The Q Word Podcast
Lisa: So Nyssa, are we talking about a tip, a trend or a taboo today?
Nyssa: Well, Lisa, we are talking about a taboo and today's taboo is a taboo with a capital ‘T’. Of all the taboos I can think of this may be the top one. It's definitely top three.
Lisa: Okay, so it's more taboo-esque than our long, extended discussion of fecal matter.
Nyssa: Oh, yeah. Yeah, definitely more taboo than that. That's not even top five, to be honest.
Lisa: Really? Alright, so what is this taboo that we're going to be talking about today?
Nyssa: So let me start you off with a couple of jokes. A guy is standing before the firing squad being ready to be executed. And the executioner says, “Would you like one last cigarette?” And the man says, “Ehh, I'm trying to quit.”
Lisa: That's a good one.
Nyssa: The other one is: the gentleman is literally standing on the gallows getting ready to be hung. The hooded executioner motions for him to step out onto the square and he looks to executioner says, “Are you sure it's safe?” So these are literally examples of something called gallows humor, which is also known as dark humor.
Nyssa: This is something that exists in healthcare and this is the taboo that we're going to talk about today.
Lisa: Oh, okay. So people laughing in the ER, people laughing at skin wasting diseases, or explosive diarrhea… any of that stuff?
Nyssa: We're going to explore all of that. Exactly right.
Nyssa: When I started looking into this, because I have experienced dark humor in my practice, you know, I think I mentioned to you that I wanted to explore maybe doing an episode on this and I found an article and after reading this article, I was like, “Lisa, abort! Abort! We cannot do this topic.” So let me tell you about this article. This was published in The Washington Post and the title is, “Nurses make fun of their dying patients. That's okay.”
Lisa: I could see how people would respond to that... I mean, that's like a clickbait title, though. I'm sure that there's a deeper story there. But right, I could see people going, “How dare people laugh at the suffering of my mommy or my little child or my brother or whatever!”
Nyssa: So you have hit the nail on the head. First of all, The Washington Post is a general audience forum. This is not a health care forum. So this is Jane and John Public that are reading this. And this is an author who just released a book that she's trying to sell. So you're exactly right. She uses a literary hook with this inflammatory title where she wants people to read her article and then buy her book. It is talking about this gallows humor, and I will go ahead and take issue with the fact that no, it's not okay for nurses to make fun of dying patients. Is it okay for nurses to make fun of death? Yes. Dying patients? No. So that is kind of where we're going to draw our line and explore and dig deep into. So this young lady's name is Alexandra Robbins. She is not a nurse. She does this thing where she follows people around for a year and then writes a book about them. And that's exactly what she did. She followed some nurses around for a year. Her book is called The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital. One of the things that she noticed when she was following these nurses around is this phenomenon of dark humor. She gives some examples in her article. So this is what the people who are reading The Washington Post were reading. She opens the story with a nurse who is cleaning up a patient who's having copious amounts of vomit and she's using the suction catheter to suction up this vomit. Well, evidently, the patient had also eaten a lot of corn the day before and so the corn kernels don't digest and they’re clogging the suction tubing. So this nurse is having to continually unclog all this corn, and corn, and copious amounts of corn.
Lisa: This is the second appearance of corn on this podcast, you realize.
Nyssa: Undigested corn. It is. Might be like a thing, I don't know.
Lisa: Apparently it is, yes.
Nyssa: So the next day this nurse comes in and she has two cans of corn; one presented to her from each of her co-workers to be funny, just to be funny. Again, they're not making fun of the patient. They're making fun of the vomit and the phenomenon of undigested food that we've all experienced on a personal level and on a patient level.
Lisa: Yeah, it’s situational humor. They're trying to make light of something that was probably completely disgusting for this woman to have to deal with.
Lisa: I get it.
Nyssa: Miss Robbins, the author, also says that she heard phrases- like, when a patient is dying or very, very critical- she heard nurses and physicians say things like, “they're circling the drain.” “They're approaching room temperature.” She heard a gunshot wound described as “acute lead poisoning.”
Lisa: Okay, I've heard that one, too.
Nyssa: Yeah. And then she quotes a professor from John Hopkins University named Ronald Burke and he says that “... derogatory and cynical humour as displayed by medical personnel are forms of verbal abuse, disrespect and the dehumanization of their patients and themselves.” You take someone when they're at their most vulnerable and powerless and make them a target of abuse. So this professor obviously is 100% against the use of gallows humor in the healthcare realm.
Lisa: I'm envisioning this shriveled up, wizened, old guy who has absolutely no sense of humor whatsoever and takes everything incredibly seriously.
Nyssa: Yes. So Miss Robbins says that she disagrees. She says that when people argue that dark humor indicates a lack of caring and abuse of power or trust or that it compromises medical care, that in her experience following these nurses around for a year she found the opposite. She found that it is a decompressing mechanism for healthcare providers. It's team building. It's definitely borne out in science and in research that it is therapeutic and that it is a coping mechanism that healthcare providers use when they see these tragedies and traumas and these horrific things, sometimes these gross things, that it can be used as a coping mechanism.
