choose whether or not to accept doctor-devolved work. It
appears, however, that within the constraints of the ward situation and the informal influence they wielded over treatment
decisions anyway, choosing to accept additional work was the
most feasible option with nurses regularly undertaking a range of
duties that fall outside the formal boundaries of their role.
Nevertheless, the lack of overt inter-occupational negotiation or
conflict did not correspond to a blanket acceptance of doctors
devolved activities; rather, nurses acquiesced only when doctors
were unavailable:
Nurses, however, had not simply incorporated this work into their
everyday practice; rather, they undertook informal boundary-blurring
work when the doctor was unavailable. When doctors were physically
present on the ward, nursing staff adhered to hospital policy and asked
the doctor to carry out these tasks. (Allen, 1997: 51112)
The shift in the boundaries of nurses and doctors responsibilities cannot simply be described as a delegation of medical
responsibilities to nurses; it was more of a practical response to
the organisational difficulties nurses experienced, such as actually getting doctors to the ward, coupled with the acknowledgement of the heavy workload doctors faced. Moreover, it is a
cautious response with experienced nurses far more likely to blur
occupational boundaries than junior staff. Because they were
110
more advanced in skill and knowledge, they were better placed to

undertake this work, but these nurses also were influenced by the
degree of confidence they had in their relationships with individual doctors: nurses were more likely to break the rules for
doctors they trusted (Allen, 1997: 512). Allens phrase break the
rules points to the vulnerability nurses are exposed to when
undertaking additional duties nurses are unsupported by
organisational policies and potentially susceptible to disciplinary
action.
Tjora (2000) examines the boundary-spanning activities
performed by nurses in Norwegian emergency communication
centres (AMK centres) in which nurses handle requests for
medical assistance both in emergency cases (when an ambulance
or helicopter may be needed) and in routine cases (where a visit
from a primary care doctor is requested). In prioritising doctors
calls, nurses are required to use the framework provided by the
Norwegian Index for Medical Emergency Assistance (NI).
However, many nurses dislike this inflexible tool, as it binds
them to rigid rules for categorising patients. Tjora observes how
the NI seeks to pre-programme nursing work according to an
idealised model of individual decision making, whereas, in
practice, decision making is frequently socially accomplished in
collaboration between two or more nurses using their own
knowledge and experience, and with the NI reserved for a postdecision check to verify their decisions. As in the doctor-nurse
game, Tjora found that when prioritising emergency visits
nurses would construct descriptions of patients in particular
terms so as to convey their impressions of how serious cases are
and in what sequence the doctor should handle them. When
doctors were unavailable, nurses would regularly draw on professional experience and pooled knowledge of colleagues to try
to diagnose patients conditions over the phone (Tjora, 2000:
733). Like Allen, Tjora specifies that this boundary-spanning
111
activity only occurs when there is no medical assistance available.

Furthermore, peer support was essential. He found nurses would
regularly pool their knowledge to work collaboratively in this
activity. Joint-competence, he posits feels safer than ones own
competence, even when all team members possess similar expertise (Tjora, 2000: 733). Again, the term feels safer alludes to a
sense in which the status of this boundary-spanning work is
similarly uncertain and fraught with risk for nurses. The value of
this boundary-spanning activity lies in the economic and optimal
use of doctors time (Tjora, 2000) which suggests both a breach in
the system that nurses feel obliged to bridge and the integral
nature of this boundary spanning work for the smooth running of
a system. However, this work and knowledge escapes recognition
with nurses being inhibited from using the term diagnosis:
That they (nurses) do not define these tasks as diagnosis may reflect a
political need to keep a low profile, but underestimates the complexity
of the judgements they make. (Tjora, 2000: 736)
This discussion gives an indication of how the distribution of

work amongst health care practitioners is often organised
around flexible and tacit arrangements. The character of the
work may change subtly depending on the practitioner who
undertakes it, and the work may be labelled differently. As such,
the delicate ordering of work through which practitioners
coordinate their activities is rarely scrutinised in the literature
concerned with health care teams (Hindmarsh and Pilnick,
2002). Instead, Hindmarsh and Pilnick (2002: 141) suggest that
the focus on team constitution and power relations tends to
gloss the tacit practices of in situ collaboration and teamwork.
Thus, they examine the accomplishment of teamwork in
anaesthesia, showing how anaesthetists and ODPs are simultaneously attentive to one anothers actions and respond accordingly whilst engaged in seemingly individual tasks. Anaesthetists
112
and ODPs will read the implications of a colleagues activities

for their own work demonstrating an intimate sensitivity to the
trajectory of colleagues actions (Hindmarsh and Pilnick, 2002:
149). Consequently, an ODP witnessing an anaesthetist beginning to engage in a particular activity can predict and coordinate
with the sequence of actions that routinely follows. Similarly,
talk, ostensibly directed at the patient, also may serve to camouflage collaboration with colleagues, as it is closely coupled
with a response on the part of a colleague. Developing this
familiarity with different practitioners activities is integral to
learning to practice ones own role effectively:
Part of learning to be an anaesthetist or an ODP is about developing
expertise in reading the embodied conduct of colleagues. The uninitiated do not have an intimate understanding of the potential or likely
trajectories of action that will emerge when a colleague has picked up a
gas mask, lifts a mask from the face of the patient or approaches with a
syringe at particular moments within the anaesthetic room activities.
(Hindmarsh and Pilnick, 2002: 152)
Learning largely occurs in everyday practices, in the flow of

experience, with or without explicit awareness (Gherardi, 2000),
and so to focus on the process of learning and participation can
yield important insights into the organisation and practice of
teamworking.
Understanding Teamwork through Learning and Participation
For Lave and Wenger (1991: 115), learning and a sense of

identity are inseparable: They are aspects of the same phenomenon. The learner is a newcomer whose evolving knowledge, skill and discourse are part of a developing identity in a
community of practice. A community of practice has three
dimensions. In the first mutual engagement participants
work together contributing to a dense network of working
113
relationships. The second dimension is a joint enterprise; this is

the lynchpin holding the community together. This is not a
given objective, it is the result of collective negotiation. Third,
the community must have a shared repertoire of routines,
words, tools, ways of working, stories, gestures, symbols and
actions that emphasises its rehearsed character and the opportunity for further engagement (Wenger, 1998). Lave and
Wengers (1991) study of apprentices and Wengers (1998) later
study focussed on single occupations. I am proposing that
anaesthetic practice composed of anaesthetists, nurses and
ODPs and various other marginal members, also can be
understood as a community of practice. To view anaesthetists,
ODPs and nurses as belonging to different (overlapping, perhaps) communities of practice belies their joint enterprise that
of ensuring safe anaesthetic care of the patient before, during
and after surgery. However, as I will discuss later, when practitioners from different disciplines form a community of practice
the boundaries within the community become important.
Wenger (1998: 11920) discusses boundaries as shaping the
edges of a community of practice:
Boundaries no matter how negotiable or unspoken refer to discontinuities, to lines of distinction between inside and outside, membership and non-membership, inclusion and exclusion.
Consequently, the production and effects of boundaries within a

community of practice are subjects that have received little
attention.
A community of practice, then, provides the newcomer with
the resources to interpret and make sense of members work
practices. Only by participating in practice can newcomers
access these learning resources and opportunities. The characteristics and potential for learning, therefore, depends upon
the structure and workings of the community. Lave and Wenger
114
suggest that learning occurs through centripetal participation

in the learning curriculum of the community. For Lave and
Wenger, a learning curriculum is not a set of dictates outlining
the skills or competencies inherent in proper practice, rather, a
learning curriculum unfolds in opportunities for engagement in
practice. Centripetal participation refers to the process
whereby individuals move through varying levels of participation, their identity evolving as they do so. Increasing levels of
participation furnishes them with different perspectives from
which to interpret practice:
Viewpoints from which to understand the practice evolve through
changing participation in the division of labor, changing relations to
ongoing community practices, and changing social relations in the
community. (Lave and Wenger, 1991: 56)
Although Lave and Wenger concentrate on apprentices as they

develop into experts hence the term centripetal meaning
movement towards the centre or a central identity this concept
is also useful in analysing the contributions of different types of
practitioners that make up a community of practice as it highlights the way that nurses and ODPs participation is constrained by the boundaries of their discipline. Furthermore, the
peripheral in legitimate peripheral participation underscores
these multiple decentred perspectives, overlapping learning
trajectories and the limits to their development.
Access, Boundaries and Their Effects
I will now follow some of the conflicts and struggles that

occurred when the boundaries of a nurses or ODPs practice
were called into question. These boundary disputes bring to
light some of the issues Lave and Wenger highlight as integral to
the process of learning as they are enacted in the anaesthetic
community of practice: the fickle rights of access, the varying
115
levels of legitimate participation, the effects of limited participation on knowledge resources and the ensuing potential to
inform anaesthetic practice.
Regulating Access: Preserving Practices
The anaesthetic room, a small room adjoining the operating

theatre, is the location in which the intricate work of inducing
anaesthesia occurs. Access to this room and the practice therein
is usually limited to those participants who have a practical
function to perform. A routine paediatric operating list takes
place in the following scenario. There are two anaesthetists, one
consultant, Dr Graham Hesketh, and one specialist registrar,
Dr Fatima Mani, who is approaching the end of her 7-year
anaesthetic training programme, and a senior ODP, Steve
Didsbury. For reasons of expediency, the surgeon wants to
perform the first procedure the extraction of two teeth in the
anaesthetic room. The consultant anaesthetist does not object
but the ODP does. As we join the scenario the child has only just
been anaesthetised. For young children, induction is usually
performed with the parent sat on a stool by the anaesthetic
machine holding the child. Once unconscious, the child is lifted
onto the trolley and the parent leaves. As in this case, the
application of routine monitoring devices before inducing
anaesthesia is sometimes waived for young children, with the
monitoring being applied immediately after induction.
The stool is moved and the trolley wheeled towards the anaesthetic machine, Mum and ward nurse leave. The surgeon enters
and goes round to the right hand side of the patient (between the
patient and the counter). The theatre sister enters and shows
Dr Hesketh a slip from the operating list, he nods, and the theatre
sister leaves. (This slip contains the next patients details, by showing it to
Dr Hesketh the theatre sister obtains his agreement to send for this next
patient.)
116
The surgeon pulls the teeth out.
There is an exchange between the surgeon and the ODP that
I dont catch.
Put the monitoring on (not sure who said this either
Dr Hesketh or the ODP)
Dr Hesketh: Done?
Surgeon: Yes, better find a specimen bottle for these. He goes
through the doors to theatre.
Dr Hesketh: Pop her on her side. The patient is turned onto her
side and the sides of the trolley are raised. He looks at the ODP:
Ill ask him not to come in the anaesthetic room for the next
one. The consultant assembles the oxygen mask. The black face
mask is replaced with the oxygen mask.
The surgeon returns and places the specimen bottle, containing
the teeth, under the pillow. He turns to the ODP: Sorry Steve, it
was just . . .
The ODP interjects No, my objection was right.
Patient wheeled to Recovery by the ODP and Dr Mani.
The anaesthetic room is a nexus of anaesthetic knowledge and

expertise; it is where monitoring is applied, lines and catheters
are introduced, the patient is rendered unconscious, breathing
tubes are inserted and nerve blocks (pain relieving techniques)
are performed. The surgeons encroachment of this territory
disrupts routine anaesthetic practices aimed at safeguarding the
patient: he removes the teeth before the monitoring is attached.
In the recovery room afterwards, the consultant anaesthetist
concedes to me that the surgeon should be excluded from the
anaesthetic room.
Dr Hesketh: I have no problem with you being there but Steve has
already complained about four times this morning that there are
too many people in the anaesthetic room . . . hes got a point
actually, we should have put the monitoring on first . . . (he turns
117
to Dr Mani) no point putting a cannula in, thats the beauty of

Sevo . . .
We go back into the anaesthetic room.
Dr Hesketh: Fentanyl please.
ODP: Thats what I was saying, you cant keep him (the surgeon)
out. (whilst opening the controlled drug cupboard).
Dr Hesketh: Youre right, we should have put the monitoring on
first.
ODP: Do you want fentanyl for all the kids?
Access to the anaesthetic room permits exposure to anaesthetic

routines and practices and the knowledge suspended within
them. Such practices must be observed in order to preserve
anaesthetic knowledge, expertise and patient safety as discussed
in the previous chapter, routines are important curriers of safe
practice. For the surgeon, however, it seems nonsensical to
persist with full anaesthetic routines when the surgical procedure
itself is so brief. Gherardi and Nicolini (2000) identify this feature of communities of practice; how they tend to persevere in
their practices even when to an outsider they seem obsolete and
irrational. This incident outlines how knowledge and expertise
can be spatially bounded and protected as legitimate access to
marginal actors is awarded and revoked. However, such policing
of the boundaries of anaesthetic territory requires purposeful
action, in this case by the ODP. Here, for the second patient that
morning, the ODP boldly excludes the surgeon.
The ODP and I go into the anaesthetic room. The surgeon follows
and as he tries to enter the ODP locks the door. The patient has
already arrived.
ODP: Can I just borrow this hand. He attaches the tourniquet,
then releases it and asks the patient to take her cardigan off,
reattaches the tourniquet.
Dr Hesketh enters.
118
This is not an isolated incident but is repeated throughout the

morning:
Patient wheeled to Recovery. I enter the anaesthetic room via the
entrance on the main corridor as I hear the connecting doors to
theatre being locked.
ODP is putting the monitoring on and then checking the name
band.
It is noteworthy that this work of safeguarding anaesthetic

practices is undertaken by the ODP rather than the anaesthetist
and it serves to demonstrate the ODPs membership of the
community of practice. Wenger (1998) suggests that participation can be seen as a distinct channel of power available to
members; by doing politics through influence and personal
authority, cultivating or avoiding specific relationships with
specific people, members are able to shape the future of community practices. The conflict this provokes is seen by Lave and
Wenger (1991: 116) as an integral element of practice: Conflict
is experienced and worked out through a shared everyday
practice in which differing viewpoints and common stakes are in
interplay. Therefore, attending to the performance of differing
viewpoints and what is at stake points to the salience of boundary
making in defining the potential of different staff groups.
Legitimacy Disputed
Legitimate forms of participation are even more contentious where

access to the learning curriculum is at stake for nurses, ODPs and
trainee anaesthetists. Lave and Wenger emphasise the dispersed
nature of an activity and identify how the structure of distributed
tasks incur many constraints on the learning environment:
The way a task is partitioned across a set of task performers has consequences for both the efficiency of task performance and for the
efficiency of knowledge acquisition. (Lave and Wenger, 1991: 75)
119
Focussing on the distribution of a task, and the constraints and

