Live at the ED: The Science of Gallows Humour
Author: Cristiana Theodoli
If medical specialties were families in Game of Thrones, Emergency Medicine would be the House of Stark. Walk through any UK based Emergency Department (ED), any month of the year and you’ll find staff mentally preparing themselves for winter like Sean Bean in the first episode of the fantasy saga. Any indication of a busy shift is met with choruses of “this is what the winter is like”, “we are hitting winter early this year!”, and the now literary classic - whispered under bated breath - “winter is coming”.
When you look at the statistics it is no wonder ED staff are weary. A report by NHS Digital, the information and technology branch of NHS England, showed a 22% rise in A&E attendances over the past decade (2018), while locally the Information Services Division of NHS Scotland (ISD Scotland) reported a 29% rise on emergency admissions over the past two decades (2018). In line with the rise in attendances and increased pressures face by ED staff, a recent survey by the General Medical Council (GMC) found Emergency Medicine trainee docs to have the highest rates of self-reported burnout among all specialties (GMC, 2018).
Increased demand and limited resources, along with the turbulence and intensity of working in such a high acuity area where staff are faced with traumatic and distressing events is a sure recipe for low morale. The challenges feel insurmountable and the solutions elusive.
Speaking at a recent NHS Greater Glasgow & Clyde’s North Sector conference focusing on joy in work by way of quality improvement, Shaun Maher, Strategic Advisor for person centred care at the Scottish Government, noted there are three primary aspects that lead to a positive work environment: camaraderie, purpose in work, and control or autonomy.
While it is difficult, on a shift by shift basis, to assess or positively impact the level to which staff feel purpose in their work or feel they have some control and autonomy; camaraderie during any shift is easy to see. Tea-room humour in the emergency services however, is not always the most appropriate.
Black or gallows humour is described as dark, cynical and morbid (Rowe and Regehr, 2010). It was originally used to describe the humour of condemned men, used by hopeless victims to relieve tension before being executed (Freud, 1905, cited in Christopher, 2015). Examples relayed in popular culture are the last words of English poisoner William Palmer who, while being prepared for his public hanging in 1856, is reported to have asked his executioner: “Are you sure it’s safe?”. Or more recently American murderer James W. Rodgers who as his last request before being executed by firing squad in 1960 asked for a bulletproof vest.
In emergency services gallows’ humour is humour at the expense of ourselves and the tragic and at times surreal situations we deal with. Historically gallows humour and derogatory humour - humour at the expense of others – were seen as one and the same, yet there is a clear difference between them. As noted by an American doctor interviewed on the subject the difference between the two is: “the difference between whistling as you go through the graveyard and kicking over the gravestones” (Wear et.al., 2009, online).
While derogatory humour has no place in modern emergency departments, gallows humour has been shown to help cope during tough and busy shifts, dealing with aggressive or violent patients as well as recovering from cases that emotionally affect us (Sliter, Kane and Yuan, 2014).
Gallows humour is laughing at the fact no one taught us how to safely dispose of two bottles of buckfast, smashed to bits in a patient’s bag. Or - after being called a “fat specky cow”, hearing the sister in charge take the power away from the intoxicated patient by shouting back - feigning offence: “I’ve being going to slimming world!” before erupting in laughter herself.
Often the line between laughing at the expenses of a patient and laughing at a surreal or strange situation is very thin. When a homeless man comes in with his leaking leg ulcer dressed in extra-heavy flow sanitary pads, jokes about the ‘fanny pad dressing’ and how it would go down with infection control are not at the expenses of the patient. He did his best and found an ingenious solution in a very challenging situation.
When a volatile, violent patient thrashes one of the side rooms, covering every surface in blood until he is restrained by police officers, joking about how the room is now straight out of a scene from films Carrie or The Shining is not at the expense of the patient. It is rather both a way to make light of an intense situation and a way to try and warn colleagues as to just how much of a mess the room is.
Research has shown gallows or black humour helps emergency staff bond by developing group cohesion (Rowe and Regehr, 2010) and aids the processing of traumatic events (Sliter, Kane and Yuan, 2014). The use of humour in traumatic or tragic presentations, where we might feel powerless in the face of death or serious illness, can contribute to a sense of common bonding, allowing us to quickly recover and continue deliver care to other patients (Scott, 2007).
Outwith emergency services, gallows humour tends to appear in society after major disasters, potentially as a tool to put tragic events into perspective (Rowe and Regehr, 2010). Similarly, within the ED the timing of gallows humour can also be an indicator of the kind of shift we are having. Launer (2016), notes it is often seen as a way for emergency staff to protect and distance themselves from tragedy and suffering, while Kuhlman (1998, online), observes that gallows humour emerges “when all else fails and where there is no reasonable hope for improvement”.
This kind of black, bleak humour is therefore a tightrope emergency staff balance on. One foot wrong and it goes from being a coping mechanism to masking signs of burnout.
Research carried out with a taskforce working with victims of sexual crimes found a clear difference between light-hearted humour and gallows humour (Craun and Bourke, 2014). The use of light-hearted, inoffensive humour was linked with low secondary traumatic stress scores, even when compared to other coping strategies such as support from family, friends or colleagues (Craun and Bourke, 2014).
On the other hand, the use of gallows humour was linked with higher levels of secondary traumatic stress, on a similar level of coping strategies known to be ineffective such as increased drinking habits and outright denial (Craun and Bourke, 2014). This mirrors the view of Row and Regher (2010, online) who note that when a joke or comment is at the expense of a patient it should “be a sign that individuals no longer have the capacity to provide high-quality, compassionate service”.
Though as emergency staff we may at times be guilty of focusing on the clinical aspects of a patient’s presentation, we are in this line of work out of wanting to make a positive difference and to help people. It is therefore important, especially with the added pressure of the winter months, to be aware of that line between gallows humour as a sign of compassion fatigue and as tool to recover from tragic events or intense shifts, so we can continue to care for our patients with the compassion and respect they deserve.
Christopher, S. (2015). An introduction to black humour as a coping mechanism for student paramedics. Journal of Paramedic Practice. 7:12. 610-615. DOI: https://doi.org/10.12968/jpar.2015.7.12.610
Craun, S.W. and Bourke, M.L. (2014). The Use of Humor to Cope with Secondary Traumatic Stress. Journal of Child Sexual Abuse. 23:7. 840-852. DOI: 10.1080/10538712.2014.949395
GMC (2018). Training environments 2018: Key findings from the national training surveys. https://www.gmc-uk.org/-/media/documents/training-environments-2018_pdf-76667101.pdf
ISD Scotland (2018). Acute Hospital Activity and NHS Beds Information in Scotland. http://www.isdscotland.org/Health-Topics/Hospital-Care/Publications/2018-09-25/2018-09-25-Annual-QuarterlyAcuteActivity-Report.pdf
Kuhlman, T.L. (1998). Gallows humor for a scaffold setting: managing aggressive patients on a maximum-security forensic unit. Hosp Community Psychiatry. 39:10. 1085–90. DOI: https://doi.org/10.1176/ps.39.10.1085
Launer, J. (2016). Humour in health care. Postgraduate Medical Journal. 92:1093. 691-692. DOI: http://dx.doi.org/10.1136/postgradmedj-2016-134567