The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital (30 page)

Many nurses told me that gallows humor is common and necessary. A survey of New England paramedics found that nearly 90 percent used it; in fact, gallows humor was by far the respondents’ most frequent coping mechanism, much more so than talking with coworkers (37 percent), spending time with family and friends (35 percent), and exercising (30 percent).

Gallows humor is not the same as derogatory humor, in which doctors and nurses appear to make fun of specific patients. But many healthcare providers use that, too, to similar effect. In 2014, a Virginia patient who left his cell phone audio-recording during a colonoscopy allegedly recorded his doctors making fun of him while he was under anesthesia. The doctors reportedly said a teaching physician “would eat [the patient] for lunch” and joked about a hypothetical situation regarding firing a gun up a rectum. The patient sued the doctors for defamation and sought more than $5 million in damages.

Despite its propensity to be juvenile or offensive, derogatory humor is a coping mechanism. Staff members at hospitals across the country make fun of patients’ names; a Virginia doctor tapes his favorites to his locker. In a Maryland ER, a travel nurse said that “Status Dramaticus” is nurse code for patients with low acuity but high drama, and a “Positive Suitcase Sign” is “when a patient expects to be admitted for a bullshit complaint and brings along a giant suitcase like they’re checking into the Hilton.” In North Carolina, whenever a psychiatric patient who often hit people emerged from his room, techs hummed the
Jaws
theme. A study of humor in a psychiatric unit quoted a doctor announcing at the beginning of a meeting, “Let’s run an efficient meeting today; only one joke per patient.”

Certain groups of patients are targeted more than others, including obese people, particularly in the OR and obstetrics–gynecology departments. In a gynecological surgery case, for example, doctors and nurses played “the pannus game,” in which they wagered on the weight of the pannus (the flap of fat on the lower stomach) they were removing. Many healthcare workers trade anecdotes about the items they find or expect to find stuck in the folds of patients’ fat. A medical student told researchers, “There’s lots of stories about larger older women who when you lift up their fat, you see Oreo cookies, a remote . . . [all] hospital urban legends.”

The patients whom hospital workers are most likely to make fun of are people “whose illnesses and health problems were perceived to be ‘brought on’ by their own behaviors, which ‘inhibited’ doctors’ abilities to take care of them,” Northeast Ohio Medical University researchers said, such as excessive smokers, drinkers, or drug users; people who engage in criminal behavior; reckless or drunk drivers; and people who practice unsafe sex.

Other categories include “difficult” patients (who are demanding, aggressive, etc.) and patients who are sexually attractive. A medical student told the Ohio researchers about cases “when the patient is out and people will come in and remark about her knockers being fabulous.” Another student assisted doctors who rated the penis size of their patients, and said, “‘Don’t look at this guy’ or ‘Look at this guy because he will make us all look good.’ ” However inappropriate it is to comment on an anesthetized patient’s genitalia, the doctors were more likely doing it to lighten the mood for the staff than to pick on that specific patient.

Healthcare professionals are careful to say that they usually make fun of situations and symptoms, not the patients themselves. A medical student explained to the researchers, “There’s nothing potentially funny about a sinus infection or earache. They’re not amusing. But . . . if somebody comes in with an object lodged in their anus, that’s entertaining.”

It’s so entertaining that some ERs keep an orifice box (also known as “the butt box”) into which nurses can plunk the objects that enter the hospital in patients’ orifices. Some of the items that patients have stuck into their rectums include: glass perfume bottles, a steak knife (inserted point-first), a six-inch bolt, soda-can tabs, bugs, animals, a broken candle jar, and an entire apple. After Indiana nurses pulled a G.I. Joe out of a man’s rectum, they hung the real unfortunate hero by his neck in the nurses station as a prank. When a California patient said he had swallowed “something,” nurses played a game of “name that object”; the “something” turned out to be a pipe, a padlock with a key, a screw, two bobby pins, and an unidentifiable object that may have been a battery. Nurses in a Virginia ER had a hard time keeping straight faces when a patient arrived with a vibrator buzzing loudly so far up his rectum that surgery was required to remove it. In hospitals that don’t keep a butt box, some nurses surreptitiously take cell phone pictures of amusing X-rays.