opportunities this offers to different practitioners, facilitates
inquiry into the organisational reproduction of identities, and
how this functions to restrict some possibilities while promoting
others. This issue is played out between the ODP and the trainee
anaesthetist during the anaesthetic process for a subsequent
patient.
As I enter the anaesthetic room Dr Mani and the ODP are already
there and the patient is anaesthetised. Dr Mani is stood at the head
and the ODP in between the anaesthetic machine and the patient.
Dr Mani removes the laryngeal mask (LM a device that holds open
the airway of an unconscious patient). ODP takes a new black mask out
of a packet. I look at the oxygen saturation monitor, it is reading
100%, the patient looks pink, normal colour. Dr Mani tries to turn
the Sevoflurane on, struggles. Dr Hesketh turns off the Isoflurane
(anaesthetic machines are configured so as only one anaesthetic vapour can
be turned on at once).
Dr Hesketh: Is it just a poorly fitting LM?
Dr Mani: Umm
ODP: Not down far enough. (He seems to answer for her.)
Dr Mani tries to reinsert it, she is unsuccessful.
ODP: Come round this side . . . (gesturing to the right hand side
of the patient)
Dr Mani: I will try it my own way, please, if you dont mind. She
reinserts the laryngeal mask.
Dr Hesketh: Its turned, you can tell its not in right because the
black line is twisted. (There is a black line that runs the length of a
reinforced laryngeal mask, it should always be uppermost). Dr Mani
removes the LM.
ODP: Come round this side . . . Dr Mani follows the ODPs
instructions and successfully inserts the laryngeal mask.
Dr Hesketh: Youve just made Steve a very happy man. ODP
secures the LM with tape. You happy? to Dr Mani, she nods.
120
Here, the ODP contests the trainees expertise by attempting to

instruct her on how to insert the airway device a simple
technique usually mastered early in an anaesthetists career. This
anaesthetist is experienced and approaching the end of her
training. She is somewhat resistant to this attempt to instruct
her, but when a further attempt fails she successfully follows the
ODPs directions. There is a palpable tension that the consultant
recognises and his light-hearted observation about making the
ODP a happy man is designed to dissolve. This incident raises
questions about the extent to which different community
members participation is legitimated. After the session, the
consultant commented on the incident.
It was obvious as soon as we walked in the room the LM wasnt in the
right place and I think they had removed it by that time. What had
happened was Steve had put the cannula in and then put the LM in,
and it wasnt in right, now it doesnt matter to me who puts it in. . . .
Fatima removed it and was trying to reinsert it, and Steve was trying to
tell her how to do it, she said she wanted to do it her way. I think that
was good but then it wasnt in right, and you can tell straight away
because either they are a long way out or the black line isnt laying
straight, and this time the black line was twisted. The important thing
was that she took it out and tried from the side, the way Steve had
suggested and it went in. The main thing is that the patient doesnt
desaturate and doesnt wake up. I have no problem with Steve telling
people how to do things, it doesnt matter to me who it is . . .
This consultant is perhaps unusually egalitarian concerning the

distribution of tasks. DiPalma (2004: 302) points to how the
fluid vagaries of power in personalities, professionalism, familiarity, education and experience and role expectations add
intricate layers to teamworking dynamics. The tension that is
provoked by this incident reflects a perception of the ODPs
illegitimate participation. Wenger (1998: 149) suggests that a
learning trajectory defines a members identity: We define who
we are by where we have been and where we are going. Here,
121
the consultants commentary indicates that the ODP was

appropriating experiences central to the development of an
anaesthetists identity. Apparently, the ODP had both cannulated the patient and (incorrectly) inserted the LM, which
Dr Mani then removed. The ODP continued to assert his
expertise by answering the consultants questions and instructing
the trainee. (It is perhaps worth noting that this conversation
revealed a fuller sequence of events, something that I would have
missed if reliant only on the observational data.) Although ODPs
may develop anaesthetic knowledge and skills, undertaking such
procedures impinges on the rights of a trainee anaesthetist both
to develop the skills themselves, and crucially, to perform the
techniques and procedures that define their identity. Wenger
et al. (2002: 146) refer to the potential of communities to stratify
participants creating distinct classes of members as a community
disorder. Here, the term stratified legitimacy refers to the extent
to which an individuals participation is contingent upon their
professional identity. This is not necessarily something to be
remedied, although modification may be desirable, rather it is as
a constitutive element in the organisation of health care.
Performing Knowledge Claims
The following scene also relates to the appropriation of a

learning curriculum but in this it is the anaesthetist laying claim
to an activity. The setting is a routine minor general surgical list,
the scene begins in the anaesthetic room as the patient is being
induced. Present are an anaesthetist Dr Trevor Rhodes, an
ODP, the patient and I.
Dr Rhodes: Bit of oxygen to breathe as you go off now.
After a few moments the ODP lifts the patients gown to wrap up
his arms in it (this secures them out of the surgical field for the
duration of the operation). The ODP points to a large pulsating
122
area in the patients abdomen (roughly half the area of the ODPs
hand span), he lays his hand on it (as if to discern its diameter).
The ODP and Dr Rhodes talk about whether there was any
mention of an aneurysm in his notes there wasnt. Dr Rhodes
tells me that it is not often you get to diagnose anything in
anaesthesia.
Dr Rhodes lifts the mask off, the ODP opens the patients
mouth, pulling down the lower jaw, and Dr Rhodes inserts the
laryngeal mask with a slight twist. The ODP inflates the laryngeal mask, tapes it in position and then tapes the patients eyes
shut. Dr Rhodes connects the breathing circuit. One of the
pumps beeps and Dr Rhodes replaces the remifentanyl syringe,
one had already been prepared and was lying next to the
pump. Dr Rhodes ventilates. The ODP secures the patients
arms by wrapping them in his gown. The patients hands are
moving.
ODP: Happy?
Dr Rhodes: Just get him a little bit more settled. He presses buttons on the pump. Pause. Yep. Dr Rhodes and the ODP disconnect the monitoring and breathing circuit, the ODP takes the
brakes off, opens the doors and they wheel the patient through to
theatre. The ODP also wheels the trolley with the pumps on.
ODP: Ready, brace, lift. Patient is transferred onto the table.
ODP connects the breathing circuit. Circulating nurse inserts the
arm supports.
Dr Rhodes: We were just wondering about his abdomen . . .
The surgeon looks at the patients abdomen, lays his hand on the
area that is visibly pulsating.
Scrub nurse: Oh, you can see it . . .
Circulating nurse: Youre not doing anything to him here!
Surgeon: He should have an ultrasound scan . . .
ODP: Legs up. He puts the patients legs in the stirrups.
Dr Rhodes turns to me and tells me this type of anaesthetic
technique (continuous infusion of Remifentanyl and Propofol
rather than using anaesthetic gases) is very good for this type of
123
patient. I am about to ask him to explain why when the surgeon

begins talking to Dr Rhodes.
Surgeon: We need to arrange a scan . . . its a big one as well . . .
Dr Rhodes turns the gases on oxygen to 1 litre, air to 4 litres
whilst saying: Dont get to diagnose many things in
anaesthesia . . .
Another nurse enters: You wanting to do this (the scan) today?
Surgeon: No, all I need is a form.
Blood pressure 83/56, pulse 51, oxygen saturation 98%.
Surgeon: Hes kicking still.
Dr Rhodes: OK. He stands and presses some buttons on the pump,
he holds down one of the buttons on the remifentanyl pump
(giving an additional amount). He writes on the anaesthetic chart.
The other nurse re-enters and talks to the surgeon about the
scan it will be next month.
Dr Rhodes goes into the anaesthetic room.
Nurse leaves and re-enters moments later: They can do it today
whilst hes in hospital.
Surgeon: Who will see the scan. . . . Mr Roberts (a vascular consultant surgeon)?
It is the ODP who initially draws attention to the pulsating area

of the patients abdomen, pointing to it and then laying his hand
on it. With no diagnostic tests or procedures and a negligible
amount of ceremony, this pulsating area has became an
abdominal aortic aneurysm, a serious condition in which a
weakness in the vessel wall herniates and may potentially rupture
with the consequent blood loss being life threatening. However,
it is the anaesthetist who claims diagnosis of the aneurysm.
This resonates with Tjoras (2000) observation, discussed earlier,
that nurses often stop short of using the word diagnosis even
when the processes involved are inseparable from those used in
medical diagnosis. The ODP, in this scenario, makes no display
124
as to the authorship of the diagnosis. On transferring him to

the operating theatre the anaesthetist is quick to draw the surgeons attention to the patients abdomen, and in a gesture
identical to that performed by the ODP, the surgeon lays his
hand on the pulsating region. Again, without the flourish of a
naming ceremony the two nurses indicate that they appreciate its
significance with their comments oh you can see it and youre
not doing anything to him here! (acknowledging that this particular theatre is not an appropriate setting in which to undertake a surgical repair of an abdominal aortic aneurysm, the
nearest intensive care unit being 25 miles away). Dr Rhodes
repeats his comment about the scarcity of diagnostic opportunities in anaesthesia thereby reiterating his claim to authorship
of this discovery. The legitimacy of the claims to knowledge and
the experiences and opportunities that produce it are stratified in
line with the professional identity to which an individual aspires.
Even in the emergency situations in which nurses have been
described as being directive, they still stop short of laying claim
to a diagnosis. Prowse and Allen describe a situation in which a
nurses request for an X-ray was countered by the doctor questioning her. Instead of simply stating I think he has a pneumothorax, the nurse stands her ground (Prowse and Allen,
2002: 93) by explaining her reasoning, pointing to the patients
shoulder tip pain as opposed to pain in the surgical area and
stating that she was not happy. As in this scenario, nurses and
ODPs may recognise a condition, but it is a doctor who can
claim to diagnose one.
Fortifying Professional Boundaries
Conferring legitimacy on various forms of participation is more

important for the learner even than formal teaching (Lave and
Wenger, 1991), for it provides access to the learning curriculum,
125
to the experiences around which identities are developed. In the

operating theatres and anaesthesia, legitimacy acts as a kind of
security clearance, providing access to certain areas, opportunities and experiences. But as with security clearance, legitimacy
is stratified, the role to which a newcomer aspires correlates with
the level of legitimacy, and rights to practice, they are granted.
Stratified legitimacy of participation and the effort exerted to
reinforce these boundaries are clearly exhibited in the following
scenario. Here, the stratification of legitimate participation
who has the right to question, to act, in which circumstances is
continually reaffirmed. In this interview, the consultant anaesthetist describes an incident in which a very ill elderly patient
with many chronic conditions and an acute bowel obstruction
had a cardiac arrest on induction. Unusually, with only a brief
spell of cardiac massage and adrenaline the patients heart
rhythm was restored.
I gave her something like 50 mcg of fentanyl and 4 mg of etomidate
and some sux (a combination of drugs to induce anaesthesia and paralyse
the patient), and she went very pale and we lost her peripheral pulse.
We all looked at each other for a couple of seconds and we were all
saying the same thing: shall we, shant we? It took maybe 10 seconds
to establish she hadnt got a carotid pulse either and I felt that we
probably had to do cardiac massage. The reason I felt that was that it
was very unlikely to work, but at least we were doing something.
I mean I knew the pathology; someone with aortic stenosis does that
to you and youre very unlikely to succeed. . . . I gave her some
ephedrine initially and some methoxamine (both used to increase the
heart rate and blood pressure) and then when it was clear that she had
arrested, I gave her 0.5 mg of adrenalin. This is all through
peripheral vein of course, but the amazing thing was that after the
second brief episode of cardiac massage. . . . she just suddenly
restored an output and then under the influence of the adrenalin she
had, she had a heart rate of 100 and a blood pressure 200/100 and she
very, very quickly pinked up. . . .
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I said well lets get on and put the lines in at which stage I think
John (ODP) and Priya (SHO) found it a bit too much because they
just said I dont think you should be going on any further. Thats
where I think they had a valid point. You could question what on
earth they are doing saying that in an anaesthetic room in that circumstance, and I found that quite challenging actually, particularly
from John. I think with Priya its ok because Priya is in a position of
training to make those decisions, so Priya has a right to know why
Im doing that. John doesnt in those circumstances, John has to do
what, under those circumstances, you know in the heat of the
moment, John has to do what you ask. I mean he can take you aside
afterwards, talk to the principal ODP or whatever, but I wasnt
pleased and I said no Im sorry I have a contract with this patient . . .
no, well put the central line in and we go ahead as we were.
Whilst this scene was not observed, what is does convey is the
consultants approach to appropriate participation. The consultant strongly positions himself as the arbiter of legitimate and
illegitimate participation; the trainee had a valid right to question
the consultant and to an explanation because her professional
trajectory points to full membership as a consultant anaesthetist.
In contrast, the ODPs participation is illegitimate, it cannot be
described as centripetal as its legitimacy is restricted to the level
of performing prescribed tasks. His questioning was challenging
because his professional trajectory reifies his peripheral status.
Prowse and Allen (2002) point out the consequences of being
considered as challenging doctors will try to avoid them, not
listen or respond to their requests, all of which results in patients
not getting what they need. Respect for professional boundaries
is integral to achieving optimum patient outcomes. Fortifying
these boundaries amongst the participants of anaesthesia,
Dr Rogers returns to the stratification of legitimate peripheral
participation later in the interview.
I was actually very angry that he challenged me in the middle of that
but in a sense he was right, he was playing it by the book. If we were
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going to resuscitate this woman we should do it properly get a few

more people along, you know give X mg of adrenalin, according to
a protocol, defibrillate at X joules. But Im stood there thinking,
hang on, you know this is my patient only I know what her medical
history is, and only I know how difficult it is to resuscitate somebody with aortic stenosis, therefore, only I am competent to make
the decision as to whether or not we progress. I dont need 6 theatre
nurses who have all been on an ALS course telling me what drugs to
use; she either responds to what I give her or she doesnt, and
nobodys going to change my opinion.
Here the consultant alights on an important point; whilst nurses

