Laughter may be the best medicine, but only if we titrate it to effect

It’s a common phrase, that laughter is the best medicine, and EMS providers are well known for making it integral to prehospital care.

In the right context, laughter does provide evidence-based health benefits. It’s been the subject of medical consideration for centuries, formal research for over 60 years and even cited as a cure for the famed Norman Cousins case during the 1960s [1-3].

Long-term physical and mental health gains for patients and paramedics are innumerable. With a focus on its more immediate, short-term benefits, it comes as no surprise that we are heavily reliant on humor within the emergency medicine environment.

Physical health benefits of humor

Humor can elicit the following physical benefits [2-7]:

• Analgesia, albeit temporary and incomplete, can be achieved through endorphin release and a reduction in stress hormones
• Cardiovascular and anti-inflammatory properties improve due to reduced cortisol and epinephrine levels
• Immune system function increases, therefore assisting in recovery from illness and injury
• Calorie consumption intensifies through energy expenditure during the physical act of laughing
• Muscle tension reduces with laughter and the feeling of being at ease

Mental health benefits of humor

Humor also has the following positive effects on mental health [2-6]:

• Instant recognition of familiar humor can be an immediate ice-breaker, resulting in rapid rapport under pressure
• Improvement in how patients and clinicians feel in the moment, often occurs quickly during a stressful situation
• Positive reframing of perspective may be achievable, allowing both patients and medics to feel more in control during discomfort
• Psychological distance from a stressor can be created, resulting in increased feelings of safety and security
• Teamwork is often enhanced and, as a result, quality and safety of the shared care provided
• Personal self-esteem may increase when laughing and by making others laugh, thereby, situational confidence can improve as a result
• Interpersonal relationships and social networks often become easier to build and work within, creating the potential for happier clinicians and therefore, attitudes towards patients and the prehospital environment in general.

The beauty of this freely available, rapid-acting elixir lies within its universal language. Humans are naturally hardwired to laugh, so it is easily recognizable despite barriers of dialect, disability or environment [3,4].

How to avoid humor contraindications or overdose

So, with its limited adverse effects and minimal contraindications, why exercise caution in the administration of humor [2]?

Misuse in the healthcare setting can have devastating and long-lasting consequences. Patients and their loved ones may feel confused, embarrassed, ridiculed, dismissed and hurt by misdirected or misconstrued attempts to ease stress or tension, making them fearful of similar encounters [8]. Such reluctance to call for an ambulance has disastrous repercussions in terms of risk to future physical and mental health.

Also, with communication, behavior and attitude cited as the cause of more healthcare complaints than clinical treatment, we have a personal vested interest in avoiding offense through poor delivery or direction of humor [8-11].

So, how do we decide when to crack the comedy vial and when to dispose of its unused contents?

1. Consent must be gained. When a patient calls for emergency medical assistance, they may not want or expect to laugh. As with any aspect of care, expressed or implied consent is vital before we go ahead, so testing the waters or reading the room is key. Despite the beneficial effects humor may bring to caregivers, these remain a perk of the job rather than an entitlement, so if the patient does not want or need comedic input, we leave it in the treatment bag until the next call.
2. Informed consent must be demonstrated. Any receiver of humor must be able to understand and identify with the cause of any laughter before they can feel amused. If confusion or difficulty in relating becomes apparent, we either proceed with caution or adopt a different approach right away [3].
3. Treatment must be indicated. It may be that we are habitually comedic, but this doesn’t mean that we can force it upon others. A sense of humor is highly personal, and what makes one person laugh may differ vastly from that of another. Where comedy may help in one instance, it may be detrimental to patient care in another. A compassionate overview will help to ascertain whether it’s necessary and, if it brings no value to the call, we don’t need to introduce it.
4. Mechanism of action must be understood. Assessing each patient and their individuality remains key to gauging potential response, just as we would with traditionally prescribed practice. Attention to personality type, culture, gender and similarly specific clues can help us to avoid complication [12]. If we find that humor causes any sign of offence, we address it immediately and avoid further attempt for the remainder of the call.
5. Titration must be balanced to maintain effective treatment. Delicate delivery can help to ascertain how well humor is received, or not as the case may be. If it seems to reassure, relax and distract our patient, we continue, but if it’s complicating matters in any way, we cease administration and reassess [3,6].
6. Overdose must be avoided. If comical conversation occurs between patient and caregiver only, it is easy to navigate social cues and assess how well the interaction is progressing. On the other hand, when an emergency crew comprises two or more, with a lone, vulnerable patient, there lies the risk of them feeling outnumbered, confused and a target of, rather than participant in, group humor. Being aware of the patient-to-provider ratio helps to create an inclusive environment. If we notice an imbalance in number, then we watch more closely for potential discomfort.
7. Precautions must be considered. With experience, we may view an emergency call as stress-free or even trivial, whereas, those on scene may view it as traumatic. What feels like reassuring, mild humor to us, may appear nonchalant and cruel to others [8]. Sensitivity to each patient’s feelings of fear, vulnerability and loss of control must guide our comedy rather than be obliterated by it [12]. If we notice signs of discomfort in response to humor, we swap out the jokes for a more empathetic approach.
8. Contraindications must never be missed. If we seek to entertain ourselves and feel superior through the delivery of humor on scene, or if belittlement becomes our “feel good” drug of choice, it’s time to stop immediately. We reflect on the motivation behind our behavior and work towards change, ensuring that no patient suffers for the sake of our ego [3].