Lisa: Sure, you break the tension, you crack a little joke, and it maybe helps you get past a difficult moment, allows you to move on to the next horrible thing that you probably have to deal with in the ER.
Nyssa: That's right. So she also described something called a butt box. And this is sort of legendary in emergency rooms and I've heard of these and read about them. I've never seen one in my own ER although there are some famous stories that we tell.
Lisa: It sounds like a dance move.
Nyssa: The butt box! The latest craze.
Lisa: Im butt boxing to my beat box!
Nyssa: Can you guess what a butt box actually is in the emergency room?
Lisa: I absolutely cannot guess what a butt box is. A box full of butts.
Nyssa: The butt box is where we collect things that we've plucked out of people's rectums. Things like perfume bottles, or apples, or a GI Joe figure. Those are all things that were in this particular department’s butt box.
Lisa: These are things that people have accidentally sat upon?
Nyssa: They slipped and fell in the shower…
Lisa: And there was a GI Joe toy?
Nyssa: And GI Joe is now in the rectum.
Lisa: Oh, yes, that happens. I've seen it happen.
Nyssa: Showers are very slippery.
Lisa: They're very dangerous and you probably shouldn't leave toys or apples on the floor of your shower just in case you slip and fall. Yeah, I'm gonna remember that now. I'm gonna move all of my small toys out of the shower.
Nyssa: That’s a good recommendation.
Nyssa: The other one that she quotes: some California nurses play a game called “Interesting Things I have Found in Obese People's Rolls of Fat.”
Nyssa: Currently third place is a fork, second place is a TV remote, and first place goes to the ER nurse who found a tuna fish sandwich in someone's role of fat.
Lisa: Oh my goodness, holy crap! I wish this was a visual media because my face is going through contortions of shock and surprise.
Nyssa: So these are typical examples of dark humor in the healthcare setting. This is not unique to emergency nursing, but certainly used in the emergency room quite a bit. And so she puts her article in The Washington Post and the most interesting piece about all of this to me is the 942 comments that were posted online about this article. Again, remembering that this is an audience of lay people. In a nutshell, they are horrified about this idea. 942 comments is the number one most inflammatory post that The Washington Post has had... over some really controversial ones.
Lisa: Are you kidding? People don't understand the absurdity of finding a tuna fish sandwich in somebody’s fat folds? And they don't want to just at least giggle about it? I'm not laughing at the poor person…
Nyssa: They hated it. Hated it. So what I did is I cruised these 942. I didn't read them all, but I plucked out some very representative comments that I want to share with you.
Lisa: Like you're plucking them out of a rectum?
Nyssa: Yes, plucked right out of a rectum or a fat fold, exactly.
Lisa: You’ve got a lot of practice with that.
Nyssa: So the first one is adorable because he's trying to be pro-nurse, but he's so far off the mark, or she, I'm not sure… It says, “Perhaps instead of debating whether or not such jokes are okay, the medical profession should focus on alleviating the problems that necessitate the use of gallows humor to begin with. Like why can't we give each nurse a mandated 30 minute break after a patient dies or require regular appointments with a therapist to curve the development of PTSD. It's time to stop treating hospital workplaces like war zones where only the strong survive- apparently at the cost of their patients dignity- and start taking steps to make it more human and humane in the process.
Lisa: What a great idea! Because when you're in the ER, you know, when somebody dies, of course you have time to stop and take 30 minutes because there's nothing about an ER that resembles a war zone.
Nyssa: Right. Adorable, sweet, totally and completely out of touch with the reality of what's happening.
Lisa: Doesn't even sound like this guy has even watched an episode of ER, seen an episode of any TV show that shows how crazy it gets- when we've already talked about how fictional those are- but at least it represents complete and total insanity in the ER. You can't stop what you're doing.
Nyssa: That's right, you do get that. What I find funny in my experience is you can barely get nurses to show up to a mandatory staff meeting, let alone a therapy session. But the response to this one was great. Whoever this person was gets it. They said “Yeah, sure. As soon as we can start scheduling deaths, we can go ahead and schedule in that 30 minutes off that you require.”
Lisa: Absolutely! Okay, we're looking at the calendar right now... Dr. Phillips, Dr. Phillips, have you taken a look at the calendar?
Nyssa: How does 12 to 12:30 sound for your death, ma’am? Are you available?
Lisa: No, I’m sorry. We've already got a 12 to 12:30 scheduled, so can we look it up? Maybe we can do a 12:15…
Nyssa: Nope, nope, that’s booked as well. Sorry, we've got a kid in peds.
Lisa: Okay, well tell the kid that he's got to hang on for at least another 45 minutes until Nurse Smith gets off of her break. And once she's off of her last bereavement break, then the kid can go ahead and you know, pass away. It's very, very sad, so that she can then take another 30 minutes of a break. Wow, you nurses would get a lot of breaks if we instituted this system.
Nyssa: We would, we would. It would be like breast feeders and smokers. We get all those breaks.
Lisa: Let's do it.