and doctors learn alongside one another on Advanced Life
Support courses, and must demonstrate the same competencies
and theoretical understandings to successfully complete the
course, back in the workplace opportunities for participation are
once again stratified with doctors retaining the interpretative,
diagnostic and prescriptive functions and nurses typically performing the prescribed tasks.
The Effects of Stratified Legitimacy on Knowledge Resources
The discussion thus far indicates how access and legitimate participation are regulated so as to reaffirm occupational boundaries
and support the customary distribution of practices. The following
scene illustrates how this stratification of legitimate participation
affects the resources a participant has to guide anaesthetic care.
Here, a consultant anaesthetist (Dr Georgina Phillips), a junior
anaesthetist (Dr Peter Frank), a medical student (Helen) and the
senior ODP (Steve Didsbury) are working together on an Ear,
Nose and Throat operating list.
The induction is under way as Dr Phillips, the medical student and
I enter the anaesthetic room.
Dr Frank stands at the head of the patient, he inserts a guedel airway
into the patients mouth. The ODP stands on the patients left.
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Dr Phillips puts a pair of gloves on and pulls out the patients
nose pack.
ODP holds the laryngeal mask.
Dr Frank: Ill just give her a bit more . . . He connects the propofol syringe to the cannula and injects. He ventilates then lifts
the mask off.
ODP holds the LM hovering over the patients face.
Dr Frank: No, not yet. (He repositions the guedel) Is she biting her
tongue? No (quietly). He continues ventilating, repositions the
black mask and then resumes ventilating. The anaesthetic machine
beeps. He lifts the jaw and holds the mask on with both hands, he
looks at the reservoir bag, it moves but is not clearly inflating and
deflating. The patient makes muffled groaning noise. The reservoir bag had been resting on the pillow, it falls to the floor.
Dr Frank turns the Sevoflurane (anaesthetic gas) down to 5% (it had
been on 8%). The bag is now clearly inflating and deflating.
Dr Phillips talks to the medical student: So you can see what Peter
is doing, getting her deep and settled so she will accept the LM . . .
Dr Frank lifts the mask off and suctions, he hesitates but the
ODP inserts the laryngeal mask, it stays in position.
Dr Frank: Thats good. Moments later patient coughs. Oh mama
mia.
Dr Phillips: This is where 20 a day doesnt help . . . airway irritable.
She looks like shes trying to cough the airway out. She is
breathing down the anaesthetic so she might actually settle . . . (to
the medical student)
Dr Phillips hands the ODP a roll of tape with which to secure
the LM.
Dr Frank slowly deepens the level of anaesthesia until he judges

that the patient will accept the laryngeal mask. The reason for
this more cautious approach becomes apparent as the action
progresses the patient is a smoker, and smokers are notorious
for having irritable airways, necessitating deeper levels of
anaesthesia for the insertion of a laryngeal mask. The first point
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to note here is that this knowledge about the patient being a

smoker and how to treat smokers during induction becomes
evident primarily because of the witnesses a medical student
and a researcher who will not necessarily understand this. As
Gherardi and Nicolini (2000) identify, giving meaning to events
often thought of as an individual activity is instead social, only
occurring in the presence of a knowledgeable community.
The second point is that the anaesthetist will have been aware
of this information about the patient from the preoperative
assessment. Without access to the preoperative assessment,
however, the ODP has fewer resources with which to evaluate
the patients condition. Consequently, the ODP and the anaesthetists judgements about whether the patient is deep enough
to accept the laryngeal mask differ. The ODP relies on anaesthetic room practices whereas the anaesthetists draw on a wider
range of resources. In a study about teamworking amongst
community mental health care teams, Griffiths (1997) identifies
the different discursive resources used by the psychiatrist and the
other members of the team. These are related to the divergent
ideological backgrounds and different practical work requirements and are always present despite apparently democratic
discussions. Consequently, it is the psychiatrist who controls the
kind of information that will emerge (Griffith, 1997). It follows
then that, as in Anspachs ecology of knowledge, the distribution of anaesthetic work results in the ODP being disadvantaged
when it comes to appropriately informing the course of anaesthetic care. Lave and Wenger (1991) explain that newcomers
shifting location creates possibilities for understanding the world
and that by denying access and limiting the centripetal movement of practitioners changes the learning curriculum. In this
way, Lave and Wenger attend to both the structural and contingent elements in the reproduction of identities. Access and
the centripetal movement of learners may be regulated and
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limited, but this still allows for individual and experiential

contingencies.
And, finally, this episode brings to light the difference between
performing a task and being accountable for it; by working under
the direct supervision of the anaesthetists the ODP may insert a
laryngeal mask without actually being accountable for it, airway
management is the anaesthetists domain and by being present
s/he retains this responsibility. This departs from the literature
reviewed earlier, in which nurses undertook doctors duties, and
would be held accountable, only when doctors were not available.
This latter scenario is more frequently seen in the recovery room
where the anaesthetist hands over the care of the patient to a
nurse, or, more recently, an ODP. Doctors may often be present
in the department but they are frequently unavailable, being
involved in activities from which they cannot be separated.
The Persuasive Potential of Knowledge Resources
Of all the operating theatre personnel, recovery nurses are possibly

the most autonomous (Timmons and Tanner, 2004). Practising
independently, facilitating the emergence of patient from anaesthesia, the need for recovery nurses to inform the course of events is
perhaps more acute, and their activities therefore more distinct,
than for anaesthetic nurses and ODPs who assist doctors. In the
following interview, a recovery nurse describes how a patient in her
care deteriorated following a routine laparoscopic cholecystectomy
(keyhole surgery for the removal of the gall bladder). Suspecting
an internal haemorrhage, the recovery nurse repeatedly raised her
concerns with the consultant surgeon and suggested a blood
transfusion might be necessary. After briefly examining the patient,
he rejected this suggestion. The nurse then spoke to the trainee
anaesthetist, who had administered the anaesthetic, and obtained a
prescription for a blood transfusion.
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Kate (the patient) continued to slowly deteriorate over the course of

the morning and at 12.20 I was extremely concerned, agitated and
frustrated, having continuously raised my concerns strongly to all
involved parties I felt unsupported and ignored. Kate by this time
appeared pale and clammy, her blood pressure was being maintained with colloid infusion but her conscious level was deteriorating and it was becoming difficult to rouse her. . . . Again I voiced
my concerns this time with the surgical senior registrar as the
consultant had left. During this conversation Kates blood results
returned from the laboratory. Kates haemoglobin was recorded at
6.8. It was now obvious that Kate was haemorrhaging internally but
by now she was visibly and physiologically shocked. Despite Kates
critical condition the senior registrar remained reluctant to take
Kate back to theatre without first discussing it with the consultant
surgeon.
The recovery nurses account highlights how the need for

nurses and ODPs to persuade other participants to act orientates their work. The nurses understanding of the situation
does not enable her to initiate action as the solution lies outside
her remit. She cannot prescribe a blood transfusion or perform
surgery, so she must persuade the doctors of the veracity of her
account, and her lack of success incurs a considerable degree of
anxiety. The nurse recounts uneasiness, uncertainty and a lack
of confidence in her assessment of the patients condition. As
Gherardi and Nicolini (2000: 13) observe, Knowing is a contested and negotiated phenomenon and this is especially the
case when, as in this situation, the knowledge in question is
located outside the nurses realm of practice. However, as the
patients condition further deteriorated this ambiguity clears
and the nurse began to feel more justified in her concerns.
I asked the nurse to elaborate on this uncertainty. She describes
how the situation only resolves when a senior consultant
anaesthetist (and director of the critical care unit) becomes
involved.
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I doubted myself. . . . I suspected that she was haemorrhaging from

a fairly early stage . . . but its very difficult to actually look at a
patient and know 100% that she is pale and clammy because she is
shocked because she is losing blood internally. Plus the fact that in
this particular case the reason why the surgeon was so reluctant to do
anything was because she didnt display the typical textbook signs of
haemorrhage. . . . The senior registrar argued with me over the
patient, that she couldnt possibly haemorrhaging because her blood
pressure was still 90 over 40, and I said yes but shes had 6 units of
gelofusion (particular type of fluid used to expand the volume of the blood)
so Im maintaining the blood pressure with the gelofusion and
thats the only reason that her blood pressure is as it is. If Id
stopped giving that, it would drop considerably. I can remember
saying to him you need to look at this patient as a whole, look at
her holistically, dont look at her vital signs look at her, she has
deteriorated. He said Well hows she deteriorated, her blood
pressure hasnt got any lower?, Look at her, she was conscious
before, she was easily rouseable, she was warm, alright she was pale,
but now shes pale, clammy, hypothermic, and Im having to put a
warming blanket on her, and shes not easily rousable. Look at the
patient, dont look at the monitors, look at her!
He argued with me for a long time and it was while we were
having this discussion that the senior consultant anaesthetist
(Clinical Director) came through. He just took over completely and
said this woman is clinically shocked, shes going to need resuscitation before she goes back to theatre. I want 6 units (of blood)
banging into her straight away, so you get onto that. I dont care
whether the consultant wants to take her back, this lady needs to go
back to theatre now and that was that. You know he almost
shouted, it was not up for discussion, she was going back and I just
remember feeling oh thank god for that, you know, thank god he
has taken over because I was just not getting anywhere.
And yet quite possibly if Im honest all the way through there
was that minute shadow of doubt, in my own ability or my own
knowledge base. . . . Even the junior anaesthetist, not junior but
the anaesthetist in charge of the case, felt out of his depth, so he
had gone across to the intensive care unit (to confer with the consultant) and said youre going to have to help me here. But I had
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felt unsupported from him all the way along in terms of, I was
saying you need to do something you know, this lady is, you know,
I think shes bleeding, what do you think?, Well I do as well but
thats the surgeons problem. In other words, thats your problem
to alert the surgeon, which I had already had done and Id actually
spoken to the consultant surgeon three times . . .
The nurse attributes her persistence of doubt and difficulty in

persuading the surgeons to the lack of textbook signs of haemorrhage. Corresponding with Anspachs ecology of knowledge,
the surgeons are distanced from the recovery period and, therefore,
are unable to appreciate the implications of the more subtle signs.
Instead, they rely on explicit and observable measurements, which
are partly being offset by the manipulation of the fluid infusion.
The nurse entreats the surgeon to look beyond the numbers displayed on the monitor and to take account of the less tangible
signs that the patient was increasingly difficult to rouse, that she
was becoming paler, clammy and her temperature was falling. All
of these signs are not uncommon in the immediate post-operative
period, but the particular configuration and direction of trends are
significant and suggest to the recovery nurse that the patient was
bleeding to the point that it would require surgical intervention.
Through working with patients in the immediate few hours following surgery, she has gained an intimate understanding of the
expected trajectories, not only in terms of explicit measurements
but also in less tangible terms. In the first instance, however, this
knowledge does not amount to what Prowse and Allen (2002: 85)
have termed effective knowledge: knowledge developed in the
clinical setting that is influential in activating intended patient
outcomes. Consequently, the lack of textbook indicators strips the
nurse of the resources with which to persuade the surgeons of her
evaluation, and invokes feelings of doubt and uncertainty.
Apparently, the junior anaesthetist was convinced but
demurred from acting on the grounds that it was the surgeons
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decision. The diagnosis of haemorrhage following surgery is

commonly constructed as a surgical decision and both the
recovery nurse (although she did repeatedly attempt to coax the
surgeons towards this conclusion) and the junior anaesthetist
were reluctant or unable to transgress these territorial boundaries and encroach on the surgeons area of expertise. It required
a senior consultant anaesthetist head of the critical care
directorate to intervene. Interestingly, he quickly reached the
same conclusions as the nurse. The work of anaesthetists and
recovery nurses are closely aligned; both adjust their care to the
effects of the surgical intervention, they look for the same signs
and indicators, and confer on the resolution of problems. Whilst
the temporal boundaries of their work are distinct, the anaesthetists during the surgery and the nurses following, they strive
towards the same ends and come to appreciate the common
post-operative trajectories and the significance of deviations
from this. Persuasion, then, is more likely to be achieved if both
participants can share an outlook, attend to the same signs and
appreciate their significance.
Regulating Participation: Processes and Effects
The literature reviewed above reflects the close and informal

ways in which doctors and nurses work together. There is a long
tradition of working across boundaries tentatively and subtly
perhaps, but in ways that blur distinct disciplinary boundaries.
The need to put suggestions or directions to members of staff
from different disciplines in ways that are sensitive to and respect
their disciplinary knowledge and practices is well established and
not in question. Griffiths (1997) suggests that the tension in
teamwork between hierarchy and collegiality can be linked to a
generalised ambiguity in the team concept. Organisational
guidelines and cultural ideas about how teams function leave an
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area of definitional imprecision where working arrangements

must be negotiated:
Team work is, in other words, an ongoing practical accomplishment: it
emerges out of the everyday interactions and micro-political struggles of
those charged with making joint working a reality. (Griffiths, 1997: 60)
Furthermore, DiPalma (2004) points out that satisfaction in

teamworking stems not from obediently performing a designated role but in modifying the role to acknowledge personal
strengths by making use of informal, backstage, crossdisciplinary, cross-professional, communication opportunities
to the benefit of patient outcomes and enhanced professional
standing (DiPalma, 2004: 303). Mostly, this kind of work goes
on without a great deal of recognition and few overt problems
(Allen, 1997). That it is so integral to successful teamworking
suggests that the relatively smooth running of most health care
work depends on this invisible work (Star, 1995). Furthermore,
Suchman (2007) points out that being invisible is not by definition problematic. Remaining out of view may result in less
reward and recognition but it also affords spaces in which to act.
However, it bears repeating that the lack of observable problems
depends on practitioners conducting themselves in a way that
bridges gaps and avoids conflict. Moreover, this work exposes
practitioners to criticism if there is reason to subsequently
inspect their actions in the light of formal descriptions of their
role. Being invisible may afford the space to act but such erasures
may later be recovered and practitioners may jeopardise their
professional registration. Therefore, in my analysis, I have
concentrated on what happens when conflicts do become
apparent: first, because this sheds light on the tacit norms and
rules which are mostly observed and as such avoid scrutiny; and,
second, because it elucidates what is at stake, what informs and
sustains tacit norms, and their effects.
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I have focussed on the ways in which status, as a position and

