Medical Skill

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Medical Skill

Date: Sat, 05 Sep 1998 21:24:00 -0400

From: Daniel Harms

Medicine was a new skill included in the 5th edition CoC rules to supposedly keep physicians from having to split their skills into Diagnose Disease, First Aid, Treat Disease, and Treat Poison. As written, the Medicine skill does have some (unspecified) effect on disease and poisons, but aside from its aid in long-term treatment, it doesn't work much differently in game terms than First Aid. In fact, I'm not certain whether someone can be treated with First Aid followed by Medicine, or if only one or the other can be used.

How does everyone use Medicine in their games?

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Date: Sat, 5 Sep 1998 19:51:17 -1000 From: "M-Zodiac"

Well, I use Hero. Paramedic is a 3-Pointer that allows basic combat medical/Paramedic type activities—stopping bleeding and the like.

Medicine, a skill of my creation, is a 5-pointer which allows use of Paramedic, Medical Doctor accreditation, and the ability to use Hospital facilities, surgery, etc. It's also required to learn Forensic Medicine. Got tired of one of my players always running Pathologists with no ability to work on the living.

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Date: Sun, 6 Sep 1998 13:15:58 -0400

Addenda : Sun, 6 Sep 1998 15:06:54 -0400
From: Graeme Price

Daniel wrote:

Well, I guess I have a little bit of expertise in this matter (trained first aider, semi-medical education, works in med school research institute), so here's my take.

First aid is basic medicine to cover emergencies and what to do immediately on arriving at the scene of an accident (for example). Things like CPR, stopping bleeding, dealing with the immediate effects of shock using only basic equipment (bandages, splints etc.). It does not allow the use of sophisticated medical devices (cardiac massage paddles, saline drips, oxygen etc.) or drugs (painkillers, anaesthetics, antibiotics etc.). Apart from immediately obvious things (his leg is missing and he has a broken arm) it does not allow diagnosis of subtle (or underlying) conditions. For example, you may realise that someone has had a heart attack and be able to make him comfortable until the ambulance arrives, but you would be unable to diagnose or treat the underlying cause (blocked arteries due to high cholesterol diet and smoking 60 a day). First aid does not deal with long term care or consequences of immediate treatment. I will go into this in a bit more detail below.

Medicine actually expands and replaces first aid (in my games). So a competant physician will be able to do everything a first aider can, and more (can use drugs and equipment noted above: if he happens to have them on him that is…).

In the absence of such equipment, all the medicine training in the world won't make much difference and the medicine skill effectively reverts to being a high powered version of first aid. Especially irritating for the practitioner, as he knows what he _should_ be doing if he _only_ had the right tools. I guess in many ways, medicine in the late 20th century stands or falls on the technology available to back up the physician. In some situations (especially diagnosis) a doctor from the 1920s would be able to take better care of a patient than a doctor from the 1990s without all his little toys and lab tests to back him up.
He is also capable of practising medicine in either a hospital or private setting, perhaps with a sub-specialisation. Thus medicine differs from first aid in that it allows provision of long term care and more sophisticated diagnosis (leading to better overall treatment). The downside is that most people do not have the medicine skill, this being taught in medical schools to those who have 5-9 years to spare (and can afford it). A reasonably comprehensive first aid course (like the St.John's Ambulance Adult First Aid Course) lasts maybe 6-10 afternoons (3-4 hours each) and is reasonably cheap (used to be about 30 pounds stirling - maybe 50 dollars).

There are two other skills (surgery and pharmacy) which are also related to medicine, and should be discussed.

I treat surgery as a seperate skill from medicine (personally, I rule that you need to have medicine at 50% plus to learn surgery). The two are quite different skills. Whilst medicine will allow you to do _minor_ surgery putting in stitches, taking out teeth, setting bones etc. Surgery would be used for major operations (as a rule of thumb, if a procedure involves general anaesthesia, or is life threatening, surgery would be the appropriate skill). This is logical as a local country doctor would not know how to carry out a heart transplant (as an extreme example) and surgeons require specialised training once gaining their medical degree.