Doctors, medical students, nurses, and techs who participate in derogatory humor generally do so in meetings, in the hall, or in group or private conversations. The nurses I interviewed said that gallows humor is more common than derogatory humor, which one doctor has distinguished as “the difference between whistling as you go through the graveyard and kicking over the gravestones.”

Why participate in either? Experts say that humor helps medical professionals distance themselves from the anger, grief, stress, and frustration that are inevitable in their jobs. Nurses depend on gallows humor so that they are not overwhelmed by anxiety and sadness. “Sometimes when something happens that is so awful that you want to cry, instead you use black humor to keep from crying,” said a Texas nurse practitioner. “They’re not really ‘jokes.’ Mostly it’s just trying to relieve the tension.”

A Mid-Atlantic travel nurse uses gallows humor to “find the bright side” in tough circumstances. “In a massive trauma, I’ll take note of the cheery toenail polish color of a patient, or remark that they picked a great day to wear clean underwear for the car accident,” she said. A Canadian nurse remembered a recent code during which the doctor in charge did an impression of another doctor “who was known to freak out during codes. He said, ‘Oh my God, somebody help this man!’ It brought some levity to the code, had all the nurses laughing, and got everyone relaxed a bit during a very stressful event. The patient survived and the code was not affected at all by the joke.”

Gallows humor is a way both to disconnect from a horrific situation and to connect with the other health team members who are together facing that situation. Humor has been shown to improve doctors’ and nurses’ morale and working relationships. It allows them to express their feelings more easily and to say things that otherwise could be difficult to say. It’s also a bonding tool; as researchers have observed, “having a common sense of humor is like sharing a secret code.”

Should gallows and derogatory humor have a place in the hospital setting? “How does it feel to be a patient in a room who just got diagnosed with recurrent ovarian cancer and to hear laughter down the hallway?” Massachusetts General Hospital oncologist Richard Penson wondered in a journal article. Referring to patients who overheard a staff member using derogatory humor that they angrily assumed was about them, a psychiatrist described “the stray bullet effect—it’s not directed at them but they perceive it [to be].” Other doctors worry that derogatory humor, like the Oscar for dramatic patients, can cause staff members to develop preconceived, negative notions about a patient or type of patient.

But the benefits to staff and ultimately to patients may outweigh occasional wounded feelings. One would hope that doctors and nurses would be permitted to take whatever nondestructive steps they need to be able to provide the best possible care. Bioethicist Katie Watson observed, “Critics of backstage gallows humor who are admirably concerned with empathy for patients sometimes seem curiously devoid of empathy for physicians. Medicine is an odd profession, in which we ask ordinary people to act as if feces and vomit do not smell, unusual bodies are not at all remarkable, and death is not frightening.”

Researchers have said that when medical students use derogatory slang about patients, they are deflecting their feelings of anger or disgust away from the patients who frustrate them because they don’t take care of themselves and, therefore, waste the hospital’s resources. It is, California researchers concluded, “a safety valve for ‘letting off steam.’ ”

Many nurses described these types of humor as defense mechanisms, as an innate reflex. “It’s depressing when you’re dealing with people hurting mentally, so much that a lot of them want to die. The only way to deal with this is to make extremely inappropriate jokes,” an Indiana psychiatric nurse said. “An example would be joking about ridiculously poor suicide attempts, which sounds terribly insensitive. The other day we got a patient who ‘attempted suicide’ by taking a few of this med, a few of that, a couple sprays of Raid, and a shot of bleach. Like, really? Is that the best you can do? Of course, we already know the answer (a cry for help), but sometimes it’s the inappropriate jokes that make the job a little easier to handle.”