an identity, is developed and achieved through the stratification
of legitimate participation in anaesthetic practice, and I have
elaborated upon how a differential in knowledge develops, and
the effects this has for the nurses and ODPs in terms of initiating
action. Lave and Wengers (1991) concept of legitimate
peripheral participation highlights the processes through which
different roles and identities are sustained. This analysis
demonstrates how legitimate access and participation are stratified in line with professional or occupational identity. When a
member participates in ways that stray outside accepted
boundaries of their practice, this may impinge on the opportunities of another to develop the skills, practices, knowledge and
identity to which he or she aspires. Tensions develop, and
legitimacy is disputed, when a participants developing identity is
jeopardised by anothers appropriation of the learning curricula. Attempts to avert this situation result in the bolstering of
boundaries between the different groups; thus the stratification of
legitimate participation which individuals have the right to act
and to question, in which circumstances is constantly being
reaffirmed. Such stratification prevents the centripetal development of participants and results in a range of practitioner
identities. Restrictions to the extent of participation within the
learning curriculum correspondingly limits the resources with
which an actor can understand anaesthetic practices and the
patients condition. This, in turn, restricts the extent to which
those participants may influence the care of the patient.
I depart from Lave and Wenger (1991) and Wenger (1998) in
focussing on a multidisciplinary community. The joint enterprise to provide safe anaesthesia for operative procedures is
partitioned across the members of this community of practice.
However, the peripheral positions of the ODP and the nurse are
not transitory resting places for apprentices as they develop a
137
skill and move on; rather, they are designated forms of

engagement. One can engage in anaesthesia as an ODP, a nurse
or an anaesthetist, but movement between these positions is not
endorsed. Lave and Wengers emphasis on legitimacy elucidates
members responses to attempts to cross boundaries the
exclusion of the surgeon from the anaesthetic room, the friction
between the ODP and the trainee anaesthetist when he appropriated anaesthetic responsibilities, the consultants anger as the
ODP questioned his judgement because movement outside
accepted boundaries jeopardises anothers identity.
Wengers (1998) discussion of boundaries focuses on those
that encompass the community and that overlap with other
communities. I have concentrated on the boundaries within a
community that distinguish and contain the different members
and their participation. For a nurse or ODP, legitimate participation in the anaesthetic community of practice involves
occupying one of the peripheral positions and performing the
tasks consistent with that role. Development here is not a
seamless progression towards a central position. There may be
some overlap between positions, but there are significant constraints on the centripetal movement of nurses and ODPs.
Developmental trajectories are contingent upon the adoption of
a peripheral position and the degree of legitimate participation
awarded in line with that identity.
The effects of these disciplinary boundaries are felt in terms
of initiating action: when the required intervention falls outside a
participants remit, initiating action hinges on persuading other
participants to act. As discussed earlier, this is not new. My
analysis, however, suggests a need also to consider the orientation of different doctors in this case, anaesthetists and
surgeons and indicates that successfully persuading others to
act requires legitimate access to the same resources. Doctors do
not draw only on technologically produced measurements, and
138
nurses/ODPs do not only use interactive cues; other configurations are possible. As the final scenario shows, the perspectives of anaesthetists and recovery nurses are closely aligned,
they interpret the significance of both the technologically produced measurements and the subtle signs in the same way. This
means that Anspachs (1997) suggestion that information from
diagnostic technology assumes a superior epistemological status
(1987: 219) isnt necessarily the case. Because they are somewhat
removed from the details of immediate post-operative trajectories, technologically produced measurements and data did take
priority for the surgeons; however, adding nuance to Anspachs
analysis, this scenario demonstrates how the anaesthetists and
recovery nurse interpreted the measurements differently to the
surgeons by taking into account the more subtle cues (colour,
warmth, rousability) along with her history of care in Recovery
(that the blood pressure measurement was being manipulated by
fluid management). Allen (1997) and Tjora (2000) show how
nurses undertake work that blurs the boundary between medicine
and nursing, particularly when doctors are unavailable, and Tjora
contends that nurses do perform diagnostic activities but do not
take ownership of it. In this chapter, I have shown how and why
this is problematic. The recovery nurse accurately diagnoses an
internal haemorrhage but encounters difficulty when initiating a
course of action as those practitioners required to act disagree
with her assessment. Unable to prescribe care, her only option is
to attempt to persuade another participant, whose role formally
legitimates the necessary activity. Such persuasion points to how,
in order to achieve optimal care of a patient, nurses and ODPs
routinely operate beyond the official boundaries of their role but
a tension arises when this informal means of organising care
fails: officially and unofficially, the practitioner has no means of
securing appropriate care of the patient.
Embodied Knowledge: Coordinating Spaces,

Bodies and Tools*
When practice proceeds smoothly, without problems, the

constitution of the place of work is largely taken for granted by
participants, treated as a transparent background for the work at
hand (Suchman, 1996). Likewise, once mastery is gained over
tools and instruments, those devices no longer hold a focal
awareness for participants (Gherardi, 2000). However, research in
areas such as airline operations rooms (Goodwin and Goodwin,
1996; Suchman, 1996), underground train drivers (Heath et al.,
1999) and telesales work (Whalen et al., 2002) have shown how
the careful ordering of materials and people affords certain perspectives which are integral to the proficient accomplishment of
practice. These studies, however, do not elaborate on what happens when the spatial arrangements are disrupted. What consequences follow from the upset of the regular coordination of
materials, people and positionings? In this chapter, I examine the
relationship between the spatial dimensions of the workplace, the
arrangement of material resources and the development of
embodied knowledge. I explore how such knowledges feature
within a team of differentially qualified and experienced health
care practitioners. I have selected examples from anaesthetic
practice in which the seamless flow of routine work is sharply
interrupted by disturbances to the usual configuration of patients,
* This work was first published as Goodwin, D (2007) Upsetting the order of team-
work: is the same way every time a good aspiration? Sociology, 41 (2): 259275.
139
140
practitioners, and tools. In these situations, the workplace and the

equipment within it is far from a transparent background but
plays a prominent role in shaping practices and knowledges.
Relating Workplace Dimensions to Working Practices
The configuration of practitioners, patients, tools and technologies within a team, their interactions and the significance of this
ordering has largely escaped attention in health care. Hindmarsh
and Pilnick (2002: 141) find a critical gap in the sociological literature, which has resulted in a poor understanding of the ways
that medical staff organise their work. Analyses of the organisation
of health care work, they posit, have focussed on the division of
labour and the boundaries that construct those divisions. The
emphasis on disciplinary boundaries is not surprising, perhaps
wholly appropriate, given that the boundaries between health care
professions are perpetually being contested, negotiated and reaffirmed, as discussed in the previous chapter. However, within this
focus on boundaries, the importance of spatial and physical
dimensions can be discerned. Carmels (2006) study of intensive
care practice elucidates the complex relationship between the
physical boundaries of a work environment and the interprofessional boundaries of practice. Carmel argues that a team
approach, engendered by close working relationships between
doctors and nurses, obscures their occupational boundary. Concurrently, the distinct physical boundary of the ICU, and the
technological paraphernalia associated with ICU beds, delineates
this territory as different from a normal ward and bolsters a conception of ownership by the ICU team. In ICU, medicine does not
dominate nursing, rather, nursing is incorporated to the benefit of
both disciplines. Carmel explains:
First, their [ICU doctors and nurses] work at an occupational boundary
serves partly to obscure that boundary, and second, their work at an
Embodied Knowledge
141
organisational boundary serves to reinforce it. The overall effect,

intended or not, of these two boundary accomplishments is a jointly
executed strategy of incorporation, which creates the impression of a
joint (medical-nursing) intensive care team closing ranks against the
rest of the hospital. By concentrating power in the ICU, this joint
strategy has the paradoxical effect of increasing the influence of both
groups in the wider hospital. (Carmel, 2006: 158, original emphasis)
Where the politics of space are at issue, again, the focus rests on
how far spatial settings support professional boundaries. Tellioglu
and Wagner (2001) argue that spatial arrangements are connected
with the politics of invisible work. In radiology, the invisibility of
backstage work is reflected in radiology reports: The result of a
cooperative work process is owned by its official author, the
radiologist, although major parts of the script have been written by
other contributors (radiographers, typists) in other spaces (Tellioglu and Wagner, 2001: 182). Other backstage areas, hospital
corridors in particular, are critical to effective medical work. Long
et al. (2007) show how corridors are often sites where significant
conversations take place. In hospital corridors, information is
imparted, expertise is shared, instructions are given and decisions
are made. Such use of the corridor may be opportunistic but Long
et al. establish how this space also was associated with economic
and carefully targeted communications. They conclude that:
Corridor talk pulses through the very heart of most clinical communication, and yet has been neglected in the study of hospital communication. For clinicians to work safely and effectively, they require
facilitative, dynamic and heterogeneous modes of communication by
means of which they monitor, adjust and refine their medical and
patient management plans. (Long et al., 2007: 198)
Anspachs (1987) study of prognostic conflict in life and death

decisions, discussed in the previous chapter, also illuminates the
significance of the spatial organisation of work; to recap, the
neonatal physicians, being relatively removed from the hands-on
daily care of the babies, relied heavily on diagnostic technology
142
to inform their decision making, whereas for the nurses, who

worked in close contact with the babies it was these interactions
that were more significant in shaping their prognostic judgements. The previous chapter, however, illustrated that, with
access to similar experiences, doctors and nurses could interpret
both the technologically produced measurements and the subtle
clinical signs in the same way.
Hindmarsh and Pilnick (2002) begin to articulate the use of
space within anaesthetic rooms and suggest that Goffmans metaphor of frontstage/backstage regions inadequately accounts for how
a backstage for collaboration between medical staff can be produced
fleetingly in the course of apparently pure frontstage work with the
patient. This may be produced through a glance or gesture designed to
delicately evade the limited perceptual capabilities of a masked patient.
(Hindmarsh and Pilnick, 2002: 159)
They demonstrate how the use of space changes in concert with

the diminishing awareness of the patient. Pointing gestures and
nods enable two anaesthetists to coordinate the induction of
anaesthesia, whereas once anaesthesia is under way, discussions
could be held frankly and unproblematically.
Goodwin (1995: 268) articulates how the organisation of
space and the skilled use of tools are intimately related to cognition and that it is only within endogenous activities in actual
settings, with their constellations of relevant tasks and tools, that
the full richness and complexity of human spatial cognition
becomes visible. An example provided by Heath et al. (1999)
exemplifies this relationship among spaces, the skilled use of
tools and understanding. Describing the work of underground
train drivers, they identify how a transitory scan of the platform
can inform the way the driver operates the train:
The drivers glance, may provide no more than a sense of what it will
take to unload and pick up passengers, but it can inform the ways in
which the driver enters the platform and applies the brakes to the
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143
vehicle. An unexpectedly crowded platform, with waiting passengers

pushed to its edge, will have the driver breaking hard, so that by the
time the vehicle is halfway into the station, it is moving gently
alongside the crowd. (Heath et al., 1999: 561)
Using mirrors and monitors, the drivers develop occupationally

relevant ways of perceiving the scene (Heath et al., 1999: 561)
which shape subsequent actions. The salience of this professional vision (Goodwin, 1994 introduced in chapter 3), which
rests on the ability of practitioners to see the significant features
of a scene for a particular purpose, for anaesthetic work will be
explored in this chapter.
Orchestrating Anaesthetic Work
Although a great deal of health care work involves the skilled use of
tools and technologies, the degree to which this characterises the
work is perhaps accentuated in anaesthesia. Anaesthetic work, with
and on the patients body, is supported, mediated and accomplished using an elaborate array of medical tools, technologies and
devices. However, Heath et al. (2003) suggest that this is a
neglected area of research in health care settings. They argue that
when the role of health technologies is studied, the emphasis is on
the construction of meaning, frames of reference and perceptual
schema, thus diverting attention away from how the devices are
actually used in interaction. For Heath et al., this disregards
opportunities to understand the way in which tools and devices
feature in everyday medical practice. Anaesthesia, with its technical
complexity, therefore appeals as a site to examine the dynamics
between the spatial orders of teamwork, the manipulation of tools,
and their effects on the development of embodied knowledge.
Networks of Expertise
For Ingold and Kurttila (2000), skills are not attributes of a body
but properties of a whole system of relations constituted by the
144
presence of the agent in a richly structured environment.

Accordingly, the study of skill requires an approach that situates
the practitioner in the context of active, perceptual engagement
with the surroundings. Here, a consultant anaesthetist elaborates
on what this means in the case of anaesthesia.
Anaesthesia isnt just a case of putting a patient to sleep. Theres an
awful lot more that you need to take into account. Theres whats
wrong with the patient. Whats the surgeon actually going to do?
Whats this particular surgeon going to do? Nurses can provide you
with all sorts of snippets about their experience of having worked
with a surgeon, and how they are likely to perform in certain situations. So theres the environment, if you like, of theatres that contributes to what you need to learn in order to be an expert. And you
can be an expert in one theatre, and in the next door theatre you may
not be an expert, because you are not used to working in that environment. I see that particularly, I moved from, well I moved a session
(from one hospital to another) two or three years ago and when I got
there. . . . OK, I had been a consultant for 15 years, but I felt like a fish
out of water. And I felt unsafe because the equipment was unfamiliar
to me. I mean it was all basic anaesthetic equipment that anyone can
use, but it was equipment that I was not at that time particularly
familiar with. Working with staff that I didnt know, working with
surgeons that operated in a different way. And all these things, I
mean youre actually degraded as an expert. And you have to start to
learn again, even though you have been a consultant for 15 years.
And that applies every time you move outside of that field which
youve built up your expertise in over the years.
The consultant recognises that anaesthetic expertise does not

come embodied in one particular human to be reliably unpacked
and demonstrated wherever the individual travels. Rather,
expertise is an effect of knowing the specificities of the people
and materials in the environment around him. In this case, as for
Ingold and Kurttila (2000), knowledge and expertise is inseparable from the actual working practices of that environment,
being acutely sensitive to the particular idiosyncrasies of a tools
Embodied Knowledge
145
performance and being able to predict how a surgeon will react

in certain circumstances. These insights afford an awareness of
potential hazards and enable creative responses. Unfamiliar
context and equipment, therefore, has a detrimental effect on
expertise: it degrades performance. The consultant reframes
expertise as a reflexively situated phenomenon that draws upon
the sequential and spatial organisation of the social and material
environment. In this perspective, cognition, knowledge, skill and
mastery are viewed as public social processes embedded within a
historically shaped material environment (Goodwin, 2000).
Choreography
The following scene exemplifies exactly how familiarity with the