Pharmacy relates to the mechanisms of action and manufacture of drugs. Whilst physicians would know which drugs to prescribe to have an effect, pharmacists would be more likely to know how that effect is achieved. Pharmacists would also be able to design (or select) drugs to have a certain effect based on a knowledge of biology and chemistry, but not have the ability to use them in a clinical setting (this would require the medicine skill in addition). I hope this is clear - bottom line is that physicians don't need the pharmacy skill above a low level to do their day to day work (but might need it to treat something really odd, or to do research into new medicines).

This brings us back to what first aid can do as far as long term treatment goes. As a reasonably kindly Keeper (imagine the disbeleiving laughter in the background…) I would suggest that first aid principles could be applied to long term care (for instance in the wilderness). To set a broken bone, or put stiches in, is possible without the medicine skill, and can be attempted with a first aid roll - but at a penalty (half to one third skill depending on circumstances). The better situation would be to take the casualty to a doctor who could use his medicine skill at no penalty for the same effect. Or better still to a hospital, where there might actually be a bonus applied for superior equipment (depending on the hospital). Note though that not seeking medical attention after being injured is a really bad idea. Infection can set in to poorly dressed wounds and be fatal in a matter of days (this has been discussed in more detail on the list before) and shock (due to blood and fluid loss) can be fatal in hours. Bottom line: go see a doctor when you are horribly mangled by hideous mythos creatures and their allies (unless circumstances dicate otherwise).

I still apply the reduced healing rate (as well as the skill reduction) in these situations. Kindly, but not that kindly. First aid rolls have been known to miraculously succeed in some situations (to preserve role playing: I ask the player if he wants me to roll his first aid for him, he (generally) takes the hint, I roll in secret and he succeeds). This has it's advantages: firstly PCs don't die arbitrarily in situations where a new character cannot be introduced easily (like in the middle of the rain forest: I mean there's only so many times that a party can bury a dead investigator and then miraculously meet a friendly missionary willing to join up with them the next day) and it puts the survivors in a position where they have to role play getting their wounded comrade home. Generally, if it preserves continuity then first aid rolls can keep characters alive following (near)fatal maulings… within reason of course. I find players appreciate being told - "you survive but have a horrible scar and a limp" far more than "you take 72 hit points of damage and die horribly…. hahahahhaahha! I'm the most evil Keeper on the planet!". But I've gotten off the point again. In the end, whatever works for your game is fine.
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Date: Sun, 6 Sep 1998 13:13:10 EDT From: moc.loa|rJrekaorC#moc.loa|rJrekaorC

In a message dated 98-09-05 21:31:16 EDT, you write:

« How does everyone use Medicine in their games? »

The rules always indicated to me that First Aid was for short-term treatment, while Medicine was to facilitate long-term healing. First Aid can be used once after an injury to mitigate the effects of shock, bleeding, to set bones, or just to give the right dose of Tylenol or a draught of whiskey to dull the pain, however you want to describe it. Medicine is used after a character has been recovering for several days under the care of one or more skilled healers, to reflect surgery, ongoing muscular therapy, care of bone fractures and sprains, treatment of infection, and so on: the expert in question makes the roll after a period of time (the book says a week, but I regard everything as mutable based on the circumstances and the flow of the story). A successful roll indicates the injured character recovers more quickly due to the treatment, to the tune of another 1d3 HP in the proper circumstances.

These effects are cumulative; first aid can deliver an "instant fix" of 1d3 HP, while Medicine can allow natural healing of 1d3 HP after a week plus the medical treatment of another 1d3 HP at the same time. This is a whole lot of healing, but I think it's about right in modern games; I might reduce all those bonuses a little in 1920s and 1890s games.