With its heat of the moment nature and the subsequent need to defuse high tension on scene, prehospital care can benefit through smart use of considered comedy [6]. The secret lies in maintaining compassion and exercising emotional intelligence to deliver it appropriately [8].

If we opt to include humor within our skillset, we must make it our duty to stay sharp in knowing when to use it and why.

Read next: Getting rid of the gallows humor in EMS

References

1. Weisse, A. B. (2017). Humor in medicine: can laughter help in healing? Baylor University Medical Center Proceedings, 30(3)378-381. DOI: 10.1080/08998280.2017.11929656
2. Roscoe, L. A. (2017). Sometimes laughter is the best medicine. Health Communication, 32(11)1438-1440. DOI: 10.1080/10410236.2016.1227295
3. Savage, B. M., Lujan, H. L., Thipparthi, R. R. & DiCarlo, S. E. (2017). Humor, laughter, learning, and health! A brief review. Advances in Physiology Education, 41(3). DOI: 10.1152/advan.00030.2017
4. Peterson, J. A. (2019). Ten things you may not know about laughter. American College of Sports Medicine Health & Fitness Journal, 23(2)51. DOI: 10.1249/FIT.0000000000000458
5. Kalaivani, S. & Karaline, R. (2017). Laughter is the best medicine for stress relief. International Journal of Advances in Nursing Management, 5(3)262-264. DOI: 10.5958/2454-2652.2017.00057.9
6. Buiting, H. M., de Bree, R., Brom, L., Mack, J. W. & van den Brekel, M. (2018). Adding shared laughter to optimise shared medicine. Journal of Clinical Oncology, 36(34). DOI: 10.1200/JCO.2018.36.34_suppl.43
7. Hayashi, K., Kawachi, I., Ohira, T., Kondo, K., Shirai, K. & Kondo, N. (2016). Laughter is the best medicine? A cross-sectional study of cardiovascular disease among older Japanese adults. Journal of Epidemiology, 26(1)546-552. DOI: 10.2188/jea.JE20150196
8. Hogg, R., Hanley, J. & Smith, P. (2017). Learning lessons from the analysis of patient complaints relating to staff attitudes, behaviour and communication, using the concept of emotional labour. Journal of Clinical Nursing, 27(5-6)e1004;e10102. DOI: 10.1111/jocn.14121
9. Colwell, C. B., Pons, P. T. & Pi, R. (2003). Complaints against an EMS system. Journal of Emergency Medicine, 25(4)403-408. DOI: 10.1016/j.jemermed.2003.02.004
10. Risavi, B. L., Buzzard, E. & Heile, C. J. (2013). Analysis of complaints in a rural emergency medical service system. Prehospital Disaster Medicine, 28(2)184-6. DOI: 10.1017/S1049023X13000046
11. Reader, T. W., Gillespie, A. & Roberts, J. (2014). Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Quality Safety, 23(8)678-89. DOI: 10.1136/bmjqs-2013-002437
12. Christopher, S. (2015). An introduction to black humour as a coping mechanism for student paramedics. Journal of Paramedic Practice, 7(12). DOI: 10.12968/jpar.2015.7.12.610