Nyssa: The next one says, “Jokes about circling the drain, etc. are tinged with hostility and frustration with some of the patients that these nurses feel they are forced to treat. I think my question about whether the level of care goes down was on target and shouldn't have been deleted.” So I included this one to let you know that of these 942 comments, evidently, the admin had to get involved and delete some of them- including this person's. It goes on, there's another one, “That's all well and good. I didn't even read the article since it was obviously biased toward nurses and doctors.” So this hoe is going to weigh in, but did not even bother to read the article. So she goes on, or he, “No need to take an oath for the people anymore. Now we’re just blindly making fun of DYING FOLKS IN HOSPITALS. Yep, that's what I want, more people trying to make money off the suffering of others. How fabulous a country we live in. No wonder foreigners hate us.”
Lisa: You know, that is really how I get most of my information. I just read the title.
Nyssa: Just the title and the comments.
Lisa: All of that stuff in between... it's useless. You really don't need to see what they're saying. Just read the title. Go ahead and jump to your own conclusions. Make a lot of broad statements about it online.
Nyssa: Use all caps- please pound it out in all caps.
Lisa: Absolutely. Lots of exclamation points. Yeah, yeah, that's really good. I like that.
Nyssa: The next one is talking about the immaturity of these people who've clearly never had personal, painful experiences. She talks about her mother, who died. Her mother was- lots of, lots of quotes, like, “My mother ‘enriched’”, in quotes, “our lives” and, “she was ‘full of wisdom’”, in quotes, “with our lives.” She says, “Were I to witness any immature fool to belittle my mother's suffering when she was facing death, I would report that person to the administration, but only after the fool received a tongue lashing that the fool never experienced before that would cause him or her to grow up or shut up in the future.” On and on… “...these people are consummate cowards.” “It's despicable...” Blah, blah, blah.
Lisa: All of these people writing these comments sound really pleasant.
Nyssa: Got another one: “Laughter at a patient’s expense is not useful medicine. In fact, it only goes to prove that the patient did not receive the best possible care from the laughing medical so called professionals.”
Lisa: So these people are not understanding that you're not laughing at the patients. You're laughing at the situations that you're constantly trapped in.
Nyssa: Yes. And I do blame Miss Robbins for that. You know, the title itself says we're laughing at the patient. So she gets a little bit of it wrong, too, and sends them off on a on a bad track. The last one says, “That was difficult to read. As patients and their loved ones, we already feel embarrassed and vulnerable to now imagine that we're barely out of earshot of humiliating jokes is mortifying. Couldn't nurses find another target for their gallows humor? Like the doctors or the hospitals they work for? Or politicians?” I gotta tell you, we already make fun of politicians.
Lisa: I was gonna say! Aren't you already doing that?! I kinda have a feeling you're sort of making fun of everything because don't we all make fun of everything all the time?
Nyssa: A little bit. There were a few nurses who tried to chime in and defend our honor and the therapeutic nature of gallows humor. They were absolutely shot down. In fact, one of the nurses was told, “Just quit your job, just quit your job.” So when I read these and how horrified the general public was and how much they hated this idea about nurses and physicians and healthcare providers using this dark humor, I thought we should probably abandon this episode because this is not going to go well.
Lisa: Yeah, I'm already anticipating the comments that we're going to get on this episode. From our legion of fans, of course, that are gonna write in. We're going to lose them all with this episode.
Nyssa: So I found another discussion of the same thing on a nursing forum. What happened was a nurse experienced one of these episodes of dark humor. Something happened, someone died, and into their head popped the song Another One Bites the Dust. And it just popped into their head. They kind of had an internal giggle, not external. But they came to this nursing forum and posted this incident and said, “Has this ever happened to you guys? So just kind of a sick, twisted, inappropriate song popped into my head and I had to kind of like, smirk at it to myself.” This nurse was looking for reassurance that they weren't a bad person, or that this was not something that only they experienced. And they got it. 202 total posts on this one. And this is exactly 180 from what was happening at the Washington Post. Probably 98% of the posts were, “Yes, this is something that we do. We all have this sick, twisted sense of humor.” So not only were nurses defending this idea of using dark humor therapeutically, but they also wanted to chime in and tell their instances of dark humor... so do you want to hear those?
Lisa: Absolutely! Wait, can I guess... is one of them Hit Me With Your Best Shot for a gunshot wound?
Nyssa: I think it was… what was the gunshot wound one... Fire Away? Yeah, I don't know... something-
Lisa: Oh, Fire Away? Yeah that’s a good one.
Nyssa: Yeah, that's the same thing.
Lisa: There’s got to be a lot of musical cues you could use.
Nyssa: There is a lot of music that pops into people's heads inappropriately. So the first one was actually an example of that: “I'm working on a Med/Surg unit helping another nurse with post mortem care…” So the patient has died... “Family member walks by and their ringtone- their phone rings, and it's In the Arms of an Angel by Sarah McLachlan.