As for the roleplaying, just because a character has recovered most of the HP of an injury does not mean that the injury should no longer have any effects. Let's say, for lack of a better example, DG-Friendly Agent Mulder gets abused by a DYSN to the tune of 10 HP damage before the thing goes all alien on him and dumps his still-living frame in a ditch to be rescued. The injuries were described as a broken leg, torn up flesh and muscles, and general bloodsucking and intrusions into Places That Man Was Not Meant To Know. (Poor Fox.) Agent Scully finds him and succeeds in her massive First Aid skill roll, setting bones and taping on gauze and such for 2 HP. She hauls him to the hospital, where he recovers under the care of local doctors while she goes out and kicks DYSN butt with that "This is weird but I'm still pissed" look in her eye. The doctor makes his Medicine roll, getting Mulder's infection under control and helping the bones to knit themselves properly and so on, and after several days Fox recovers 2d3, for 5 HP. He's now down by only 3 HP, so like any self-respecting investigator he's not going to stick around in the hospital while the others have all the fun. But fate (meaning the Keeper) rules that it takes more than a week for a broken leg to get completely knitted, so Fox will be at reduced DEX and Movement, and, by the way, any time he tries to Dodge or fight hand-to-hand he needs to make a Luck roll or take 1d6 HP (the damage level of a solid kick or clubbing) from his bone collapsing again.

Once Fox recovers those last 3 HP, the Keeper might still say that his DEX and Move and physical skills are down a little for another week.

Now that I reread the original question, I guess Daniel already knew all that stuff I just wrote, so what about other uses for Medicine? Well, I wrote a bunch of chunky rules-suggestions a while back that included a suggestion to inflict infection on characters who don't respect their injuries. I think that should certainly be played out with the Medicine skill: if a character gets First Aid for that .22 gunshot but otherwise leaves it alone, give her a Luck roll or a CON x 5% roll to see if infection sets in for the loss of 1d3 HP a week until the injury is fully healed. This will almost certainly require treatment with Medicine to augment the 1d3 natural healing rate.

Diseases are certainly left vague in the rules. I have just about zero knowledge of how most diseases really work, so if I had an urge to dump one on somebody I'd probably ask the docs on this list for some juicy tips or poke around on the Web for some appropriately nasty articles and photos to adopt into the game mechanics, and allow Medicine skill to alleviate the effects.

Poisons are detailed in the rules in a simple manner: POT vs. CON to see if the victim is truly screwed or just mostly screwed. I would usually allow Medicine rolls, with the proper equipment and drugs available, to give a bonus to the roll or maybe a chance to repeat the roll, or just to treat it like a normal HP loss and aid the victim's recovery. One option would be to disallow using First Aid to treat poison damage, but to allow Medicine to act as First Aid in such cases, for an "instant fix" of 1d3 HP if the doctor has antidotes or whatever on-hand.

Then there's always death. (Or usually, anyway.) Personally I have always disliked the 'now you're at positive, now you're gone unless you get a Heal-3 spell within 10 Strike Ranks' aspect of Chaosium's HP system. I tend to treat it a little fluidly, allowing possible resuscitation (in the CPR sense, not the Karotechia sense) with Medicine skill depending on the circumstances and the nature of the injuries. A victim of 20 HP damage from six knife cuts (blood loss, shock, muscle trauma) might have a better shot at surviving than a victim of 20 HP from one shotgun blast (destruction of vitals or massive fatal shock from the sudden absense of a limb). I might allow the former victim to be kept alive at negative HP for a short while with First Aid, then for up to a week with Medicine treatment. If the victim is still at zero HP or lower after a week, it's time to talk to the estate lawyers.

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Date: Sun, 06 Sep 1998 15:45:36 -0500 From: William Timmins

In my games, Medicine could double as first aid in most situations which, now that I'm thinking about it, is probably a bad idea. ;)

However, Medicine, in my game, had uses such as the following:

Pharmacology - truth serum, dosages of psychoreactive or other drugs Anatomy - examining wounds or bodies to find things that Should Not Be There Diagnosis

First Aid handles stress reactions and, perhaps, allergies and reactions to toxins. Medicine will be able to tell you things like 'hmm… this blood work suggests repeated exposure to stress…'

These are just off the top of my head. Other potential areas include genetics, virology, neuropsychology (which really is more a matter of medicine than psychology, though you'll get arguments about the differences between neuropsychology, neuroanatomy, and so forth)

Generally, Medicine can serve as a skill much like Library Use or Anthropology… a source of information for the PCs about what is going on. A character with Medicine can make observations and tests in the field, much faster than sending work to a NPC offscreen.

