Your High Horse

What happened to kneeling?

People have problems, so they call the ambulance. We arrive and find them — mostly — seated in a chair, or lying in a bed, or perhaps down on the ground. Then we kneel beside them and introduce ourselves. We ask questions, put our hands on them, give medicines, and so on down that clinical flow you learned in school.

Here is what we don’t do: stand six feet away, look down at the patient (and maybe, maybe deign to bend over a little, with our hands on our thighs like we’re admiring a gregarious puppy), and shout in their direction. “Do you want to go to the hospital?” This is not yodeling practice. This is caregiving.

When did we stop kneeling? More and more, this practice seems to be spreading, and it’s reached the point where I can hardly remember the last time I saw one of us kneel beside a patient. Occasionally somebody will kneel to take vitals, but the provider actually speaking and interacting with the sick person still towers over them like a cop chalking off a body.

Yes, yes, I get it. Your knees are bad. I’ve been there. And your back, it’s stiff. You’re not 21 anymore, you can’t go kneeling willy-nilly. Sure.

But we’re not talking about an Olympic sport here, okay? We’re talking about kneeling, at least for a moment, in whatever manner you can successfully perform. At the very, very least, sit down on something so you’re level with the patient. Park your butt beside them on the sofa or pull up a chair.

It’s about patient comfort, because they want to feel like they’re engaging with a fellow human, not yelling up at Rapunzel’s tower. But it’s also about the dynamic it creates between you. As a novice provider, when I first read Thom Dick write about humility, I didn’t understand. But as time passed, it made more and more sense to me (something that happens suspiciously often with Thom’s stuff). Body language says something, not just to others, but to yourself.

When you kneel, you’re saying: I’m here to help. I’m here to serve you. We don’t kneel very much anymore, not in the modern Western world, but we understand instinctively why one would kneel before a king. It’s not in spite of the effort it takes you to get down there, it’s because of it: by making yourself uncomfortable, you’re demonstrating a willingness to put someone else’s needs before your own.

It’s not saying that they’re your master, and you’re not making them the boss of anything. They’re not making you kneel, which is all the difference: it’s a gift, freely given. You’re acknowledging that the patient is important. More prosaically, it’s very much like the relationship that the cashier at Wal-Mart is supposed to have with you (at least in theory). If you met him on his day off, he might cut you off in traffic, flip you the finger, and drive away cackling. But while you buy batteries, at least, it’s his job to help you out. If he’s lucky, he enjoys doing that; if he’s not, he feels forced into it because he wants to keep his paycheck. We’re in a different boat, though, because our obligation doesn’t come from a boss looking over our shoulder. It comes from the fact that we accepted a duty (perhaps sacred, perhaps mundane, but a duty either way) — that when someone calls 911 and asks for our help, we’ll come and serve them. That makes us servants, and not in a bad way.

Something different happens when you refuse to lower yourself before a patient. It tells everyone in the room, including the patient and especially including yourself, that although you’re here, and although you might perform the clinically-indicated medical treatment, you’re not putting yourself out at all. Drive-by care is all you’re willing to offer. It’s like telling the patient: “Just to be clear, we were in the area anyway, and I thought you might have some snacks.”

I have great respect for police, and we work alongside them often. But their business is very different from ours, and it highlights the dangers in conflating the role of EMS with that of public safety. The job of a caregiver is to serve. The job of a cop is to enforce. It means they have to elevate themselves — you can’t exert authority unless you’re coming from a place of some kind of superiority (legal, moral, even physical). It means they have to judge. I don’t know if they enjoy it, and I do know that it’s highly necessary. But it takes a different kind of person, or at least a different kind of thinking, to judge people than it takes to serve them. Try to imagine a cop kneeling, or helping to wipe Mrs. Smith’s bottom. Now imagine yourself wearing aviators, crossing your arms and leaning against the wall while you bark at her, and understand that it’s just as misplaced.

What’s funny is that when you accept this “lesser” role, you can find an awful lot of meaning in it, because it’s a privileged place too. The privilege isn’t something you exert over others: rather, it’s freely granted to you by the patient. When they see that you’re here to help them, they give you permission to enter their home, to touch their body, to ask them the most intimate questions. This is essential, because you need that access to do your job (and it’s why I believe that mixing EMS and law enforcement would mean a major blow to our ability to treat people). But it’s still a gift. And I think that’s worth something. Even sore knees.

