Guest Editorial: Don`t Open the Box

A sealed box is an innocuous and enigmatic thing, an object of mystery with the promise of glad discovery. It brings visions of children shaking brightly wrapped gifts, or families discovering long-lost memories in creaky old chests in a loved one’s attic. The only way to solve the mystery is to open the box, which as we all know does not always end well. Ask our good friend Pandora (and I do not mean the music program), whose curiosity released all the evils of the world, and it was only dumb luck that Hope snuck out before the box shut.

A box is synonymous for containment (box it up), restraint (boxed in) and even creativity—or lack thereof (think outside the box). If you close the box, then you put it away; if you go home in a box, you’ve died. Here at home, a “box” also means ambulance. Ultimately, one way or another, we all end up in a box of our own design.

If you say “box” aloud in a crowd comprised of the people I work with, it is a pretty safe bet that one of them will snicker and make a vulgar reference. Why? They can’t help themselves. EMS folks rely on any number of tactics to keep their psyches intact, and humor is just one of them. It does not matter how tragic your circumstance is, at some point someone will objectify it enough to view it from a perspective that will result in a comical observation. We can, will and do laugh at circumstances that are often horrific.

The idea of humor in the face of death is nothing new; “gallows humor” (galgenhumor in German) has been around for centuries. Possibly the first documented case of laughing in the face of death comes to us from Catholicism’s St. Lawrence in the 4^th century AD. This early church official must have really upset the Romans, for they opted not to speed him to the pearly gates atop a cross or at the end of a spear, but rather through roasting him over a charcoal fire. At one point he is alleged to have turned to his executioners and instructed them, “Please turn me, I am done on this side.” For his ability at keeping his cool under pressure (yes, I went there), the Church made him the patron saint of comedians…and cooking. Who says the Church doesn’t have a sense of humor?

In his 1927 essay Humour (Der Humor), Sigmund Freud put forth the following theory behind the nature of gallows humor: "The ego refuses to be distressed by the provocations of reality, to let itself be compelled to suffer. It insists that it cannot be affected by the traumas of the external world; it shows, in fact, that such traumas are no more than occasions for it to gain pleasure." Basically he felt that by turning the perceived enemy or circumstance into something comic, we make it smaller and manageable, actually resulting in a sense of pleasure at being able to now overcome it. In Freud’s rationale, the psyche is lazy and because it would rather expend energy at pleasurable pursuits, it turns a stressful situation into one the ego would rather deal with.

This use of contrived bravado to shield us from the sights and experiences of our daily traumas does not work for everyone, and certainly not everyone is funny. People who work in EMS long enough—no matter how psychologically sound you think you may be—will be broken. We are simply not wired right and our perspective on daily life shifts dramatically from “normal.” There are different avenues for everyone when it comes to developing coping skills, not all are successful. One of the other theories on the use of gallows humor has to do with an inherent inability to express discontent or process stress in a different fashion. Making a joke of it provides an outlet when open dialogue is impossible.

Studies done in the early 1990s showed that health professionals who actively use humor as one of their outlets have some of the highest rates of job satisfaction and senses of personal accomplishment. Those same studies also demonstrated that we know our version of funny isn’t for everyone and that we often deliberately shield our loved ones and those not in the field from it, yet another factor that pushes us out of general population and toward socializing only among ourselves.

Do you know what that means? Without an outlet, we put all those strong feelings in a box.

Those boxed-up emotions are dangerous things; they can wreak long-term havoc on us. We don’t like to look in the box, there are scary things there. I know that the shelves of my psyche are loaded with boxes, feelings and experiences (personal and professional) that are too strong or painful for me to leave out in the open. So I carefully seal them away and put them on a shelf and hope the tape holds. Sometimes it does, sometimes it doesn’t, and sometimes…it is precisely what the doctor ordered.

I come from a long line of people highly dedicated to their addictions. I have the Virginia State Police on my speed dial and calling my parents is very much like listening to an episode of Cops. My family has been surviving all the evils that come with polysubstance abuse for well over a decade. Being in EMS is difficult enough on its own, being on the receiving end of services from police, fire or EMS is even more frustrating and confusing because it’s just not our traditional role in these types of circumstances. It was only a matter of time before the demons won and someone in my family lost. Last August, I received the phone call that while not totally unexpected, caught me off-guard by the timing: “Your brother’s dead.”

So it was that six short months before his 40^th birthday my only sibling achieved a BAC of .505 and succeeded in drinking himself to death. (He would be the first to point out that it wasn’t even his personal best.) My parents were devastated. He was their only son and they’d been his safety net for so long that they felt it was their fault and they failed him. At the same time, they suffered the exquisite pain of double-edged guilt, because there was relief that the war was finally over. No parent should bury a child; much less feel relieved about it.

The reason I share all this is so that this part makes sense—I didn’t cry when they told me. I was there for my parents, I listened to my mother’s sobs and father’s voice shake, but it was like I was taking report, completely detached as I worked through the details of the coming weeks. Even as I took on the responsibility of notifying his friends and helping them get through the arrangements, all I could do was feel sorry for them.

When I finally arrived in Virginia, my brother had already been cremated and my parents were sorting themselves out, healing slowly. There was still a lot to do, and I was there to do the tasks they couldn’t. While I was there I stayed in his room. Much of the house has damage from him and the room was no better. I found myself watching the series finale for TV’s Rescue Me. The scene came on where they are traveling to the memorial service with their friend’s ashes, the intent to scatter them during the ceremony at his request. During the drive, one of them says, “I want to see what’s in the box.” Denis Leary’s character responds with, “Don’t open the box!” Arguments ensue and in a hapless coincidence, they open the box at the same time that the truck windows open, resulting in an explosion of ash. What follows is possibly one of the funniest 10 minutes of television I have seen in a long time. Whether you follow the show or not, it’s worth looking up.

So there I am on my brother’s mattress that is covered with odd stains and cigarette burns, hysterically laughing at this whole irreverent sequence when two things happen at the same time. The first is I look up on the dresser directly at my brother’s urn, a sealed pink marble box with a small brass plaque bearing his name. The second is that my phone goes off with a text message from one of my EMS friends. It says: “Whatever you do, don’t open the box!”

I collapse into renewed hysterics. It doesn’t matter to me that he’s referring to the remains of my only brother; it’s funny and that gave me the venue I needed. Eventually the laughter turns to tears and I can finally express the grief that remained, not for the person who left, but for the brother who was and for the brother and uncle who could have been.

It becomes only the first in a series of “dead brother” jokes and frankly some of them are really pretty funny. They’re only shared with my EMS friends, who laugh right along with me and understand full well that while 4x4s stop the bleeding, there are wounds only laughter can heal.

Tracey A. Loscar, NREMT-P, is the training supervisor in charge of QA at University Hospital EMS in Newark, NJ. Contact her at taloscar@gmail.com. She is also a member of the EMS World editorial advisory board. To hear more from Tracey on the issue of women in EMS, listen to the September 2010 edition of the EMS Squadcast, a podcast series dedicated to discussions relevant to the world of EMS today.