The public would find nurses’ frequent use of gallows humor “scandalous,” said a Texas travel nurse. “Laypeople would think I’m the most awful human being in the world if they could hear my mouth during a Code Blue or Priority 1 trauma. It’s a by-product of being placed in situations where death is common and unimaginable horrors are just another day at work. Gallows humor helps to deal with some of the horrible things we see in a way that bonds us together as a team against the bad stuff. We have to take care of these dying, abused, neglected, sick patients and then turn right around and take care of the minor things without missing a beat,” she said. “Bad things happen, and I can’t stop it. All I can do is try to support my patients to the best of my ability. Keeping that in mind helps me sleep at night. In the midst of those traumas and tragedies, I compartmentalize: I allow a part of myself to mourn and feel sad, while the majority of my attention is focused on the task at hand. I’m trying to save a life and that is my primary goal, but sometimes the stress of doing that task builds and needs a release. We use gallows humor to relieve that stress.”

Joking, even during codes, can empower healthcare workers, provide a fresh perspective, create a sense of control, and locate joy or playfulness in a devastating moment. This is important because nurses must get through the traumas intact so they can be fresh and focused for the next patient and the next. They have to concentrate intensely in critical situations one minute, and then let go so they can immediately move on. Gallows humor helps to ease that transition and to leave work thoughts in the workplace. “Nurses need to blow off the adrenaline pent up after patient care. It’s better to dress up those feelings behind laughter than carry that burden home with you,” said a Washington State hospice nurse.

A Canadian study found that nursing school educators who used humor experienced less emotional exhaustion and higher levels of personal accomplishment than other educators. In fact, experts specifically recommend that healthcare professionals utilize gallows humor as a survival tactic and to combat burnout. Nurse and humorist Karyn Buxman encourages nurses to find humor in their work: “Start a collection of humorous comments, events, or charting notes, keeping in mind that patient confidentiality is paramount.”

Gallows humor in hospitals has not been heavily researched, but the existing literature mostly supports using it. “When is behind-the-scenes gallows humor okay, and when should it cause concern?” Katie Watson, the bioethicist, asked. “To answer, I would first want to think about who is harmed by the joking.” Ultimately, in cases such as the pizza-tipping joke, she concluded, “To me, the butt of the doctors’ tip joke is not the patient. It’s death. The residents fought death with all they had, and death won.” And that’s why the joke is okay.

Humor is a way for nurses to find dawn in the darkness, to self-empower, and to unite with each other, determined and defiant. Above all, humor is a way to locate hope amid hardship, which is exactly what patients need nurses to do.

“The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.”

—
Code of Ethics for Nurses
, Provision 3

“Hospitals tend to focus on what they get sued for. Hospitals used to have COWs: computers on wheels. A while ago, a nurse said, ‘What’s up with the COW in Two?’ Well, the patient in Room Two knew she was in Room Two and filed a lawsuit and won. So now hospitals call them WOWs: workstations on wheels.”

—a Washington, DC, ER nurse

The first few weeks of Lara’s separation from her husband were terrifying, while she tried to figure out whether she could support herself and two small children on her own. She couldn’t afford the mortgage on the house, which broke her heart because she and John had built their home, and her brother lived next door. She let John stay in the house because she didn’t want their children to have to adjust to two new homes. He was sure his gambling could cover the costs.

At first, Lara waited for John to apologize and agree to get treatment. Even as she moved her things out of the house, she thought he would realize that he needed her and he needed help. He watched the children while she worked and attended NA meetings, but when they exchanged them, he showed no signs of wanting to reconcile. In response to people who asked him why Lara left, John said, “She’s jealous about something I wrote on Twitter,” trivializing his years of issues down to one tweet.

As much as it hurt, John’s delight at being single helped Lara move past her initial doubt about her decision to leave him. It was more difficult for her to get over being sad, lonely, and scared. How would she pay the bills by herself and have enough time for her children? How would she resist the temptation to turn to narcotics?

Eventually, Lara’s realtor found a small rental house within her budget and near the kids’ school. Several NA friends helped her move, and a girlfriend gave her two U-Hauls worth of free furniture. The men she knew in NA offered her handyman assistance. Many of the women called to say they had gone through something similar, offering consolation and strength.