If you’re a health care professional, you know black humour. Inculcation starts early. When I was a student working through a med-surg rotation, I cared for a demented patient who was literally bleating like a sheep; my instructor, walking by her room, began to sing “Mary had a little lamb” before throwing a mock-shocked hand to her mouth, and giggling. Later on, younger and idealistic, I was appalled by what I now know is typical cynical emergency department humour. GOMERs* go to ground and GOMERs never die. Elderly patients with conspicuous luggage, dropped off by families unable to cope, have a “positive suitcase sign”. Certain patients get labels, humorous in intent, but not usually in execution. Repeat visitors are called “frequent fliers”, young women (“MIDs” — muffins in distress) and persons wanting narcotics (“DSIs” — drug seeking individuals). Codes and death are in particular subjects of black-toned laughter, as we rustle the body bags and remove the tubes. I’ve heard some remarkably dark humour after the death of children, none of which I can bear to repeat. As nurses and physicians, we’ve all been there. Something unbearably awful happens to a patient, and somebody cracks wise. It’s all wildly inappropriate, horrible, demeaning to us and to the patient. We laugh anyway. Is it unwise? Perhaps.
Recently I heard a physician make a comment that this patient is “a classic case of FTD”.
I as a naive medical student enquired what “FTD” meant?
The physician responded drly, “failure to die”.
This comment left me with a deep sense of discomfort and reminded me of the type of humor I had witnessed many times before in the ER, OR and ICU. Often in the health care profession we are placed under extraordinary amounts of pressure where human lives hang in the balance. Doctors and nurses say things which would horrify the lay public (or even sometimes ourselves in any other context).
I’ve heard the term “FTD” myself in my emergency department. It’s not a term I particularly like, though it has a certain currency with my younger colleagues. Having said that, I know exactly who this FTD patient is. She is the nonverbal, contractured, 80-something from the nursing home down the road, with Alzheimer’s dementia and multiple strokes, who’s come for the fifth time in three months in for aspiration pneumonia/urinary tract infection/blocked PEG tube. She’s the one being kept alive, almost pointlessly, because our professional ethics demand no less. I’ve written elsewhere about black humour. We can talk about how stress, and the peculiar institutional culture of health care agencies fosters gallows comedy in all of us. But I think now there is something more essential happening; the term “Failure to die” provides a real clue. Simply, black humour allows us to maintain a semblance of control, and perhaps more importantly, distance over the seemingly endless, ungovernable suffering of the human beings we treat. Having seen, assessed, and cared for such patients in the multiples of hundreds, I can understand the impulse intimately. And so it goes for all the other instances of black humour. Laughter is insurance against giving up completely.
Black humour can be unwise. Patients and families may overhear us, and misconstrue our words as indifference or callousness. Danger lies when black humour stereotypes and therefore devalues a patient or worse, dehumanizes or even demonizes. It can destroy empathy and distort objectivity. This is how nurses provide poor care, and physicians misdiagnose. The wisdom is having the insight to understand the sources of black humour in our own relative helplessness, and to recognize it, first, as an inevitable part of our practice, and secondly, as having a time and a place. Truthfully, we see ourselves in our patients. We are burdened with the knowledge of what will debilitate, and eventually kill us. We laugh against fear. To that end, perhaps, black humour allows us to remain fully human professionals and to carry on treating and caring for our patients with care and empathy.
*GOMER = Get Out of My Emergency Room, i.e. typically elderly, demented patients with chronic, complex and usually incurable conditions.