Medicine is a discipline built for the campfire. Or a theatre. Or for the gossip of the tearoom. We build knowledge and teams quicker with the stories we share than the papers we read.
This is particularly the case for prehospital and retrieval medicine. This is an area of medicine bordering different lands to hospital practice. Borderlands tend to be inhabited by strange beasts (and let’s be honest, a few strange people). Some of the situations we find ourselves in are unlikely to repeat themselves quickly and if we don’t hear the stories of those who have been there before, it’s a lot harder to be ready for some of those more colourful days at work. That’s partly what sites like this are about.
We also inhabit a time when sharing stories is easier than ever. Not only in the brilliant and stimulating FOAMed community either. Everyone wants to share their version of events. Everyone in the media. Everyone with a phone. This only makes it more vital to ask: who benefits from the stories we share?
Somewhere on a Road
This might be easier to think about using a case. A prehospital medical service is called to a road traffic accident. There’s just the one car involved with a 35 year old male unconscious at the scene and thought to have chest injuries. On scene there is a challenging extrication requiring assistance from the local firies. Before that though the decision is made to anaesthetise, intubate and mechanically ventilate while in the vehicle. The patient is thought to have a head injury but also has free fluid in the abdomen on ultrasound and the subsequent packaging and resuscitation during transport is worthy of plenty of discussion.
This would not be an unusual case but there is plenty that would make you want to talk about it. That chat would be most useful if it included details of the accident, an assessment of the injuries at the time, what was done and what the outcomes were. We’d all like to hear it.
Of course it might not just be the medical crews who want to spread the word. The prehospital service may well have an interest in telling the world of the work their teams are doing. That might be part of showing off what they do, or to promote important health messages.
The media, desperate to fill any available empty space with something other than coverage of plasticised reality show contestants shedding their dignity to secure a future in C-grade dinner theatre restaurants, will be all over it.
Then there’s the potential for modern digital rubbernecking. It isn’t at all unusual to see numerous phones out recording footage of prehospital teams in action. By the time the team restocks the pack, that job may already be a fresh online instalment of very literal car crash TV.
All of these groups have something they feel they gain from sharing the story. Except for the patient of course. What do they gain? Not much that I can see. Which is why it’s only getting more important to do what we can to protect our patients from their stories spreading too wide.
Protecting our Patients
So extra care is probably needed in safeguarding their privacy, at least for the information that is in our control (media and bystanders add an extra level of complexity). The debrief after the job is one thing, but if you’re sharing cases for education or meeting purposes it seems like there’s a few obvious things to do:
1. Ask the patient
The best way to go about it is surely to seek permission from the patient wherever possible. The limits of what you can and can’t say will be clear and any discussion will be far better informed by knowing how the story developed for them.
2. Decide how much of the story is vital
This applies to any one of those players interested in telling the story. Plenty of good learning is still possible without every last detail.
3. Deidentify everything That should be obvious. There’s no need to retell identifying information but deidentification should extend further than that. For cases where you plan to present details in another forum or via other media, everything stored about that case should also be de-identified. I used to be more relaxed about what was stored electronically, but given alarming descriptions of the laxity of computer security from people who actually know stuff (like here), it’s safer to assume everything is always vulnerable.
4. Leave some things unsaid
Any time you share the story, even when from your perspective, you’re also sharing the patient’s story. So is the potential gain from the story, be it educational or any of the other potential benefits, enough to justify telling another’s story? There may be some cases where the potential risks of story details coming out make it much more important to suppress information.
What if that crash involves a kid? Would that change your approach to retelling the story, or letting the story get out to a wider audience?
What if the crash occurs because the car goes into a tree? The one tree on a long, straight stretch of road. Wouldn’t it be more important to protect the patient from their story potentially getting out into the community? Some stories should probably be left in place.
Perhaps I’m overthinking this. Maybe some would not see there being much risk when we share battle stories. But the more I think about the full range of responsibilities I have to the patient, the more I think I need to try and draw a line somewhere. The problem is the line keeps shifting on me.
This post came from Dr Andrew Weatherall who does prehospital medicine with CareFlight and kids anaesthesia most of the rest of the time. He also blogs over at http://www.theflyingphd.wordpress.com on stuff related to being a PhD student amongst other miscellany.
2 thoughts on “Who gets to tell the story?”
Nice approach to making the best use of clinical stories. The idea of an open resource of road traffic accidents (with patient consent of course) to help inform those planning / training emergency response teams is a really interesting one. A centralised ‘confidential enquiry’ is one that has been used and published previously. Which would have the better outcomes I wonder? I agree with you that training may be better with stories and real-world accounts. Planning the syllabus is probably best based on comprehensive and confidential enquiries.
Dr Dean Jenkins (Editor-at-large BMJ Case Reports)
Thanks for the comment Dean (and apologies for the delayed response). I don’t think there’s anybody working in critical care medicine who doesn’t rely heavily on case stories in education. When I look back over my training at how it’s been done (and how I’ve done it), I now think we haven’t spoken nearly enough about patient privacy. We too often figure that all patient stories are open to us.
Any chance you could elaborate on the centralised confidential enquiry?