Текст книги "The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital"

Автор книги: Alexandra Robbins

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Текущая страница: 17 (всего у книги 33 страниц)

Making Fun of Patients: The Truth Behind Dark Humor, Double Entendres, and the Butt Box

Humor and pranks might seem crass in an emotional environment where people are coping with or fighting illness, trauma, tragedies, or death. But that’s exactly why nurses depend on them.

Researchers have found, historically, that healthcare professionals use humor with their patients and each other in all but three circumstances: around uncooperative patients, with patients who are upset, and when interacting with dying patients’ loved ones. Plenty of studies have shown that humor can help patients; in addition to spontaneous banter, many doctors (such as oncologists) use prepared jokes about their treatments. Studies also reveal that nurses use humor with patients more frequently than doctors do.

What’s less well known is that behind the scenes, doctors’ and nurses’ humor among colleagues is different—and darker than might seem appropriate to an outsider.

At the milder end of the spectrum, nurses try to lighten the mood by staging pranks on each other or unsuspecting doctors. Some nurses like to crouch in an empty room, turn on the call light, and when the summoned nurse enters, jump out to scare the bejeezus out of her. In one hospital, a nurse hid under a sheet on a gurney that two nurses were told to transport to the morgue. On the way, the hidden nurse groaned and then began to sit up, sending her coworkers shrieking down the hallway.

A California nurse has sprayed Mucomyst (an inhaled substance that treats breathing problems) into the top gloves in the supply box so that the next taker would have sticky, smelly hands. Nurses have awakened night shift colleagues with a sternal rub, an uncomfortable method to test for unconsciousness by firmly fist-rubbing midsternum. An Illinois nurse remarked, “I am not the only nurse I know who has farted in a sedated patient’s room and blamed it on the patient when someone walked in.” Nurses are not above leaving fake poop in bedpans for unsuspecting staffers (including on the front seat of an ambulance). A unit in Oklahoma has a pranking tradition that sends new nurses on a scavenger hunt for a “window that opens” on a floor where no such window exists.

When a young Southern nurse asked an older nurse how to warm a bag of blood before administering it to a patient, the older nurse joked that she should microwave it. The gullible nurse’s resulting explosion resembled a crime scene.

During a Virginia nurse’s first week in the ER, a physician exited a patient room holding up a large splotch of brown mush on a gloved finger. The doctor asked the nurse, “Hey, do you think this looks like it has blood in it? I can’t decide.” The nurse recalled, “Horrified that he’s walking over to the nurses station with shit on his finger, I stutter and tell him I don’t see anything. He looks perplexed. He then proceeds to lick the sample off his finger. ‘It doesn’t taste bloody,’ he says. It was chocolate pudding. I’d been punk’d.” Juvenile, yes, but a common hospital prank.

A doctor at Pines Memorial set up new students by teaming with a nurse like Molly to hand him a urine specimen cup full of apple juice. When teaching the med students how to diagnose, he’d drink the juice and say, “It tastes infected.” Molly joked that someday she was going to hand him a cup of urine without telling him.

Nurses say that urologists tend to have a lewd sense of humor and a strong affinity for penis jokes (“Urology department—can you hold?”). Operating room nurses proudly boast that their unit has the bawdiest sense of humor in the hospital. “We get very naughty; we blame it on the fact that we wear what look like pajamas all the time. Just about everything that comes out of our mouths is a double entendre that probably borders on harassment, but that’s how we get through the days,” said a Pennsylvania OR nurse.

When the Pennsylvania nurse pokes her head beneath surgical drapes to check a patient or flush a catheter, her male colleagues make slurping blow-job sounds. If the surgeons turn the lights off to better view the monitor, they announce they do their “best work in the dark.” As the nurses help them fasten their surgical gowns, the doctors quip, “Tie me up like you mean it.”

Much of the time, hospital humor is harmless because nobody is offended. But when the patient isn’t unconscious or family members are within earshot, doctors’ and nurses’ jokes can be misinterpreted. A Texas nurse remembered a case when a patient stopped breathing; staff hustled his brother from the room so that they could work the code. The patient died. Afterward, the brother furiously reported the nurses and doctors to hospital administrators because he saw them joking with each other as they tried to save his sibling’s life.

What were they thinking? And what could have been so funny during such a traumatic time? Few outsiders are aware of doctors’ and nurses’ reliance on “gallows humor,” a phrase popularized by Sigmund Freud in reference to a story about a man joking as he goes to the gallows to die. Also known as dark humor or black humor, gallows humor is a morbid way to joke about, or in the face of, tragedy or death. Gallows humor describes, for example, when a doctor calls out a patient’s long list of extensive injuries to a nurse and then adds, “and he’s got a stubbed toe, too.” Or when nurses call a coworker “Grim Reaper” because, through no fault of his own, three of his ER patients die in one night.