Nyssa: She says, “I wouldn't normally laugh at this but the other nurse started singing it way off key really loudly and I nearly peed myself. We both had to go to the break room and get our giggles out before we went and finished the care of the deceased patient.” Another nurse says, “When I'm working in the hospital after a tough night, day shift comes on. They ask for report, I look at them with a deadpan face and say ‘In the bed. Not dead,’ and move on. Clock out.”. This one is one of my favorites. So this nurse says, “I accidentally got a knife impaled in my arm a few years ago. It's a polite way of saying, ‘I accidentally stabbed myself.’ Should’ve used the scissors to cut off the plastic tie on the baby gate but the knife was right there, slipped, and ended up about three inches into my left forearm. Blood was pouring out of my arm, dripping all over my kitchen and my living room. I'm trying to find something clean and absorbent to put pressure on it. My little toddler’s finger painting in the blood while I'm trying to keep him out of the mess, call my husband to come home from work, and not bleed everywhere.” So she gets this trip to the ER, she gets several stitches, and, “the very nice ER doctor happens to see that I'm on Zoloft for postpartum depression- a very bad case of postpartum depression. He did his job and asked me if I had intentionally tried to hurt myself. My response: ‘Sir, I'm a nurse and if I'm going to off myself, I'm going to do it right. My cephalic vein? That would not be my vessel of choice.’ He died, roaring with laughter. Was my joke inappropriate? Probably. Did it bother me that the doctor laughed too? Absolutely not. It got us both through the day and I got a chance to flip the bird at the illness that nearly cost me both my job and my life.” Referring to her postpartum depression. Yeah, I really love that one. That she was able to poke fun at the disease that caused her, you know, had so much potential to cause her damage.
Lisa: Yeah, you laugh at yourself, you have to laugh at yourself or else it gets too serious and you can't cope with it.
Nyssa: This nurse says, “I worked in a spinal rehab center years ago. I learned just how humorous some, but not all, the patients could be. I would see the paraplegic say to the quadriplegics, ‘Hey, quad, can you do this?’ as they flap their arms. The quad would then say, ‘I'm doing it right now but you're too dumb to see it.’” They said, “This kind of humor goes on and on with these patients.”
“When my mother passed away, it was her wish to be cremated and not have a viewing. So my brother and I provided the funeral director with a favorite outfit of hers and then asked for a private viewing just the two of us.”
Lisa: This is another story though? Okay.
Lisa:I was like, wait! Wait! Your mom!? When did this happen?! I’m so upset!
Nyssa: No, no, no. “So when we looked at her, she looked very nice. The director cleared his throat and said, ‘I wasn't really sure what to do with these,’ and pulled out a pair of sunglasses that mama had stashed in her pocket. She had Alzheimer's and was always tucking things away. My brother looked at him said, ‘Well, the fire’s going to be really bright. Right?’ We all cracked up.” So they're not making fun of mama. They're making fun of Alzheimer's and death.
Nyssa: Here's another one. I think this is my last one then I'm going to give you my favorite personal example. “I had a patient who passed away during my shift. It was an expected, you know, expected death. So the granddaughter had been staying in the room. When it came time to do the post mortem care, I asked the young woman to step out of the room. She said, ‘No, I want to be here for my grandmother, I want to help with that part, too.’ So it wasn't typical for family to do this and I was a little bit reluctant but I went ahead and agreed to let her do it. She was holding up really well, actually, being very helpful. We got to the part where we needed to turn grandma on her side and she helped me and then it happened. Grandma farted. Not a quick little expulsion of air, but a long whiny, drawn out f-f-f-faaaarrrrrttttt escaped her body.” And that's how it's spelled, with lots of f’s and a’s and r’s. “That was it. I quickly shot the granddaughter a look. She was directly across from me. I thought she'd freak, jump, bolt out of the room... But no, she cracked up laughing and I did too. How the heck could you not and that was that.”
Lisa: Farts are always funny.
Nyssa: Even when you're dead they're funny. “We did manage to pull it together and finish but it was a way to take the tension from 10 right on back down to a normal level.”
Nyssa: So my favorite example of gallows humor is told to me by one of my flight paramedic partners. He was flying with another nurse and they picked up a patient that was a gunshot wound. They're flying the patient to the trauma center and they're very close- five to ten minutes out from the trauma center- and the patient codes. So here are these two clinicians in a tiny, little, shaky, tin can in the sky trying to do CPR- which is normally done by a team of six or eight- trying to do compressions, get meds, get an airway, fluid resuscitate, so forth. It's very, very difficult and undesirable to do it any time, but particularly 1500 feet up in the air with just the two of you. So they said to the pilot, “Listen, we're super busy. This guy, he's gone bad. He's coding. Can you please give a report to the hospital? Just tell them we’re coding him and we'll be there in 10 minutes.” Well, obviously, it's very unconventional for the pilot to give the medical report. So the pilot gets on the radio and says to the receiving facility, “We're 10 minutes out, the patient's gone south. They're currently coding him. It’s a gunshot wound victim and we’ll be there on the helipad in a little less than 10 minutes.” So the hospital on the ground, the receiving hospital, comes back and says, “Can you tell us where he was shot?” And the pilot says, “Las Cruces.” That one is never not funny! The flight crew hears him say the geographical location and not the anatomical location. They can't help but die laughing. You know, here's this pilot who's so wound up because the crew is so wound up in this very undesirable situation. They're losing the battle to death and it's just a simple mix up- an unintentional one. He wasn't trying to be funny.