sequencing of actions and spatial positioning of instruments and
practitioners in the theatre environment can lead to a slick and
polished work performance. It describes a routine bronchoscopy,
in which a camera is passed into the patients lungs. The routine
consists of an elaborate choreography coordinating the positions,
movements, actions and responsibilities of materials and participants, moment by moment. For this procedure, the physician and
the anaesthetist must share responsibility for the patients airway.
The excerpt begins before the patient arrives, with the consultant
anaesthetist discussing the routine with a trainee anaesthetist.
The consultant runs through the sequence of activities with the
trainee: They get a blue cannula, then midazolam (a sedative). . . . We
take them through to theatre . . . Its quite a nice choreography . . .
its the same way every time. . . . He (the physician) goes down the
right side (of the lungs) first. . . . We insufflate (meaning to ventilate
using a specific piece of equipment known as an insufflator). . . . we
insufflate at times when he is not looking, when hes in the
trachea . . .
The patient arrives, his details are checked and he is wheeled into
the operating theatre by the consultant and the ODP.
146
The consultant immediately puts the black mask over the
patients face, the ODP attaches the monitoring. The trainee
stands to the left of the patient, next to the anaesthetic machine,
she leans over and turns a valve on the ventilator.
The consultant turns to the trainee: Spray. She goes into the
anaesthetic room to get a local anaesthetic spray. The consultant
continues: OK young man (whilst injecting the anaesthetic),
youre going to have fantastic dreams. . . . Feel nice and warm . . .
well wake you up when its all over. He speaks in a soft, hypnotic voice. He picks up the laryngoscope handle and shows it to
the ODP, there is no blade on it. (When connected to a blade the
laryngoscope forms an L shape. Holding the handle vertical the blade is
inserted into the patients mouth enabling the lower jaw to be raised to
view the vocal cords.) The ODP goes into anaesthetic room. The
consultant injects a paralysing drug, then more anaesthetic. He
explains to the trainee: I dont like leaving sux (the paralysing
drug) in the cannula . . . 0.2 ml is enough to give a patient fasiculations (in which all the muscles contract).
The ODP returns with another laryngoscope, complete with blade.
The consultant inserts the laryngoscope, then inserts the lignocaine spray (a glass syringe of local anaesthetic with a long
white nozzle and black marks about half way down) into the
patients mouth (so that the black marks on the nozzle reach the
patients trachea) then injects (spraying the vocal cords with local
anaesthetic).
Consultant: Ready. He lifts the patients head and the trainee

removes the pillows.
The physician wraps up the patients head in sterile towels.
The consultant moves to the left of the patients head. He picks
up the insufflator (a pipe attached to an oxygen cylinder with a lever
about a foot from the end): Just check. The consultant depresses
the lever and a whoosh of gas can be heard.
The physician inserts the bronchoscope.
The consultant shows the trainee how the insufflator connects to
the bronchoscope: There is a zero here and a zero on here . . .
He attaches the insufflator to the bronchoscope. The trick is not
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147
to insufflate too quickly . . . if you wash out the carbon dioxide

they wont breathe.
The trainee asks about the local anaesthetic spray.
Consultant: . . . black line to the cords, look at these things. He
shows her the lignocaine spray. . . . insufflate now, no one has
their head anywhere near . . . The consultant insufflates. Have a
feel, gently insufflate, see how easy it is. He passes the pipe to the
trainee who depresses the lever.
The physician squirts the contents of a 20 ml syringe down the
bronchoscope into the patients lungs.
Consultant explains: That was a wash, so we dont insufflate . . .
then theres a brush, like a chimney sweep . . .
Theatre sister: Lights. The lights in the room are switched on.
The physician removes the bronchoscope.
Consultant: These patients are bound to have dirt at the back of
their throats . . . He suctions around the patients mouth and
throat then places the black mask over the patients face and lifts
the patients head. The trainee replaces the pillows. She picks the
reservoir bag (which is squeezed to ventilate manually) up off the
floor, the consultant drops it back down and ventilates, squeezing
the bag with his foot.
Consultant: Its so easy this way, when youve got so many things
going on, makes it easy, have a go. The trainee squeezes the bag
with her foot.
The recovery nurse joins the consultant by the head of the
patient.
The choreography to which the consultant refers is a carefully

scripted routine finessed by regular practice. It incorporates
knowledge of how and when to use an insufflator a device only
used for bronchoscopies. It organises the oscillation of control
for the patients airway between the physician and anaesthetist,
and it specifies the position each participant should occupy at
each moment. The choreography is an intricate sequence of
movements and actions replete with knowledge specific to
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anaesthesia for this procedure. It combines tool-specific details

with an acute awareness of how best to manipulate those devices
in that environment.
However, whilst maintaining a regular sequence of actions,
the choreography allows for contingencies: a wash and brush
isnt always necessary, nor is there always a trainee to incorporate.
This is an improvisational choreography (Whalen et al., 2002).
Improvisation means to fabricate out of what is at hand, whereas
choreography refers to a pre-determined sequence of actions.
This incongruence is resolved, Whalen and colleagues argue, by
appreciating how workspaces, technologies and materials are
carefully arranged to afford the composition of routines, the
precise accomplishment of which is necessarily extemporaneous.
Positioning of the workers body and the ordering of artefacts
in a workspace are integral to proficient practice (Whalen et al.,
2002). The bronchoscopy routine shows an intricate interplay
between the anaesthetist and the physician: the anaesthetist
induces unconsciousness, paralyses and ventilates the patient;
then, while holding the patients head, the pillows are removed.
The physician then takes responsibility for the patients head,
wrapping it in sterile drapes and inserting the bronchoscope.
From the removal of the pillows until the bronchoscope is
inserted and the insufflator attached, the patient is not being
ventilated. Understandably then, this sequence of persons,
devices, movements and skilled practices is accomplished in
seconds. The positioning and use of the anaesthetists body, with
the adapted use of anaesthetic tools, is demonstrated when the
anaesthetist ventilates the patient by foot. The reservoir bag is
usually hand held but the bronchoscopy procedure requires
simultaneous adjustments to the position of the patients head,
for which the anaesthetist needs both hands.
Interestingly, the practiced nature of this performance and the
regularity of the position of tools fulfils a further purpose the
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149
consultant sees instantly that requisite items of equipment are

missing. At the mention of spray, the trainee goes to find a local
anaesthetic spray. The consultant then shows the incomplete
laryngoscope to the ODP, who replaces it moments before its use.
Goodwin and Goodwin (1996) propose that a competent practitioner must see more in a scene than is visible s/he must see
absences. This is achieved by applying knowledge of expected
configurations of activity to the scene before them. The ODPs
incomplete preparation is exposed and repaired before the missing items are required. Quietly, the consultant makes the shortfalls in preparation visible to his co-workers. A simple, non-verbal
gesture, for example, picking the laryngoscope out of an
arrangement of equipment, highlights the salient feature its
missing blade. Highlighting conveys professional vision;
emphasising an element of the material environment, shapes not
only ones own but also ones co-workers the perceptions
(Goodwin, 1994). Moreover, by requiring co-workers to repair
these shortfalls, knowledge implicit in the routine is more readily
available to them (Smith et al., 2003). Seeing, therefore, is always
part of a larger course of activity which shapes the act of perception (Goodwin and Goodwin, 1996). Picking up the incomplete laryngoscope is only comprehensible as highlighting
incomplete preparation when set in a sequence of activity that
immediately precedes its use.
Perfect Views
Central to the accomplishment of many anaesthetic techniques

and practices is the ability to achieve particular views, which, in
turn, rely on the concerted positionings of patients, materials
and practitioners. These views may be of an inaccessible part of a
patients body, or, more generally, perceiving the scene in an
occupationally relevant way (Heath et al., 1999). I explore here
150
how seeing is not only a visual but a multisensory perception,

and demonstrate how spaces and artefacts can support and
shape actions. This next scenario illustrates how the skilled use
of tools coupled with intricate knowledge of the purpose of their
design is integral to seeing and acting appropriately. Here, the
consultant anaesthetist (Dr Georgina Phillips) works with an
SHO (Dr Frank) and a medical student (Helen) on an Ear, Nose
and Throat operating list. They are in the anaesthetic room,
have just induced anaesthesia and are about to intubate the
patient.
Dr Frank waits, holding syringes and looking at Dr Phillips.
Dr Phillips: I can ventilate.
Dr Frank: 35 or 40? (mg of atracurium a muscle relaxant)
Dr Phillips: 25
Dr Frank: She is 60 kilos.
Dr Phillips: . . . they might do this operation very quickly . . . nice
airway (the medical student takes over ventilating) . . . hold the
mask . . . pull the face up into the mask . . . The medical student
holds the mask with one hand and squeezes the bag with the
other. Dr Frank comments on her good two-handed technique,
Dr Phillips agrees, noting that it is advanced for her second day
in anaesthesia.
Dr Phillips: We need to do that for 2 minutes. . . .Youve got a leak
around the mask somewhere . . . she holds the mask on as well.
The medical student then holds the mask on with both hands and
Dr Phillips ventilates.
Dr Phillips: Some people you can ventilate really nicely without an
airway (meaning airway adjuncts) . . . (presses buttons on the
monitoring) . . . thats a minute . . .
The ODP secures the patients arms by her sides using the sheet.
Dr Phillips turns the nitrous oxide off, lifts off the mask and
inserts the laryngoscope. Helen, if this is a good view Im going
to let you do the laryngoscopy . . . absolutely perfect view . . .
Embodied Knowledge
151
Dr Phillips removes the laryngoscope, replaces the face mask,

ventilates two or three times and lifts the mask off again.
ODP: Use this hand (to the medical student).
The medical student inserts the laryngoscope: . . . got the epiglottis . . .
Dr Phillips: . . . slide down a bit further . . .
ODP: Lift away from you . . . youve gone a touch too far (looking
at patients neck).
Dr Phillips talks her through the technique: Come back a bit . . .
Medical student: Got the cords. She intubates using a RAE tube
(this is an n-shaped tube which bends down from the mouth towards the
chin, it is commonly used in ENT as the tube and the connection with
the breathing circuit is directed down and away from the surgeons
access).
ODP: Yes.
Dr Phillips: You saw it go through the cords?
Helen: Yes. She looks up as she is speaking and continues to feed
the tube down further.
Dr Phillips: Wo, wo! The medical student has pushed the tube in
so the end of the tube is almost at the patients mouth, Dr Phillips
pulls it back so the bend in the tube is at the patients lips and the
end of the tube is down by the patients chin. Dr Phillips turns and
looks around at the anaesthetic machine. Now if I had a stethoscope . . . Dr Frank passes his stethoscope to the medical student.
The ODP holds the tube in place, pressing it to the patients chin.
The medical student listens to the patients chest placing the end
of the stethoscope to the side of each breast as Dr Phillips ventilates.
Medical student: Yes. ODP places a length of tape across the tube
and onto the patients chin.
Dr Frank waits for confirmation that Dr Phillips can ventilate

before injecting atracurium, the paralysing drug that will enable
intubation. He suggests a standard dose on the basis of the
patients weight; however, Dr Phillips opts to give a smaller dose
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anticipating that these surgeons might do this operation very

quickly. In this, she shows a sensitivity to the pace with which
the operating list may proceed and her role within this she does
not want to incur delays by having to wait for the paralysis to
wear off before being able to hand the patient over to a recovery
nurse. Dr Phillips then attends to teaching the medical student a
rudimentary skill of anaesthesia: ventilating a patient using only
basic apparatus. The anatomical structure of some peoples faces
means that they do not easily fit the mask exactly making it
difficult to achieve a seal. Furthermore, the internal structures of
a patients airway (the pathway from the patients nose and
mouth to their lungs) can necessitate the use of airway adjuncts
specific devices that fortify this pathway. As Ingold and Kurttila
(2000) indicate, knowledge, in this case of a patients anatomy, is
perceived in terms of how it affects the use and performance of
tools and equipment. As this patient has a nice airway that can
be easily managed without using additional airway adjuncts
she provides the ideal opportunity for the medical student to
achieve this technique. However, the medical student is successful at holding the mask on with one hand and squeezing the
reservoir bag with the other hand only momentarily before Dr
Phillips identifies a leak where the seal of the mask on the
patients face is not complete and gases escape. The difficulty
the medical student encounters illustrates the body of practices
(pull the face up into the mask, and achieve a seal) that must
be accomplished to utilise even such a mundane device as a
facemask.
Again, as the patients anatomy offers a perfect view the
medical student has the opportunity to perform a laryngoscopy
and intubation, although even perfect views do not just present
themselves to the eye. As Goodwin (1994) identifies, defining
features must be made present through embodied work. A relevant object of knowledge (vocal cords) emerges through the
Embodied Knowledge
153
interplay between a domain of scrutiny (visualisation of the

internal anatomy made possible by the use of the laryngoscope),
and a set of discursive practices (instructions on how to
manipulate the laryngoscope) being deployed within a specific
activity (intubation) (Goodwin, 1994). The medical student
demonstrates some knowledge of the process of laryngoscopy
and intubation when she states got the epiglottis and got the
cords, but Dr Phillips and the ODP supplement this with advice
on how to manipulate the laryngoscope in this specific instance
so as to yield a view of the vocal cords. It is these sensitive
adjustments to the handling of the tool and the talk shared
between experts and learners that allow the vocal cords to
become visible. Consequently, the medical student successfully
passes the endotracheal tube through the vocal cords. Nevertheless, without an understanding of the specificity of the tube,
and an awareness of the purpose of the tubes shape, she still
misplaces the tube passing it down too far, an error corrected by
Dr Phillips.
Recognising Abnormalities
Seeing, however, is not solely about the visual. Suchman (2005)

points out that for Goodwin, seeing entails complex, multisensory embodiments. Ingold and Kurttila (2000) argue that perception, in their case of the weather, is multisensory, being as
much auditory, tactile and olfactory as it is visual. Likewise,
Tellioglu and Wagner (2001) insist that the experience of
physical space is multisensory and that smell, touch, hearing,
shape, weight, texture and temperature are dimensions integral
to spatial analyses. The role sound plays in professional vision
becomes apparent in this interview when an anaesthetist discusses an incident in which a patient had a severe allergic reaction during a caesarean section. As anaphylaxis is relatively rare,
154
I asked him about preparation for such events. His response

develops the notion of how expectations highlight irregularities.
I suppose you prepare every day by doing your job. . . . You have got
to be able to recognise normal to recognise abnormal, and this is it
with her (the patient). It wasnt right. That should not have happened
to her at that stage, its take down the (sterile) drapes and go back to
the (patients) room you know. OK, sometimes people do occasionally feel nauseous near the end (of the operation) when the anxiety
levels come down, but not everything else. It shouldnt happen. . . .
You know what normal is, so when things diverge from normal then
you turn your brain on. . . . You know, has a litre (of blood) just fallen
to the floor? That was one of the things that occurred to me was she
bleeding internally? Is this hypotension (low blood pressure) secondary
to it. You know, had they (the surgeons) ruptured something and not
noticed? It could have been but, it wouldnt have responded to the
adrenalin. . . . But then as soon as her voice started going (faint), that
diagnosis went out the window. It didnt fit . . .
You have got to recognise abnormal, so you prepare for it
everyday by seeing normal. Every other caesarean section that
I have done is a preparation. . . . I have expectations about whats
going to happen during this case, and if it doesnt happen, then
I have to react to it and find out why.
The anaesthetist refers to what Sacks (1972) called normal