Comments

  1. I know a lot of the medics I work with have stopped kneeling because, in their own words, “I wouldn’t be able to get back up.” They then point to their knees or back. They aren’t spring chickens anymore I guess :)

    • I mean, I’m not going to point to anyone individually and call them out, because I don’t know their story and maybe they wake up in agony every day. But I strongly suspect that for many of us it’s less medical and more lazy. You can often graph an inverse relationship between how often they kneel and how burned out they get. Stand rather than kneel, it’s a short trip so skip the 12-lead, and hey buddy can you walk to the truck?

      At least sit. Sitting’s easy.

  2. Excellent post.

    As an FTO and preceptor, I give my students an excerpt from Thom’s book “People Care” and have them read and understand it before they step foot into a truck.
    I firmly believe one of the healthiest human experiences is that of personal contact. For many, that provides a calm reassurance that you’re there to help them.

    Definitely something that can’t be taught in a classroom.

    • Which excerpt do you use? I’ve had similar ideas before. I don’t think squeaky-new providers will really understand a lot of it until they’ve gotten their hands dirty a little — it almost seems like more of a “how to redirect yourself away from burnout” manual for veterans — but I think it could help set them up in the right frame of mind for the work, particularly since most people come in with such warped ideas of the job.

    • emt.dan says:

      Thanks Brandon for citing this book, I hadn’t seen it before (although I’ve read Thom’s articles). Do you know where I could get my hands on a copy of the book– it doesn’t seem to be easily accessible on Amazon.

      • I am saddened to see that used copies on Amazon have become exorbitantly expensive. I’m told that a revised second edition will soon be available, although I don’t know through what avenue; if anybody knows more about it I’d love to hear. (Supposedly advance orders were being placed at EMS Today this year.)

        I can loan you mine if you promise I’ll see it again. I’ll drop you a line.

  3. I’m new to the world of EMT-ing, but I was once an amateur bicycle racer and have been a volunteer firefighter for several years. In doing both, I was taught to never stand when you can sit or kneel – it wastes less energy. So I see no disadvantage to getting down at the patient’s level.

    Physical fitness can play a big role in minimizing the effects of arthritis and back pain (and minimize the risk of sustaining a career ending back injury). Responder safety first – a physical fitness regime can help avoid little and big injuries faced in the field.

    There is one reason I don’t like to kneel – my boots are a lot more protective than my pants. Nothing like kneeling down next to a postictal patient on a brown shag carpet and realizing that your knees are getting wet. Sigh. Nothing a washing machine and a shower won’t take care of, I guess. But boots do protect against broken glass, other debris, and body fluids.

  4. The caring attitude and print are beautiful. Kudos

  5. emt.dan says:

    Very, very interesting, thank you. I’ve learned the art of kneeling, without my knees making contact with the ground, frankly, because I’m not always in the most pleasant places.
    Kneeling communicates that we are bringing ourselves to the patient’s level, we are ready and willing to hear what is ailing them, and prepared to help them feel better, but that we’ve made the first attempt to come to their level. Particularly when there are cultural, religious, language gaps and barriers, it shows that you’re working to bridge those gaps, and are prepared to help. (See LEARN model for cultural bridging, http://etl2.library.musc.edu/cultural/communication/communication_2.php)

    On the other hand, there are dangers to placing yourself in a possibly compromising position, kneeling down. You significantly less able to react if threatened, and in a difficult place if you need to escape. Police officers absolutely need to assert dominance, but they also don’t kneel because it’s so compromising. EMTs and Medics should of course consider their own safety and the dynamics of the scene before considering this.

    • Well said, Dan. In a way, I’m inclined to view the “funkiness” of most places we kneel as part of the point. Imagine laying your coat down over a puddle for your date. Saying “… but it’s wet” is missing the point. Obviously we shouldn’t be putting our knee into used needles or gross contaminants, but I don’t think we’re usually talking about that… we’re talking about yuckiness.

      But that’s just me, and I suppose I have a high tolerance for grossness. You can always “pop a squat” without touching the ground, although I think this requires a little more athleticism than the kneel. Sitting on something is a decent compromise.

      In a way, the willingness to do it is as important as actually doing it (admittedly the former means something for us, the latter for the patient). I try to imagine someone like a cop kneeling even if he safely could, and I can’t. (For what it’s worth, I studied a martial art called silat for a while, and we spent half our time on one knee! It’s not so flat-footed if you know how to do it.)

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