Nyssa: He was being literal.
Lisa: Right! Well, he's the pilot. He's not the paramedic. He’s just thinking about where he picked up the patient. Not necessarily-
Nyssa: Exactly right! He asked where he was shot, he was shot in Las Cruces! My unofficial summarization from this forum of 202 posts is totally not scientific but the people who have the most incidences of dark humor are your psych nurses, your palliative and hospice nurses, your ICU nurses, and your ER nurses and you can tell why that would be. Another few things that I picked up from this forum: somebody made a good point about everyone's taste and humor is different. The comedians that you like might not necessarily be the ones that tickle my funny bone. Slapstick humor might not be for you, but it might be for you. Some people find dark humor therapeutic and a very, very few population of others don't. Those folks were also here on this forum weighing in. There were roughly about three nurses that weighed in that said it's never appropriate, it's always unprofessional, find some other ways to cope with the things that you are seeing because this is not okay. And there was a really good point that was made: we protect our patients’ and their families’ right to grieve in whatever way they find necessary. Some people get angry, some people get sad, some people cry, some people get stoic, some people get catatonic. I've had a rape patient who laughed through the entire sexual assault exam... wildly inappropriate reaction, but you don't know how you're going to react in those circumstances and so we protect their right to do it whatever way they see fit.
Lisa: I would even think that there's a certain amount of hysteria; that nervous energy where you just can't stop giggling, you kind of want to cry, or you want to scream or you want to punch something and the only safe thing for you to do is to giggle just to let all of that out. I could see how that's a perfectly reasonable way for someone who's gone through a horrible experience to try to process that.
Nyssa: And so this nurse’s point was when we protect our patients and our families, their right to grieve in any way that they want, but how come we're not afforded the same protection when we are mourning and grieving? How does it have to be in such as prescribed way? And I thought that was a really great point. The other comment that I thought was very interesting was someone that said, just simply, “It's because of these Judgey McJudgensteins that we shouldn't post on threads like this one.” And this nurse was basically saying, “This is not something that we should even air in public. This is not something we should even talk about because we can't get along.” There was a little bit of back and forth between the people who were for it and the small minority of people who weren't. It almost became like a tennis match. And it got down to like, fifth grade name calling.
Lisa: Like Judgey McJudgenstein?
Nyssa: Yeah, he's Judgey McJudgensteins. Yes. The nurse who is opposed to it says, “You guys are unprofessional.” And then the ones who are for it say, “Please kindly remove the stick from your colon,” which is nurse humor. Then she tells them to grow a set and then they say, “Well, I have a set... of boobs.” And then someone says “You're being holier than thou,” and then the admin has to get in and say, “Hey, let's avoid this one on one. Let's get back on the topic.” And then they're called ‘buzzkills’ and ‘humbugs.’ They say that those who are for it reek of immaturity and they find it disgusting and sickening. Bottom line: this is a highly charged topic. I think that there is a small minority of healthcare professionals who are absolutely against dark humor. It's not their coping mechanism of choice and they think that it can never be professional. There's the vast majority of healthcare providers who do find it helpful and therapeutic. And then there's a small subset of healthcare professionals who use it inappropriately and do cross the line into inappropriate and unprofessional. When I was reading the article by Miss Robbins, she quotes an article that was posted by The Hastings Center. They explore ethical and social issues in healthcare, science and technology. There was an article that was written in there called Gallows Humor and Medicine. It's written by a woman named Katie Watson and Katie Watson is a bioethicist, so she has the science part, the biology part, she has the ethics part, and she's adjunct faculty at the improv place Second City.
Nyssa: So she actually also has the humor part, as well. She's got the whole trifecta. She has a friend who's a physician and he told her his story about dark humor and the story is: It’s 3 a.m. you have three tired emergency room residents and they had ordered pizza but it was taking a really long time for it to get there. As they're waiting on their pizza, they're starving, there's a nurse that comes running in and said there's a GSW (which is gunshot wound) coming to trauma one. No pulse, no blood pressure. They go running into treat this patient, and they realize that it's their favorite delivery boy from the pizza parlor.
Lisa: Oh, no!
Nyssa: He In fact, has been shot and made them work even harder. They cracked the kid's rib cage, they took a look at his heart… the bullet had torn it open. He wasn't stable enough to go to the OR and after 40 minutes they called it and the boy died.
Lisa: Poor thing.
Nyssa: These three young doctors went out into the waiting area. They actually found the box of pizza where it had been dropped in his footsteps right before he was mugged and faced attackers. So they picked it up and one of the doctors looked at the other one and said, “How much do you think we should tip him?”
