“You are Being Unappropriate!”

During a long day shift, which included, by-the-by, a multiple system trauma sent downtown and a VSA, a few of us, the doc and a couple of RNs, are by the Treatment Rooms desk, when Triage brings us a couple of charts. The first is a 24 year-old woman presenting as “Difficulty Swallowing” and the second, has the very unfortunate chief complaint of “Salty Taste in Mouth.” Some things you cannot make up.

Much mirth, all in completely adolescent bad taste, ensues. Is there any other in the Emergency? A patient or family member, clad in Middle Class Canadian Suburban Winter Attire, overhears us a little and waxes indignant. She marches up the to the nursing station, and announces, “You are being. . .”

A pause while she searches anxiously for that particular damning word

“. . .unappropriate!”

Which provokes more unappropriate laughter after she haughtily stomps off. Of course, we’re being unappropriate. No doubt about it. It’s a truism emergency staff, nurses and physicians alike, have a wicked black sense of humour, explained away by the uncontrollable stress we face. Regular readers have seen numerous examples of it on this very weblog. But like any truism, it needs some examination. It’s true emergency staff use humour to blow off steam. Some of the funniest one-liners I have heard have been uttered while body-bagging the particularly difficult, tragic, and ultimately unsuccessful code. It’s a coping mechanism. We have to laugh, lest the awful meaninglessness of it all overwhelms us.

But there are other reasons. You have to see any emergency department as a kind of pressure cooker, where egos as toothsome as sharks swim the corridors, with its own peculiar culture, jargon, ritual, etiquette and notions. Those new to the emergency are sometimes overwhelmed by the intensity. Humour allows newcomers to be socialized to emergency department esoteria, to share in its particular mores. It helps them to become one of us. And among the veterans, it sustains a sense of cohesion when times are tough, tempers flare, and tension runs high. In short, humour keeps us from feeding on each other.

All humour requires a theme and stock characters. The general theme — with variations — in emergency department humour is Our Unending War with Human Stupidity, the narrative features our own cleverness in dealing with the stupid, the stock characters typical: the Drug Seeking Individual, the Foreign Body in Unlikely Places, the Muffin in Distress, the Drama Queen, the Nursing Home Dump, the Too Stupid to Live, the HBD and Went Boom. But there is danger in creating the Us-and-Them mentality implied in warfare, because it also implies treatment and care according to our subjective whims. Labels and caricatures deceive and misrepresent, when what is needed is accurate assessment. The Muffin in Distress, after all, might be a septic gallbag; the Drama Queen, an ST Eelevation MI; the HBD, a cerebral bleed. Most of us, it’s true, work beyond the labels, and treat the patient, not the caricature. But we have all seen cases where the opposite was true.

Yet unlike hospital administrators or professional regulatory bodies or other bloodless types, I cannot pass judgement. I use humour myself. I am, at times, irredeemably unappropriate. But sometimes, life in the emergency department sucks, and in ways unimaginable to most people. To use a catchphrase, embracing the suck allows us to do our jobs.

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  1. #1 by JC on Friday 05 February 2010 - 1128

    Most patients/families who believe we are being “unappropriate” wouldn’t last a day at our jobs. We see the best and worst of humanity, and if we didn’t laugh, all we’d do is cry.

    And I couldn’t have said it better myself.

  2. #2 by James M. Burton on Friday 05 February 2010 - 1238

    People who don’t understand the pressure cooker should shut the f*** up. That being said, she did provide substantial laughs – and you are appropriately thankful for thankful for that ;-) Emergency workers are under such tremendous stress – complex PSTD abounds – and so many people do not understand – and do not understand the release mechanisms used by people under such constant stress. If you were belittling her in a hateful or hate propagating manner – that would be different.

    Laugh and breathe deeply.

  3. #3 by Maha on Friday 05 February 2010 - 1608

    I’ve been told that I’m becoming more and more ‘unappropriate’ after each shift… and I like it! The only way to survive the pressure cooker is to laugh… and eat. Though the former is probably healthier than the later!

  4. #4 by Random Internet Person on Tuesday 09 February 2010 - 1401

    I don’t condemn the humour, but if the marks — err, I mean, patients — overheard it, that’s a fuck up. You have a hard job, no question, but you chose it and most of them are having an even worse day than you are, and they are not even being paid to be there. They are trapped and scared, they don’t have a clue what is going on because no one will talk to them, and meanwhile the people who are supposed to know what is going on and look out for them are being openly antagonistic. That’s a literally horrifying situation to be in.

    I’m sure you know all that and you are just explaining why the culture is the way it is, so this isn’t criticism. I just thought it deserved to be said on the same page.

    • #5 by torontoemerg on Tuesday 09 February 2010 - 2312

      Thanks. I might quibble a little with how you characterize it, but your main point is absolutely valid, and I think I said as much in post when I talk about the inherent dangers in creating an Us versus Them situation, which is absolutely inimical to good patient care.

  5. #6 by James M. Burton on Tuesday 09 February 2010 - 1602

    Random Internet Person’s comment does prompt a question – were you folks using a patient’s name, or referring to a room number or anything that could give away the identity of the patient in question? No need to answer if the answer is yes, because that would expose you to substantial liability, professional discipline, and prosecution under a number of statutes.

    I made an assumption that you were yucking it up around the nursing station and that it was the laughter and tone that was “unappropriate”. Patient information privacy is critically important – I still make the assumption that it is a part of everyday practice that identifiers are not used in earshot of those who have no need to know.

    General discussion about cases with no patient identifying elements is fair game.

    So, with the above stated, I will continue on in my belief that there was no privacy compromising occurring.

    • #7 by torontoemerg on Tuesday 09 February 2010 - 2306

      Good point. The patients involved were nowhere near us, and as you surmised, the laughter was a bit boisterous, perhaps, which caused the offence. Trust me, we are so sensitized to patient confidentiality issues (and professional and ethical issues attached), that even when we are being unappropriate, it’s always in front of us.

      For the record, and I’ve said it in about 20 different ways here, I take enormous pains to ensure nothing can identify actual patients in my writing.

      • #8 by James M. Burton on Wednesday 10 February 2010 - 1237

        Just to take similar pains – I work with nurses and medical professionals every day. When I made my original assumption(s) it was based on the daily care I see taken by the medical and care professionals who surround me as part of our team. I assumed the same in your case.

        Full disclosure: I am the privacy officer in our facility. I made my second comment above primarily because i realised that the possibility would exist that someone could thwack me on the head someday for my comment (being as the iNtertubeZ are permanent…). That I might not have sounded sufficiently uptight enough about privacy, when I understand implicitly and explicitly the pains taken by medical professionals to maintain confidentiality.

        I have read some of your back posts and I see what is said and what is skipped and the care you take.

        —-

        I enjoy your blog.

        • #9 by torontoemerg on Wednesday 10 February 2010 - 1504

          James, believe it or not, I am glad to have people like you reading my blog — keeps me on the straight-and-narrow.

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