appearances, patterns and expectations that are time ordered:
what is normal for a place is normal for the place at a time
(Sacks, 1972: 286). At a stage when they should have been
packing away the equipment, a sudden drop in the patients
blood pressure was incongruous. The blood pressure reading
alone might be explained by the relief of anxiety, but the
anaesthetist indicates that it is the combination of disparate
features that is important. The feature elucidating this configuration was not visual but auditory the patients voice
becoming faint. This feature, in combination with a low blood
pressure that responded positively to adrenaline, at a time when
a sudden loss of blood is unusual, most clearly didnt fit.
Embodied Knowledge
155
Heath et al. (1999) note how this ability to render features of

particular scenes noticeable enables underground train drivers to
see danger at a glance. Similarly, the anaesthetist indicates the
consequences seeing has in medicine. Again, the emphasis is on
the specific combination of disparate features, whether visual,
auditory, measurements of bodily parameters or routine consequences of surgery.
When you are junior you dont know the difference between normal
and abnormal. You could have somebody who is a bit tachycardic
(has a fast heart rate): Oh yes I saw that yesterday, the consultant had
a patient that was tachycardic, thats all right. And Oh yeah, so and
so always had a blood pressure around seventy, so thats fine. But
you dont realise that this, in combination with something else, with
something else that you havent noticed, means that something is
going wrong. You dont know . . . the amount of blood loss related to
each operation. So when you are junior you dont have the experience to recognise that something is going wrong.
The immediate recognition of situationally salient features not

only contributes to the effortless fashion by which the work is
accomplished but also provides for the possibility of anticipating
events (Whalen et al., 2002). In medicine, the implications of
anticipating (problematic) events and the actions they require go
beyond the production of a proficient performance, it is central
to avoiding injury to the patient. The bronchoscopy scenario
shows how effortlessly failures in preparation can be overcome,
and injurious outcomes averted, given an acutely tuned professional eye. The anaesthetist here outlines the potential consequences of an anaesthetist yet to develop a body of normal
appearances. However, normal appearances rely, for their
intelligibility, not only on their position within a time ordered
sequence of activities but also on their spatial position. My
question, then, is what happens when the spatial orderings are
disrupted?
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Spatial Orders Interrupted
The usual spatial configuration of practitioners, tools and the

patient is disrupted in the following scenario. Two trainees are
working together one experienced (Dr Fielding) and one
novice (Dr James). The patient is lying on a new operating table
specifically designed for shoulder operations the anaesthetised
patient (especially the patients head) can be secured to the table,
sat upright and the table components around the shoulder
removed allowing the surgeons greater access. During surgery,
the anaesthetists have limited access to the patients airway so
they decide to intubate the most secure form of airway
maintenance using a flexible tube that can be angled away from
the surgery. The excerpt begins with Dr James (the novice)
administering oxygen to the patient before induction:
Dr James stands behind the patients head holding the black mask
over her face. Dr Fielding removes a pillow from under the
patients head.
Dr Fielding: Big deep breaths. (To the patient, then to the ODP)
That head ring (a table component designed to stabilise the head) is in
the way a bit, can we take it out before we intubate?
ODP: No, its fixed.
Dr Fielding has already injected some anaesthetic and now turns
on the anaesthetic gases. He turns to Dr James: Happy you can
ventilate? . . . (waits) . . . Yep, ventilating OK? I cant hear
Dr James reply but Dr Fielding injects the paralysing drug and
then more anaesthetic.
Dr James struggles to reach the patient and hold the mask on
adequately. She is small and this table is big and cumbersome.
Dr Fielding moves up to the head, repositions the patients head
and holds on the mask. Dr James hands Dr Fielding the reservoir
bag and steps back. Dr Fielding ventilates.
Dr Fielding: Thats fine. I think we are going to have to slide her
down the table. . . . Ready, brace, slide . . . (The patient is moved
Embodied Knowledge
157
so that her head lies flat on the table rather than resting in the
head ring.) Thats the best way. OK, do you want to take over?
Dr Fielding hands the bag and mask back to Dr James who then
ventilates, her eyes focussed on the patients chest.
(The consultant surgeon enters; Dr Fielding talks to him about the next
patient then turns back to Dr James.)
Dr Fielding: You happy Ann? Do you want to intubate?
Dr James: Ill have a go. Standing to the left of the patient in order
to reach the patients head, she inserts the laryngoscope, takes
4 or 5 seconds to intubate, then swiftly removes the laryngoscope
and connects the breathing circuit. (She looks confident.) The ODP
removes the bougie (a thin length of gum elastic inserted down the
centre of the tube to give the flexible tube some form) and inflates the
cuff on the tube.
Dr Fielding looks at the monitor: Why arent we getting CO2 back?
Is the CO2 sensor not connected? (If the tube is correctly placed
the monitor will measure the amount of carbon dioxide the
patient exhales.)
Dr James: Can I have a wee look? She inserts the laryngoscope.
I cant see, shall I take it out?
Dr Fielding: OK, if in doubt take it out.
Dr James removes the tube and ventilates using the face mask.
Dr Fielding: Quick, frequent breaths Ann, thats fine. The
patients colour is pinker now. When the sats (oxygen saturation
measurements) are back up have another bash. What do you think
the problem was?
Dr James: I assume I wasnt in (the trachea) but I was in something.
There are lots of bleeps from anaesthetic machine.
Dr Fielding: Were struggling with the sats, are you having trouble
ventilating?
Dr James: Not that much, shall I turn the oxygen up?
Dr Fielding: Can I have a bash? He takes over ventilating looks at
the screen then the patient, then the screen again. Have you used
the bougie before? OK, come on Ann.
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Dr James reinserts the laryngoscope. Dr Fielding stands behind
Dr James looking over her shoulder.
Dr Fielding: Can you see the cords? Put the bougie between them,
pull the bougie down beyond the tube, Ann, get the bougie
through the cords. Dr Fielding looks at the screen.
ODP: Youve got CO2 back. . . . Struggling.
Dr Fielding, speaking softly: Shes doing fine. . . . Are you happy
with the position?
Dr James picks up a stethoscope.
Dr Fielding: I listened.
Dr James: Did you, this time?
Dr Fielding: Yes.
The ODP secures the tube using a large white sticker.
As the anaesthetists and the ODP have no experience of using

this table, they are unaware of how the head ring aligns the
patients body in a way that prevents the anaesthetists from
achieving an adequate head and neck position for airway maintenance. The anaesthetists must abdicate their customary positions, which incurs further difficulties when intubating. It seems
that the experienced anaesthetist, Dr Fielding, suspects difficulty; focussing on the position of the patients head, he adjusts
the pillows and requests removal of the head ring. Indeed,
Dr James, the junior doctor, struggles to reach the patient, and
the head ring prevents her from ventilating adequately. Overcoming these difficulties requires restoring the patients normal
head and neck alignment by moving the patient down the table,
making the head ring redundant. However, to reach the patient,
Dr James now has to abandon her usual position and stand to the
left. This jeopardises her view of the vocal cords and her ability
to intubate. The spatial position a participant occupies is not
arbitrary but gives rise to particular views, experiences and
knowledge.
Embodied Knowledge
159
As Heath et al. (1999) explain, underground train drivers rely

on resources such monitors and mirrors that, although providing
fragmentary information, enable the driver to see in particular
ways. Anaesthetists are similarly reliant on tools for fragmentary
views of parts of the patients body. Despite impoverished visual
access, however, practitioners develop a rich multisensory vision.
Carbon dioxide readings complement the view of the vocal cords,
at first indicating the tubes misplacement, then confirming its
correct position. It also can be seen how the anaesthetists use
their bodies to compensate for the immutability of the operating
table (Whalen et al., 2002). This scenario illustrates how normal
appearances depend upon embodied vision the positioning of
the anaesthetists body in a particular spatial relation to the tool
and the patient. Disruptions in this spatial alignment result in a
failed intubation. Importantly, however, with coaching from
Dr Fielding, Dr James succeeds on her second attempt.
Contriving Normal Appearances
Multisensory awareness of the environment and its human,

material and technological components are critical to spatial
orientation and coordination of activity (Ingold and Kurttila,
2000). A consultant anaesthetist discusses his management of a
difficult intubation in the following interview. Here, it was the
structure of the patients anatomy that prevented a view of the
vocal cords using standard equipment. The consultant explains
how actions are shaped by the efforts to produce a normal
appearance.
This lady, who was going for a pelvic floor type repair, was quite
obese and we decided that we were going to intubate for safety of
anaesthesia. She had a couple of crowns at the front (of her teeth),
but I wasnt anticipating a difficult intubation. I assessed her pre-op
and she had good mouth opening, no problems with previous
160
anaesthetics, although she hadnt been intubated with the previous

anaesthetic, she had had a laryngeal mask (another airway management device. As it does not go through the vocal cords it can be inserted
blind). . . . Robert (a trainee), who can intubate, attempted the
intubation and he suddenly realised that she was difficult to intubate. He had to be careful of the crowns . . . but all he could see on
laryngoscopy was just the tip of the epiglottis, which makes her a
grade 3 intubation (on a scale in which 4 is the most difficult). So then
he tried with cricoid pressure (where the ODP applies pressure to the
front of the neck) to just try and bring the (vocal) cords into a better
view, because he couldnt see the cords at all. He tried with the
bougie (a thin length of gum elastic over which the tube is passed) going
down to where we thought that the cords might be but the tube
went into the oesophagus so we took it out.
I then took over and . . . had a look, and my view was exactly the
same as his, I couldnt make the view any better and it was still a
grade 3 intubation. I had a go at putting the bougie down blindly,
and again the tube went into the oesophagus, so we took it out.
I bagged (manually ventilate) her again and we kept her asleep with
the volatile (anaesthetic gas), she was easy to ventilate by bag and
mask, so we were in a controlled situation.
We then questioned, well, what do we do next? Well, there are a
number of options as to what we could have done: One was just to do it
under a laryngeal mask, but she was big and if wed have had problems
ventilating with the LM then wed have aspiration problems (where
stomach contents enter the lungs only an ET tube effectively seals the
lungs). We knew that she would be difficult to intubate, and then with
being a couple of steps behind, it could have been a potentially
dangerous situation. . . . The other option was to use the McCoy
laryngoscope (on which) theres a lever to pull the tip of the epiglottis
up and try to improve your view. But because it was so difficult to do
because of her teeth and everything, and wed cut her lip already,
I thought that wed just go straight for the fibre optic intubation
(passing a flexible fibre optic scope which allows visualisation of the airways
as the scope navigates its structures). So the anaesthetic nurse basically
just brought the scope in and we just put the tube over the scope. We
lifted the jaw up after pre-oxygenation and then making sure she was
well anaesthetised, straight in, it went in after about 2 minutes.
Embodied Knowledge
161
The consultant articulates the body of practices required to use

the intubation devices to position the patient and achieve a view of
the vocal cords. Taking over from the trainee, he states that he
was unable to improve the view. Later, I asked the consultant how
he might have done so. His response focussed on minor adjustments to the spatial configuration of the patient, anaesthetist and
artefacts: checking the patient was fully paralysed to allow full
mouth opening, adjusting the pillows to obtain the classical
sniffing the morning air position, and adjusting the cricoid
pressure. The consultant reorganises the elements of anaesthetic
practice to achieve a normal appearance. Failing this, he discusses his options. In choosing not to use a laryngeal mask, he
hints at the importance of anticipating and avoiding uncontrolled
situations. He opts for a fibre optic intubation, and as he is skilled
at this procedure, the view that this provides affords a straightforward intubation. A different tool might provide a different way
of seeing, but it also necessitates a different technique. Nevertheless, this scenario points to the utility of being familiar with the
normal appearances from different positions it offers the
possibility of accomplishing a task in different ways.
Multiple Perspectives
The benefits (and tensions) of multiple perspectives are further

illustrated here. The scene was discussed in the pervious chapter
in relation to access to the learning curriculum and the development of professional identities. It warrants further scrutiny,
however, in view of what it reveals about the value of multiple
perspectives. The trainee and the ODP have already anaesthetised the patient and inserted a laryngeal mask when the
consultant anaesthetist and I enter the anaesthetic room.
The trainee stands behind the patients head and the ODP stands
between the anaesthetic machine and the patient. The trainee
162
removes the laryngeal mask. The ODP takes a new face mask out
of a packet. I look at the oxygen saturation reading: 100%. The
patient looks pink, a normal colour. The trainee tries to turn on
one of the anaesthetic gases but struggles. The consultant turns
off a different anaesthetic gas (only one anaesthetic gas can be used at
a time).
Consultant: Is it just a poorly fitting LM (laryngeal mask)?
Trainee: Umm
ODP: Its not down far enough. (He seems to answer for the trainee.)
The trainee tries to reinsert the LM but is unsuccessful.
ODP: Come round this side . . . (He gestures to the right hand
side of the patient.)
Trainee: I will try it my own way, please, if you dont mind. She
reinserts the LM.
Consultant: Its turned, you can tell its not in right because the
black line is twisted. (A black line that runs the length of the
laryngeal mask should always lie uppermost.)
The trainee removes the LM.
ODP: Come round this side . . . The trainee follows the ODPs
instructions and successfully inserts the LM.
Consultant: Youve just made Steve (ODP) a very happy man.
The ODP secures the LM with some tape.
Consultant: You happy? to the trainee, she nods.
I want to focus here on how multiple viewpoints are used