Nyssa: And then they laughed and ate the pizza. So this physician finds his friend Katie Watson and says, “This happened to me 15 years ago and it's been rolling around in my head since... Was it wrong to make the joke? You're the bioethicist. You tell me- were we wrong to laugh at that situation?” So then she does a deep dive into this gallows humor. She says “Gallows humor typically takes something serious, frightening, and painful and makes light of it in a satirical way. Death is what literally fits the term of gallows humor, but it can be anything life threatening, disastrous, terrifying, gross... any of those things.” And so the difference in gallows humor being appropriate and then derogatory humor- which is crossing the line of professionalism- one doctor summed it up really well when he said, “The difference between gallows humor and derogatory humor is the difference between whistling as you go through the graveyard or kicking over the gravestones as you go through the graveyard.” Miss Watson says that, “... the blanket dismissal of gallows humor as being unprofessional undervalues the psychological, social, cognitive, and linguistic ways that joking and laughing can work.” She says that, “... healthcare providers deserve for people to understand that it's much more nuanced than that. It's not just, ‘we're for it’ or ‘we're against it.’ There's a fine line and fine nuance in it.” So she goes on to point out, too, that if you think teachers aren't making fun of your kid in the teacher’s lounge or the firefighter isn’t making fun of the way your house was kept before it burned down or war correspondents making jokes, that you are being fairly naive.
Lisa: Absolutely. Have you had any instances in the ER where you've been called out by a nurse? If you've giggled about something or laughed about something? Has anyone ever looked at you sharply and said, “That's not appropriate! You shouldn't be laughing right now!”
Nyssa: It's a great question. I have not. One of the reasons is because you should never attempt or participate in this without knowing your audience. So in other words, there are certain nurses that I have worked with that I would never make a dark humor joke in front of because I know that it's not their form of coping mechanism. You have to know your coworkers to know who's going to appreciate it and who's not, and who is appropriate to participate with and who is not. Also, who might take it to a whole nother level and make it unprofessional…
Nyssa: There's a observation that humor is what happens when we tell the truth quicker and more directly than we're used to. Humor is actually “rapid truthing” is what Kurt Vonnegut* said, “rapid truthing.” And I think in medical, that is extremely true. We are going to rapid truth you right through this because that's how we do everything. There is also a phenomenon that we kind of heard in the nursing forum where patients initiate jokes about themselves, their own medical condition with their physicians, and it kind of crosses categories and is an even more nuanced place to be. There's a story that an ER physician tells: a thief was escaping a bank robbery, crashed his car, and the police brought him into the ER for a trauma evaluation. So part of the trauma evaluation- and this guy's going to jail once he gets cleared- part of the trauma evaluation is a rectal exam. The ER doctor expected that the prisoner was going to object because that's the normal response, as most people do, but instead when the ER physician said, “I need to do a rectal exam,” the prisoner said, looked at all the cops, and said, “Well, I guess I better get used to it.”
Lisa: Frankly, just the whole concept of a rectal exam is kind of funny- unless you're going through it, I'm sure.
Nyssa: Unless it's you! Exactly. Well, we don't like to do it. No healthcare professional is excited about having to do a digital rectal exam.
Lisa: You don't?! I mean, I've been meaning to ask you if you take a look, just, ya know, come on Nyse! We've been good friends for a long time. You're a nurse. So anytime I bend over, I expect that you're, you know, trying to take a look up there and see what's happening.
Nyssa: Yeah, we're gonna leave some mystery in our relationship, for sure.
Lisa: I’m so hurt!
Nyssa: So it's kind of unclear whether this is a joke about prison rape, or is it a joke about body cavity searches? Or…? At any rate, it's pretty inappropriate/hilarious.
Nyssa: And the fact is, the only person in that room that could make that joke appropriately is the patient. The cop can't make that joke. The doctor can't make that joke. It would be horrifying if they did. And what the patient did by making that joke is he bridged the divide between “it's me and them” and he made it about all of us and the physicians thinking, “Man, you know, if circumstances were different, we might be friends... like we have the same sense of humor, buddy.” So Freud says that the jokes we make are as revealing as our dreams. He says that jokes are socially appropriate way of dealing with things that are otherwise taboo. Things like death, sex, excrement, religion- they take this tension that we all feel about, and you turn it into laughter and now all of a sudden we can talk about it. So when we joke about our boss, it's often a substitute for fighting with our boss. Fighting with our boss is not socially acceptable, joking with our boss or about our boss is. And if you shine that light on to the healthcare world, “Who is a higher authority or more impressive boss than death or illness or injury?” Miss Watson says. There is one important caveat to dark humor- I guess there are a lot of them but this one is kind of in bold, and with an asterix- and it's about cadaver antics. So there used to be a-
Lisa: I'm sorry. Cadaver antics in and of itself is very... I'm just seeing like dancing skeletons or zombies... Zombies? That would be considered cadaver antics?
Nyssa: Yes, that’s cadaver antics.
Lisa: Got it.