When patients are dying, some doctors and nurses say they are “circling the drain,” “headed to the ECU (the Eternal Care Unit),” or “approaching room temperature.” A nurse team calls motorcyclists who don’t wear helmets “donor-cycles.” Some staff refer to the geriatric ward as “the departure lounge.” Gunshot wound? “Acute lead poisoning.” Patient death? “Celestial transfer.” That’s gallows humor.

One of the best true-life examples of gallows humor occurred a few decades ago. In the middle of the night at a hospital in an unsafe neighborhood, three ER residents were waiting for their pizza delivery when a gunshot victim was rushed inside: It was the delivery boy, who had been walking toward the building when a mugger shot him.

The doctors tried to save the victim, but had to call his time of death after forty minutes of resuscitation efforts. “The young doctors shuffled into the temporarily empty waiting area. They sat in silence. Then David said what all three were thinking. ‘What happened to our pizza?’ ” recounted bioethicist Katie Watson in a 2011 Hastings Center Report. “Joe found their pizza box where the delivery boy dropped it before he ran from his attackers [and] set it on the table.” The hungry doctors stared at the box. Then one of them asked, “How much you think we ought to tip him?”

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.

Chapter 6

The Stepford Nurse

:

How Hospitals Game the System for Patient “Satisfaction”

“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

LARA

  SOUTH GENERAL HOSPITAL, February

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.

Still, Lara was unsettled most of the time. She tried to stay busy, because when she wasn’t, she either dwelled on her anger or cried. She was able to pull herself together only when she was at work or with Sebastian and Lindsey. It helped to focus on getting them through their homework or finding activities to do together on weekends.

Lara had seen a lawyer to begin divorce proceedings, but she didn’t like when the lawyer said, “We’re going to get him.” Instead, she went to a mediator, who worked things out amicably.

Now Lara’s main worry was how to afford her rent. Luckily, South General had been accommodating. The first time she called to ask whether there were any openings on the schedule to increase her hours and her paycheck, the ER director said there were not. “Do you need to just come in to work, though?” the director asked, and created a spot for Lara anyway. She allowed Lara a nontraditional schedule: two twelve-hour shifts plus her children’s school hours. Lara dropped the kids off at school, arrived at the hospital by 11:00 a.m., worked for four hours, and left to make the forty-five-minute drive to pick them up.

Lara pulled this shift every weekday in addition to the twelve-hour night shifts. John was happy to watch the kids because he believed the babysitting got him out of paying child support. Lara knew her children were fine with John; for all of his shortcomings, he was a decent father. But it killed her to spend so much time away from them. Every NA meeting she attended was another hour that she could have spent with Sebastian and Lindsey.

At South General, Rose, the ER’s kindest nurse, connected Lara with Holly, a skilled, businesslike African American nurse whom Lara liked but had not gotten to know well. Holly, it turned out, had just divorced a cheating husband whose behavior was eerily similar to John’s; the women joked that but for the racial difference, their husbands could have been the same man. Every shift they shared, Lara and Holly made a point of checking in on each other, exchanging quick hugs and comparing stories. It was a relief for Lara to hang out with someone who understood her situation.

Several other nurses were so supportive that Lara felt as if she had a sisterhood looking out for her at work. To her knowledge, no one had complained that the nurse manager let her come to work whenever she wanted. Once, Lara was crying in a bathroom stall when she overheard the charge nurse say, “Lara’s here but don’t give her anything stressful. Just keep her busy.” Lara smiled, warmed because, despite some poor choices she’d made in life, she had chosen a career that was flexible enough to accommodate a single mom and that attracted the kind of women who protected each other.

One day Fatima approached her at shift change. “I heard you were having a hard time with your separation,” Fatima said. “I hope it goes better than mine did.” She told Lara about the fighting and drama that had plagued her own marriage and subsequent divorce. She mentioned that her ex-husband had been an alcoholic, a fact Lara filed away for future reference. Sometime when they were alone, she could talk to Fatima about her own family’s battles with alcoholism to segue into a discussion about addiction.

Lara was glad that Fatima felt comfortable enough to approach her. She couldn’t mention the drugs because they were in the middle of the ER, but she wanted to. She wanted to say that she knew why Fatima always wore long sleeves in the heated ER (track marks), and that she knew why Fatima’s hands were red and puffy (frequently shooting into a vein impeded blood flow). Perhaps after a few more conversations they would be friendly enough that Lara could raise the issue.

She sensed that time was running out.