(somewhat reluctantly) as a resource when the trainee has difficulty inserting the laryngeal mask from her usual position. The
ODP instructs the trainee to insert the laryngeal mask from a
position to the side of the patient, adjacent to the patients
shoulders. Later, I ask the consultant anaesthetist about this
incident. He comments that the twisted black line indicates the
obvious misplacement of the laryngeal mask, then outlines
some possible ways of contriving a normal appearance: the slight
Embodied Knowledge
163
adjustments to the way the device is handled, or to the positions

of both the anaesthetist and patient.
There are several things you can do: with the normal LMs you can
try putting them in the wrong way round and then turning them,
with the reinforced LMs you can reposition the (patients) head, or
take away the pillow, or move yourself round to the side. The
reason ODPs do it from the side is that is where they learn to do it
from. Ive always done it from the head so if I was to take over
I would have done it the same way as Fatima, but if Id had trouble
I would have tried it Steves way.
The consultant makes the insightful observation that ODPs and

anaesthetists learn varying techniques when inserting laryngeal
masks because of their different spatial position during the
course of induction; routinely, the anaesthetist stands behind the
head of the patient, whilst the ODP is positioned to the side.
Crucially, then, the spaces occupied by participants engender a
certain set of possibilities: the opportunity to develop particular
techniques, experiences and embodied knowledge. Disruptions
to the customary spatial configurations also function as opportunities to experience normal appearances from a different
perspective. Multiple perspectives can be a useful resource when
confronted with unanticipated difficulties, but its use depends on
the ability and willingness of practitioners to appreciate the value
of spatial variations in normal appearances.
Conclusion: Is The Same Way Every Time a Good Aspiration?
The situated nature of knowledge has long been recognised, and

Haraway (1991: 190) has argued for the need to learn how to
position knowledge in dimensions of mental and physical space
we hardly know how to name. However, the spatial arrangements of collaborative, technologically mediated work and its
relationship to embodied knowledge have largely escaped
164
attention in the literature on health care. As a contribution to the

critical gap identified by Hindmarsh and Pilnick (2002) I have
examined the spatial coordination of multidisciplinary teamwork
in anaesthesia. I have concentrated, in particular, on the careful
ordering of people, tools and devices, and its relationship with
proficient practice. The intricate sequencing of movements and
actions, the skilled and improvised use of tools and the precise
positioning of bodies (both patients and anaesthetists) actively
shapes perception. Against the routine, absences and irregularities are highlighted. Such professional vision was shown to
comprise of multisensory embodiments that form a body of
normal appearances. In medical settings, it is the particular
combination of disparate elements, rather than any single feature, that is significant. Here, the consequences of choreographies and the recognition of irregularities go beyond the
production of a competent performance and are central to
avoiding injury to the patient.
Sacks (1972) pointed out how normal appearances are timeordered. My contention is that they also are spatially ordered.
Disruptions to spatial arrangements can significantly affect the
ability of practitioners to perform routine procedures because
these depend on embodied vision on the sensory familiarity
that comes from the precise alignment of the anaesthetists body
with the tool and the patients body. So integral to competent
practice are these normal appearances that practitioners do not
just use them to chart the range of normal or even to highlight
the abnormal. Rather, normal appearances are actively contrived
by practitioners in order to accomplish safe and proficient
practice, and, in this way, competent seeing becomes competent
practice.
The standardisation of anaesthetic practices, tools and devices, anaesthetic rooms, operating tables and anaesthetic
machines might, therefore, seem an appropriate aspiration.
Embodied Knowledge
165
Ensuring conformity to accepted ways of working and spatial

arrangements would surely foster an environment that supports
competent practice by reifying normal appearances. However,
I think this would be to the detriment of anaesthetic expertise.
Disruptions to spatial arrangements, and consequently to
embodied vision, offer an opportunity to broaden ones knowledge of anaesthetic techniques and practices. Learning to see
normal appearances from a different perspective, and to
accomplish anaesthetic techniques from these altered positions,
furnishes a repertoire of techniques that can be used when facing
unanticipated difficulties. Such difficulties would not be eradicated by standardisation because many of the difficulties faced by
anaesthetists arise from the variations within the human body.
This leads me to suggest, paradoxically perhaps, that disruptions to the usual arrangements and routines of anaesthesia
are a necessary part of the development of expertise. Hutchins
(1996) makes a similar argument about error: A low level of
error that is almost certain to be detected will not in ordinary
circumstances harm performance; however, every error correction event is a learning context not just for the person who
commits the error but for all who witness it (Hutchins, 1996:
58). Hutchins argument derives from a study of quartermasters
learning to navigate. Navigation is a complex skill distributed
amongst a hierarchically ordered team. The knowledge of these
quartermasters overlaps as each has performed, at an earlier
point in their career, the tasks of the junior members. The
redundant distribution of knowledge makes for a robust team
well placed to diagnose errors (Hutchins, 1996).
The situation in health care is slightly different as work and
knowledge are partitioned amongst various disciplinary practitioners with less (formal) knowledge overlap and different career
trajectories. When overlap of knowledge and practices between
disciplines occurs, this can cause tensions. As discussed in the
166
previous chapter, when one member of the team appropriates

the practices and techniques of anothers discipline, this can
intrude on the ability of the other practitioners to develop the
skills and techniques that are central to their professional identity. And yet it is precisely pushing the boundaries of ones
practice that is vital to the development of expertise and a core
aspect of safe medical practice. It is perhaps in part a result of
these opposing pressures that boundaries are so inescapably
contestable.
Recognising Agency, Legitimating

Participation and Acting Accountably
in Anaesthesia
I began this study with questions about learning knowing and

doing: who/what can act, in what ways, how is this learnt and
how are actions recognised and rendered accountable. My concern relates to what is made visible and what is left unacknowledged in the drive to shape the organisation and delivery
of health care around standardised practices and the implications
of this. The ways in which this standardising ambition is manifested are manifold EBM, patient safety initiatives, clinical
governance and professional accountability, to name but a few.
I have focussed my analysis on EBM and professional accountability in particular, but I believe the strength of all these
approaches lies in their coherence around a human-centred,
individual model of action in which decision making is a discrete
cognitive process that can be isolated and located to certain
individuals at certain points in time and place.
A quite different view of health care practice is advanced in this
book: one in which clinicians and patients act in concert with each
other and various medical technologies, machines and devices.
Activity, decisions and participation are fluid, and agency is
relational. In supporting a collaborative notion of practice, and a
socially, materially, temporally and spatially distributed view of
action and decision making, I have sought to counter the conception of the patients wishes and contributions, the sociotechnical and material environment and other situational
167
168
contingencies, as somehow being obstacles to implementing a

pre-defined plan of care. Contesting this position in which these
elements are other than legitimate participants has meant
developing an expanded conception of agency, exploring the
range of participants and the various ways of contributing to, and
shaping, action. Decisions are taken to be distributed amongst
many more actors than a rational framework supposes, and agency
comes in forms that lack the attributes usually assigned to an
actor: intentionality, consciousness and the ability to verbalise.
These other forms of agency may be quieter and more subtle,
but their effects and contributions can still be traced. By elaborating the intricacies and extent of their involvement, I am arguing
for the legitimacy of these elements to inform health care decisions, and for greater recognition of their contribution, particularly when considering issues of accountability.
Agency
Conceptions of agency are central to policies that seek to

organise the structure and delivery of health care. Questioning,
and seeking to expand, traditional (rational, autonomous, individual) notions of agency allows the development of a deeper
appreciation of the dense sociotechnical arrangements that
comprise contemporary western medical practices. This, in turn,
enables the equity of health care policies to be better appraised.
Analysing the union between an unconscious patient and
anaesthetic machine as a cyborg a living, vital, communicating
entity opens a window on the constraints and elements shaping
practitioners actions, sensitivity to which is negligible in current
attributions of accountabilities. As discussed in chapter 2,
cyborgs convey a sense of unpredictability, they invite caution
and wariness, which is an instructive heuristic for thinking about
medical practices. Analysis of this cyborg relationship enabled a
Recognising Agency, Legitimating Participation
169
delineation of the forms of agency made possible by the intertwinement of humans with technology that anaesthesia requires.
Further, it provides an example of how bodies can communicate
outside a persons consciousness. Far from being passive and
homogeneous, unconscious patients retain their specificity in
their embodied form, in the signs and signals that the body and
the technology produce, and in the interventions their unconscious bodies require. Agency, in this sense, is respecified from a
capacity intrinsic to individuals to an effect generated through
collaborative sociotechnical practices coupled with accepted,
routinised forms of interpretation. However, the range of human
and non-human participants that have been shown to inform the
unfolding delivery of health care means that, far from being
predetermined, practices are contingently enacted and thus,
potentially, easily disturbed. Consequently, acknowledging the
contributions to practice made by the cyborg requires that the
limits of, and constraints on, practitioner agency be given further
consideration.
As I have insisted, the anaesthetist cannot implement his/her
plan of care irrespective of the expressions of the cyborg. The
evidence of readings and measurements cannot be disregarded
lightly. Actions, treatments, interventions and omissions must be
legitimate, reasonable responses, and doctors are expected to
practice with a degree of certainty. A notion of distributed
agency, therefore, works well to understand practice, to elucidate
contributions to it, and to indicate the limitations of a deterministic critique of medical practice; however, it also broaches
questions around how the legitimacy and accountability of
actions are achieved. It has been noted how it falls to the practitioner to reconcile the differences between the plan and the
practice (Suchman, 2007), but this task becomes particularly
problematic on those occasions when the planned care is
derailed by participants who tend to go unrecognised in formal
170
descriptions of practice, and on those occasions when the contributions are incomprehensible to practitioners.
Given that incoherences and disunities form an integral part
of medical practice, it therefore warrants consideration of how
the risks involved in working in such complex, dynamic and
multifaceted situations are addressed by practitioners. Personal
routines, established through experience, are employed as a way
of maintaining safety. Checks and monitoring activities become
part of routine practice, an effect of the culture of certainty in
which doctors operate. They constitute legitimate and
accountable action. The difficulty arises when actions cannot be
justified in terms of these explicit, externally verifiable indicators.
Incoherent bodies generate insecurities. Explicitly identifying
warrants for interventions and the recognition of these amongst
the team not only enables the doctor to be convinced he/she is
acting appropriately but also renders publicly available the
accountability of these actions. However, the sticking point comes
when decisions that might seem reasonable to co-participants who
share professional vision are subject to post-hoc scrutiny and
reconstructed as unwise when questions of accountability are
raised. In these circumstances, it is unclear how far notions of
expertise, tacit knowledge and professional vision would go to
support a practitioners actions, and would depend in large part
on the degree to which they could be articulated and supported
in other words, constructed as evidence.
I have highlighted the tensions between understanding
practice as something fluid, unstable and multiple, the cultural
expectations of certainty and the need to act sometimes in the
absence of certainty. I suggested that tracing the different
manifestations of accountability and the links between them
allows one to discern why disunities must, on occasions, be
addressed by practitioners. Incoherences must in some way be
comprehended so that actions can be made accountable. In this
171
description of anaesthetic work, the idea that action follows

decision making in a linear process is thoroughly eroded, which,
in turn, prompts a need recognise, and in some ways legitimate,
the logics of professional vision and tacit knowledge.
Participation
The effects of the visibility of knowledges and informal working

practices are brought sharply into focus when considering the
practices of multidisciplinary teamworking. There is a long
tradition of working across boundaries in health care, tentatively
and subtly perhaps, but in ways that blur distinct disciplinary
demarcations. This work offers the opportunity for practitioners
to develop their knowledge and expertise, to individualise their
participation within the team, to bridge gaps and fissures in the
provision of health care ultimately in the aim of providing a
better patient service. However, one cost of this work is the
potential exposure to criticism if there is reason to subsequently
inspect a practitioners actions in the light of formal descriptions
of their role, whether these be codes of professional conduct,
clinical practice guidelines or local policies and procedures.
Another cost is the conflict that might arise from role reconfigurations. When members participate in ways that stray outside
accepted boundaries of their practice this may impinge on the
opportunities of another to develop the skills, practices,
knowledge and identity to which he or she aspires.
Tensions develop, and legitimacy is disputed, when a participants developing identity is jeopardised by anothers appropriation of the learning curriculum. Legitimacy of participation
is, at once, stratified according to professional identity, and yet
always available for challenge and renegotiation. In this way,
boundaries both shift and endure, being re-enacted and remade
afresh. The stratification of participation, however, results in
172
certain practitioners having fewer resources with which to

interpret a scene or event. Moreover, formal role descriptions
tend to designate diagnosis and prescription as medical activities. In order to achieve optimal care of a patient, then, nurses
and ODPs must rely on persuading others (doctors) of their
interpretation and the interventions they think necessary, but
they are disadvantaged in terms of resources with which to do so.
Insofar as this informal means of organising care works, it
remains largely unrecognised. However, problems arise when it
fails: officially and unofficially the practitioner has no means of
securing what is in their view appropriate care of the patient.
Understanding the effects such an ecology of participation
has for the development of knowledge and opportunities to
contribute to treatment decisions, allows one to extrapolate the
implications this has for future developments and current trends
within the organisation and delivery of health care. Nancarrow
and Borthwick (2005) identify how the notion of workplace
flexibility has received increased international attention resulting in widespread policy level support for boundary renegotiation. This support, coupled with the upward expansion of
existing roles and the introduction of new workers, they suggested, has led to the noticeably diminished dominance of the
medical profession. However, the increasing propensity to
organise health care by establishing protocols and clinical
practice guidelines (Berg et al., 2000) implies that although the
limits of a participants practice may have advanced, the overall
shape of the service, and the relationships between participants,
remains much the same. The difficulty here is that it is probable
this new configuration will inherit the same problems as the
old, in that working across boundaries and adjusting guidelines
to fit local requirements will still be necessary but it will remain
invisible, or at least obscured, often being relabelled. When
undertaking this work, practitioners will continue to be
173
unsupported by organisational policies, a difficulty that may even

be exacerbated if safety is coupled ever more tightly to the
guidelines with which practitioners must work.
The ecology of participation the relationship between people, tools and devices, and their positioning in the workplace
also can be seen to have significant effects in the development of
embodied knowledge and its implications for proficient practice
and patient safety. The intricate sequencing of movements and
actions, the skilled and improvised use of tools and the precise
positioning of bodies actively shapes perception. Against the
routine, absences and irregularities are highlighted. Such professional vision was shown to comprise of multisensory embodiments that form a body of normal appearances. I have
demonstrated the way that practitioners experience physical
space, and develop understandings of patients anatomies
through the effects this has for their use of tools. Practitioners
draw on this sensory familiarity to replicate safe and proficient
practice. With their bodies, their use of space, and their
manipulation of equipment, practitioners actively seek to construct normal appearances. All of these elements become
inadvertently perhaps scripted into routines finessed by
practice and in this way competent seeing becomes competent
practice.
As I have suggested, the standardisation of practices and
clinical environments might seem to be an appropriate aspiration. Conformity to accepted ways of working and spatial
arrangements would foster an environment that supports competent practice by reifying normal appearances. However, this
paradoxically may be to the detriment of expertise. Disruptions
to spatial arrangements, and consequently to embodied vision,
offer an opportunity to broaden ones knowledge of techniques
and practices. Learning to see normal appearances from a different perspective, and to accomplish techniques from these
174
different positions, furnishes a repertoire of techniques that can