Nyssa: There used to be a culture that, it was kind of part of initiation or hazing maybe or even a rite of passage that when residents- nurses don't frequently deal with cadaver labs in nursing school but residents and medical students do and on occasion we will- I've been to a few but it's not generally part of our training to have human cadavers. Usually it's animal. It's kind of a rite of passage. And it used to be that there was a culture of this cadaver antics where you make jokes, clown around with, you know, dismembered body parts, pull pranks on your labmates... There is now a total change in that, which is much more appropriate. You have people who have donated their body to science with the idea that healthcare providers are going to learn and save lives using their bodies, reverently and respectfully, so it is absolutely not allowed anymore. In fact, they oftentimes will do a moment of silence for the people who have donated their bodies before or after the cadaver lab. Any kind of jokes are inappropriate, you know, playing with the bodies or whatever will get you kicked out of a cadaver lab very, very quickly. And before you even enter the cadaver lab, you are given these rules and this idea that we are going to respect these people for helping us learn in a way that we couldn't do out of a textbook.
Lisa: Alright, I'm going to put my DNR order- that's donating my body to science- and that I want to go to the cadaver comedy lab for nurses and medical professionals who would like to do funny things with my body- not to my body, please, but you know, like maybe make me wave-
Lisa: -or dress me in funny clothes, or, you know, put my severed head, you know, in somebody’s refrigerator. That sounds really funny, don’t you think? Something along those lines, just to give you guys the opportunity to use the dead bodies the way that you've always really wanted to but are now prohibited because of the Judgey Mcjuggers-, Judgey McJudgenst- what the hell is it?!
Nyssa: Judgey McJudgensteins!
Lisa: The Judgey McJudgensteins out there! So now you know. You can add that to my long list on my DNR order. We're going to take notes, right? About what we each want?
Nyssa: We really do need to take notes. It's getting long.
Lisa: Yeah, hopefully our fans out there will start a list for us of the things that we both want when we die.
Nyssa: Miss Watson points out that medicine is a really odd profession and that we ask ordinary people to behave as though feces and vomit don't have a smell to them, as whether unusual body parts are not remarkable at all, and that death is not frightening. Health care providers are still human and even though we do deal with those things much more regularly than the general public, they do stink, they are scary, they do look weird. And sometimes being off balance can make us laugh. It keeps us from toppling over.
Lisa: Absolutely. Absolutely.
Nyssa: I love that. Alright, the last article. And literally these are the only three articles that I could find on the World Wide Web about these subjects. Miss Robbins, Miss Watson and then this final one. And this final one is also in response to Miss Robbins’ article. This is one that appeared in the American Journal of Nursing, on their blog- on their website. So this is a professional organization for nursing. So this is, again, a nursing audience and it is written by a nurse. He is a psych nurse with a particular interest in nursing ethics. And he is writing sort of a little bit of a response to Miss Robbin's article and it’s sort of-
Lisa: She was the New York Post article, right?
Nyssa: She was the Washington Post.
Lisa: Ahh, Washington Post. That’s right.
Nyssa: Washington Post. That's right. And he has two arguments about this dark humor thing: he says that jokes are going to be made no matter how you prohibit them. So you can make as many rules as you want, but you cannot keep that song Another One Bites the Dust from popping into your head. The fact that the person walks by and the ringtone is singing In the Arms of an Angel... you can make as many rules as you want, that's not going to stop it. Grandma is still going to fart when you roll her to the side. And his other argument is that there is considerable good that comes from this type of humor. But, because the jokes are going to be made, and because good can come of them, why don't we establish an ethical framework for them to be hung on so that we don't get stuck in the Judgey McJudgenstein and we don't cross over that very thin nuanced line into unprofessionalism? So, this gentleman's name is Doug Olsen. Douglas Olsen. And he proposes an ethical framework which I want to share with you as our kind of concluding remarks. He quotes Miss Watson's article where you're supposed to do a self examination as you're participating in this dark humor. Is the joke about the patient, the situation or the clinicians themselves? Are you joking about the patient or the disease? The patient or death itself? Does the joke reveal disdain or contempt for the patient? If so, you've crossed the line. Could the joke affect their care? If so, you've crossed the line. What is the underlying intent of the joke? So another example that he gives is a triage nurse gets all bent out of shape when a drug addict lies to her about her drug abuse. And he says, “Well, I mean, of course, they're lying about their pain... What would happen if she told the triage nurse that she has a five bag a day habit, and her dealer is out of town?” So he's kind of joking, but it's a joking chide. Like, think about what you're saying there. She’s not gonna be honest with you. We're playing a game here. She's just playing her role in the game. He says he generally gets a laugh with that and it's a very low key way of reminding someone about what the situation is. Is this true humor? Is it inclusive, clever, insightful? Or is it just mean spirited and mocking? Do you feel ashamed when you say it or hear it? And then this is the part that just blows my mind, but I 100% agree with him and this is why this topic is taboo with a capital T. He says to avoid negative consequences of clinical humor, nurses should be careful with the context. The kind of obvious: it should never be within earshot of a patient, families, passers by, never accidentally overheard. That is huge and key. You should never post anything online on social media making fun of a patient because you don't know who's going to read it, even if you de-identified it. Making fun of them is just mean spirited and unprofessional and it harms nurses everywhere, healthcare providers everywhere. And then this is the other one that gets me: do not use clinical humor with non-clinicians in social gatherings. Just like the first one said, don't be posting on these posts because you're going to hear from these Judgey McJudgensteins. Don't take this out into the general public. This is something that we're going to keep quiet!