be used when facing unanticipated difficulties. Such difficulties
would not be eradicated by standardisation of practices and
working environments because many difficulties arise from the
variations within the human body. Therefore, disruptions to
the usual arrangements and routines may be a necessary part of
the development of expertise.
Legitimation
Legitimacy and its production is a theme that runs throughout this

book in many guises. First, as discussed earlier, EBM, professional
accountability and other associated forms of governance serve to
undermine the legitimate involvement in decision making of many
integral aspects of health care patients, technologies, the local
environment and so forth. So, one motivation underlying this
analysis is to argue for the legitimate participation of such marginalised elements in attempts to discuss and understand how
action occurs, and thus to plan and inform the organisation and
delivery of health care. Recognition of the more silent participants
of health care practice is vital if policies are to be equitable.
I also take up the question of how legitimacy, accountability,
and the specific sense of professional accountability are related
and yet distinct. Legitimacy, I proposed, relates to the reasonableness and appropriateness of a diagnosis, proposed treatment
or action, and legitimation to the processes that establish it as
such, whereas accountability refers to the public recognition of
legitimacy. It has been posited that the ethnomethodological
sense of accountability tends to be rather ambiguous in relation
to which public does the recognising (Neyland and Woolgar,
2002), with the immediately surrounding public being implied.
In my view, professional accountability subsumes and extends
this notion of the public; those participants immediately present
175
serve to establish a consensus of accountability that facilitates the

ongoing unfolding action. Whilst not specifically addressed in
this book, there is a great deal of scholarship exploring the status
of records and texts as artefacts of accountability. What I have
tried to convey is how a notion of professional accountability
pervades and informs practice, for example, an awareness of the
need to describe events to other publics (relatives) and a consciousness that such actions might be subsequently scrutinised.
I also sought to expound the notion of legitimate and illegitimate participation drawing out the consequences this has for
learning about practice and the potential to inform practice. The
effects of legitimate participation are not only of interest to
sociologists; rather, the tensions produced by perceptions of
illegitimate participation have tangible effects on those practitioners who have to rely on persuasion in order to inform a
trajectory of care.
In the scenarios discussed throughout this analysis, claims for
legitimacy would involve soliciting increased recognition making invisible work and knowledge visible. Such a transformation is
not without problems both practically and ideologically. Star
and Strauss (1999) identify how attempts to make work visible
are fraught with trade-offs and politics. More visibility may
mean more surveillance, an increase in paperwork and the
eradication of discretion. In this vein, McDonald et al. (2006)
have noted how the specification of tasks in EBM guidelines
provides a tool with which nonmedical managers can appropriately question medical practices. Increased visibility, therefore,
may not be a desirable option to all concerned. My unease,
however, lies with the increasing propensity for movements such
as EBM, clinical governance, patient safety and professional
accountability to close down spaces of action by coupling safe
practice ever more rigidly to the implementation of guidelines
and policies. In further diminishing the legitimacy of patients
176
and situational contingencies to inform treatment decisions, a

situation is likely to ensue in which the knowledge and expertise
that have contributed to such decisions, and on which safe
practice depends, will be obscured and driven underground. The
disadvantages of increased visibility, listed earlier, could be said
to be already mounting, one way, then, to balance this might be
to fill those spaces of action that are being closed down with
knowledges that allow for and grant the need for individualised
care, discretion and a broader notion of participation.
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Index
access, 114, 11518, 124, 127, 136, 137

accountability, 16, 22, 26, 28, 30,
32, 37, 52, 59, 602, 69,
736, 803, 89, 92, 94, 96100,
1004, 105, 130, 16770, 174
accounting, 20, 24, 25
ethnomethodology, 74, 92, 96, 97,
102, 103, 174
professional, 16, 23, 25, 28, 31,
69, 82, 97, 100, 102, 104, 167,
174, 175
responsibilities, 24
vulnerabilities, 21, 80, 89, 103, 135,
170, 171, 173
accounts, 55, 56, 71, 73, 79, 131
action, 32, 43, 55, 62, 735, 83, 89,
909, 1025, 111, 145, 164,
16770, 174, 175
capacities for, 26, 27
collaborative, 23, 25, 32, 167
courses of, 21, 27, 62, 71, 79, 83
individual, 23, 25, 167
initiating, 1304, 137, 138, 172,
175
agency, 26, 369, 41, 42, 50, 5662,
66, 79, 105, 167, 16871
expressions of, 43, 4852, 54, 57
relational, 26, 57
without intentionality, 43, 56,
57, 168
anaesthesia, 26, 40, 424, 519, 70,
105, 139, 142, 143, 165
anaesthetic machines, 26, 33, 43,

489, 53, 55, 56, 58, 59,
164, 168
anticipation, 48, 75, 99, 104, 155
bodies, 33, 51, 57, 64, 94, 102, 148,
14953, 15661, 165, 169, 173
acting, 79
augmented, 43, 46, 4850, 53, 56,
59
coherent, 61, 63, 65, 706
incoherent, 61, 62, 656, 72,
7683, 1004, 170
passive, 66
patients, 26, 30, 3943, 99, 101,
148, 164
practitioners, 30, 148, 164
specificity, 50, 58, 69, 169
boundaries, 10514, 1214, 125,
1304, 1368, 140, 166, 1712
disputes, 29, 30, 109, 114, 11518,
11821, 135, 171
of normal practice, 48, 71, 75, 101
professional, 29, 11821, 124, 126,
127, 137, 140, 141
certainty, 28, 62, 736, 83, 91, 1024,
16970
choreography, 1459, 164, 173
clinical governance, 16, 212, 68, 175
codes of conduct, 226, 62, 69, 100,
104, 171
185
186
community of practice, 29, 11214,
117, 118, 121, 136, 137
configurations, 139, 143,
14556, 15965, 172
disruptions to, 30, 139, 1559,
1635, 173, 174
workplace dimensions, 30, 13943,
173
cyborg, 339, 43, 44, 46, 4853, 559,
61, 62, 68, 168, 169
analytical resource, 369
communicative resources, 46, 49,
546
decision making, 18, 20, 23, 25, 27,
31, 32, 41, 60, 61, 713, 10710,
134, 141, 167, 1702, 174
distributed, 25, 69, 80, 81, 104,
110, 111, 167, 168
individual, 25, 69, 101, 110
depersonalisation, 27, 40, 58
diagnosis, 24, 41, 66, 88, 89, 91, 96,
97, 99, 101, 104, 111, 1214,
127, 134, 138, 172, 174
ethnography, 715
fieldwork, 715
access, 7, 8
ethics, 7, 1214
identities, 8, 911
interviews, 7, 1415
observation, 7, 9, 14
evidence, 1719, 26, 73, 169, 170
evidence based medicine, 1621, 52,
60, 68, 167, 174, 175
guidelines, 1621, 26, 60, 62, 68, 73,
104, 134, 1713, 175
identity, 112, 114, 11921, 124,
12730, 1304, 1367, 166, 171
knowledge, 15, 19, 20, 26, 29, 32, 40,
52, 624, 101, 10512, 11517,
Index
1214, 12734, 136, 140, 145,
147, 149, 150, 152, 153, 163,
165, 171, 172, 175, 176
embodied, 16, 30, 139, 142, 143,
1635, 173
experiential, 18, 107
formalised, 16, 18, 20, 22, 26, 32,
69, 135, 171
situated, 16, 18
tacit, 803, 102, 170, 171
Lave and Wenger, 29, 113, 114, 118,
129, 136, 137
learning, 16, 30, 11214, 165, 167
curriculum, 114, 11821, 124, 129,
136, 171
legitimacy, 29, 32, 52, 6870, 736,
89, 115, 11721, 124, 126,
1368, 168, 169, 171, 1745
stratified legitimacy, 121, 12430,
136, 171
legitimation, 52, 53, 68, 79, 81, 83,
89, 96, 97, 99, 103, 1746
making meaning, 628, 713, 7880,
8494, 96
medical dominance, 31, 32, 39
medical technologies, 26, 27, 3942,
59, 668, 102, 107, 143, 167, 174
Mol, 646, 90
multiplicity, 28, 61, 64, 65, 82,
104, 170
normal appearances, 30, 154, 155,
159, 161, 1635, 173
participation, 32, 43, 53, 105,
11238, 167, 1716
access, 29
identities, 29, 40
illegitimate, 120, 126, 175
legitimate peripheral, 29, 136
patients, 25, 26, 42, 43, 4851, 536,
63, 66, 71, 76, 78, 81, 88,
Index
98100, 105, 110, 115, 121, 125,
126, 130, 138, 140, 143, 147,
154, 167, 168, 174
acting, 27, 41, 42, 49, 53, 56, 58, 59
passive, 26, 31, 33, 3943, 49,
61, 169
Poovey, 42, 43, 55, 56, 59
practitioners, 24, 26, 43, 58, 59,
62, 66, 75, 84, 100, 101,
106, 111, 112, 114, 118, 119,
121, 135, 13740, 143, 145, 148,
152, 1625, 16773
anaesthetist, 27, 50, 52, 53, 557,
61, 67, 70, 72, 76, 7881, 84, 86,
99, 104, 105, 111, 113, 115, 129,
131, 134, 138, 142, 158
nurses, 19, 28, 52, 84, 86, 93, 98,
105, 106, 107, 109, 113, 130,
131, 134, 138
ODPs, 28, 48, 105, 111, 113, 115,
118, 126, 129, 130, 149, 158
professional regulation, 22, 68, 103
187
professional vision, 81, 82, 88, 100,
102, 143, 149, 153, 164, 170,
171, 173
resistance, 59, 120
routines, 16, 18, 20, 52, 55, 7383, 86,
89, 1014, 107, 110, 112, 113,
115, 117, 139, 1459, 164, 165,
170, 173
seeing, 14964
standardisation, 1618, 20, 22, 68, 69,
165, 167, 173, 174
teamwork, 24, 10512, 120, 129, 134,
135, 139, 140, 143, 164, 171
tools and devices, 16, 30, 55, 101,
104, 120, 139, 140, 14253,
15664, 167, 173
uncertainty, 23, 82, 86, 89, 91, 102,
131, 133
Books in the series (continued from page iii)

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Computation and Human Experience
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Communities of Practice: Learning, Meaning, and Identity
Etienne Wenger
Learning in Likely Places: Varieties of Apprenticeship in Japan
John Singleton
Talking Mathematics in School: Studies of Teaching and Learning
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Punamaki
Dialogic Inquiry: Towards a Sociocultural Practice and Theory of
Education
Gordon Wells
Vygotskian Perspectives on Literacy Research: Constructing Meaning
Through Collaborative Inquiry
Carol D. Lee and Peter Smagorinsky
Technology in Action
Christian Heath and Paul Luff
Changing Classes: School Reform and the New Economy
Martin Packer
Building Virtual Communities: Learning and Change
in Cyberspace
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Adult Learning and Technology in Working-Class Life
Peter Sawchuk
Vygotskys Educational Theory in Cultural Context
Alex Kozulin, Boris Gindis, Vladimir S. Ageyev, and Suzanne
M. Miller
Designing for Virtual Communities in the Service

of Learning
Sasha A. Barab, Rob Kling, and James H. Gray
Bakhtinian Perspectives on Language, Literacy, and Learning
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The Learning in Doing series was founded in 1987 by Roy Pea and John
Seely Brown.

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Acting in Anaesthesia: Ethnographic Encounters with

Patients, Practitioners and Medical Technologies

2 Refashioning Bodies, Reshaping Agency

3 Accounting for Incoherent Bodies

4 Teamwork, Participation and Boundaries

5 Embodied Knowledge: Coordinating Spaces, Bodies

6 Recognising Agency, Legitimating Participation

This series for Cambridge University Press is widely known as

successful learning wherever it occurs. The series invites

I would like to express my sincere thanks to all the people who

Acting in Anaesthesia: Ethnographic Encounters with

Understanding Anaesthesia: Theory

After changing into my theatre blues I walk down the corridor

size 5 face mask, a size 14 or 16 naso-gastric tube, intravenous

these dynamics in knowing, doing, acting and intervening can be

here and now in the operating theatre, to a life and history

Fieldwork Identities and Local Knowledge

The study adopted an ethnographic approach grounded in

negotiating access, on an individual level. Each time I observed in

either be a stranger to the life as usual character of everyday

This criteria laid out by Hess placed me at an advantage, and in

useful resource. During the fieldwork, then, I sought to utilise

Guided by the expertise study design, the clinical observation was

which everyday anaesthetic practice proceeds. And, as I suggested

Paradoxically, then, where rapport was at its best, and my identity

participants also exert their agency and in doing so contribute to

My remit to ascertain and elucidate the tacit aspects of practice,

This book utilises the fieldwork I undertook for the expertise

to person, gets embedded into personal and local routines, is

knowledge about the effectiveness of treatments) and have

EBM is emblematic of such a standardising logic: it is the

The political and ethical dimensions of this classification system

However, Berg (1997a) notes that guidelines do not confine

command less publicity, and research interest and funding than

Accordingly, EBM and clinical guidelines are just one of the

Suchman (2007: 200) elaborates this point in respect of the

Suchmans observation about creative accounting draws

documenting clinical practice, which, in conjunction with the

So as indicated in this discussion, where practice is formalised,

however, is the model of practice on which they are based. For

This assumes that it is always possible to know the cause of the

These statements reify a model of practice in which practitioners

influence over doctors diagnoses and prescriptions, perhaps by

Here, the composition of teams is implicitly taken to be regular

And doctors must:

Practitioners must be able to give an adequate account of their

unfolds and the way that formal descriptions of practice insist it

body, in this configuration, the patient as a unique individual is

practitioner. More recently in Science and Technology Studies

addresses the tensions that develop when practitioners stray

teams of practitioners and the hospital environment, along with

of medicine, however, this book will delineate the limits of this

Refashioning Bodies, Reshaping Agency*

The purpose of anaesthesia is to temporarily insulate a patients

The word cyborg was coined in 1960 by Clynes and Kline,

agency. Science, Technology and Human Values, 33:3 (34563).

creature enhanced by computer-controlled bio-feedback systems,

Space travel, according to Clynes and Kline, would be better

The technological components of the cyborg, therefore, are

Again, the defining feature of the cyborg is his/her vigour and

Refashioning Bodies, Reshaping Agency

The cyborgs of fiction have increased in imaginary complexity