Lisa: Like... except for what we're doing right now.
Nyssa: Well, this is because this is a nursing healthcare audience. Yeah, we're going to talk about how the best way to do this is to not talk about it. So don't go to your cocktail party, don't go to your husband's office party, or whatever, and expect to get the same response with this dark humor because as we clearly illustrated with Miss Robbins, the general public does not like this. They don't want to know about this. And Mr. Olsen agrees that we should protect them from it. So it is a therapeutic coping mechanism when appropriately used. There is a very fine line between it being appropriate and unprofessional. The other thing to point out is this shouldn't be your only coping mechanism. It's a little bit of a red flag when you have a co worker who only ever jokes about patients. It probably means that they need to develop some more coping mechanisms. That may be a sign of some compassion fatigue, or some burnout. So that's what I have for you on dark humor. What do you think?
Lisa: I think it's a sticky wicket. It's very complicated. I've been trying to think of other professions to which these restrictions might apply. Of course, any emergency responder, police, firemen, EMTs... all of that sounds like the type of fields where people would be upset to find out that they were the inspiration for humor. I guess the difference is the object of ridicule versus the inspiration for a laugh would be where the line is drawn. I know as a teacher, when I see a paper that is just atrocious or someone's grammar is ridiculous, it's hard for me not to share that with my co instructors and to laugh about it because it hurts the eyes for an English instructor to read something that's just tore up enough- just has absolutely no basis in the English language. But it also makes it a little bit easier to not rip that person apart. We can laugh a little bit about it, and then we backtrack and try to figure out: how do we express to this student that the way you've interpreted this poem is... batshit crazy? That's not what the author intended. You know, you kind of have to laugh about it first, or else you get angry about it, I think.
Nyssa: I think soldiers in war, or probably soldiers at any time, they are also asked to be in really frightening situations that the normal public just can never understand. I feel sure they have their share of of dark humor as well.
Lisa: I mean, under great stress, that's always been a mechanism for me, is to giggle about it.
Nyssa: That's right. We want to hear your stories of gallows humor. I want to know what you think about this ethical framework or what you think about this nuance. Do you fall in the “this is always unprofessional”? Do you find this therapeutic as a coping mechanism? Yeah, we definitely want to hear from you.
Lisa: I don't know, I still think our health care professionals should have the right to cope with all of the horrible things that they see. You know, you're a patient and you're suffering with that one thing, and it's the most central thing to your life. Your health care professionals, your emergency nurses, your emergency doctors- they're seeing you times, what, 20, 50, 100 in a day? Then it doesn't stop until your shift is over. I can't imagine how you would do that without taking an opportunity to laugh whenever you got the chance.
Nyssa: And I think health care providers deserve to use that coping mechanism. I also think that patients deserve to be shielded from it and that the public deserves to be shielded from it.
Lisa: So if you have any examples of gallows humor that you have encountered in the hospital. If you're a nurse, how you feel about it. If you're a patient, whether or not you fall on the “it's okay from time to time” or “it's absolutely not okay at all to ever engage in any humor in the ER.”
Nyssa: Sounds great! So find us on Facebook. We are at TheQWordPodcast all one word. We are also on Twitter and on Instagram. And you can also find us at firstname.lastname@example.org.
Lisa: If you like what you hear, give us a five star rating so that we will move up in the ranks.
Nyssa: The comment number to beat: 942. So go!
Lisa: Yes. More than 942 comments. So I don't have that many friends on my Facebook list and neither do you, but we need to make a lot of friends so that we can go ahead and beat that number.
Editor's correction: Kurt Vonnegut was mistakenly attributed with the "rapid truthing" quote. The actual attribution reads "'Humor is what happens when we're told the truth quicker and more directly than we're used to,' writer George Saunders observes in his analysis of the gallows humor in Kurt Vonnegut's war novel Slaugtherhouse Five."
Olsen, D. (2015). Good Jokes, Bad Jokes: The Ethics of Nurses’ Use of Humor. Off the Charts: Blog of the American Journal of Nursing. Retrieved from https://ajnoffthecharts.com/good-jokes-bad-jokes-the-ethics-of-nurses-use-of-humor/
Robbins, A. (2015) Nurses make fun of their dying patients. That’s okay. The Washington Post. Retrieved from https://www.washingtonpost.com/opinions/2015/04/13/18ecc874-d309-11e4-ab77-9646eea6a4c7_story.html?utm_term=.08a6f876b422
Tenebrae. (2015) Black Humour. Allnurses.com. Retrieved from http://allnurses.com/nursing-humor-share/black-humour-983371-page16.html
Watson, K. (2011). Gallows Humor in Medicine. The Hastings Center Report. Retrieved from https://www.loyolamedicine.org/sites/default/files/u406/gallows_humor_in_medicine.pdf
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