One problem I have with Medicine focused on healing is that, generally, PCs will have access to hospitals and potentially better doctors than any of the PCs. Granted, you never know when you'll be stuck in a backwater country… or dimension.

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Date: Sun, 06 Sep 1998 16:22:52 -0400 From: Daniel Harms

Having looked over the previous posts, here's my current thoughts on how the system might work in my game. Comments and criticism are welcome, as always.

First Aid:

- On a successful roll, allows the user to restore 1D3 hit points to an injured friend (1 such roll per injury). If made in the round after an investigator reaches 0 HP or below, this roll may return a dead investigator to life if the 1D3 gain brings their HP up to 1 or better.

- On a successful roll, the user may awaken a victim of a knock-out attack, or a person who has fallen unconscious.

- On a successful roll, the user may slow the progression of a poison in another person's body. The person does not have to make the POT vs. CON check for a matter of minutes or hours, depending on how the poison entered the body and its efficacy.

- On a successful roll, the user has some very basic medical knowledge (such as that a wound is likely to become infected in that climate, or the symptoms of a common disease).

Medicine:

- No short-term healing effects, save for those in the following case.

- On a successful roll, the user can restore 1D3 HP to a person below 0 HP, if the skill is used within a minute or so.

- On a successful roll, a patient may regain 2D3 HP in a week, in addition to those given by First Aid.

- On a successful roll, the user may diagnose the symptoms of a disease. Treatment is possible, depending on the availability of medical supplies and the severity of the affliction.

- On a successful roll, the user may attempt to treat poison. With minimal medical gear, the practitioner may reduce the POT of the poison by 1d6 before it is compared to CON. Once again, the availability of medical supplies and the strength of the poison are factors.


Date: Mon, 07 Sep 1998 00:05:46 EDT From: Michael Layne

Having looked over the previous posts, here's my current thoughts >on how the system might work in my game. Comments and criticism are >welcome, as always.

This sounds quite a bit like the way I've used First Aid and Medicine.

One of my characters has used First Aid for such things as CPR on a lightning strike victim (got his heart going again, and was able to hand him over to the paramedics before she got completely worn out - single-person CPR is fatiguing!). Medicine was useful for such things as blood work, diagnosis of disease, setting broken bones, and (in one case) delivering a baby in a refugee camp.

Medicine seems to imply a greater theoretical knowledge of the medical sciences than First Aid, which is an immediate treatment skill.

A Paramedic, EMT, or (in some cases) a Hospital Corpsman, can get by with just a decent skill in First Aid, while someone in medical practice (or a good Independent Duty Corpsman aboard a DD, for example) would have Medical skill. (An MD with a high Medical skill would not necessarily have a high First Aid skill — my character does, partly because of the time she has spent in Emergency Medicine, and as Medical Officer of an Antarctic station, but many MDs who are specialists in important-sounding fields of medicine haven't seen the inside of an ER since their Residency days, or maybe their Internship!)

In the case of my character, Medicine was also used to represent familiarity with cold effects and their treatment (she spent a year stationed in Antarctica), and (with SCUBA Diving skill) to reflect her knowledge of diving physiology, breathing gases, pressure effects, oxygen toxicity, HPNS, etc. (Dr. Falworth holds both MD and Oceanography degrees, and is entitled to wear the Diving Medical Officer badge on her Navy uniform.)

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Date: Tue, 08 Sep 1998 00:25:06 +1000 From: Rob Shankly

Hi there:

You are quite correct, the difference between the two seems to merely be in the healing rate after successful application, and whether the injured character goes to hospital!

For some reason a lot of PCs I write for tournaments have one or other of these skills. I suspect it's because the Theron Marks' Guide suggested all parties have a doctor! Anyway, here are my thoughts about rules applications for First Aid & Medicine:

1/. A character must have Medicine @ 50% or more, and Education 17+, to call him/her self "Doctor" and have a licence to back it up. When you consider the frequent need for credentials to get a look at evidence, this is quite important. This is a "rule" I have instituted for player created PCs too.

2/. A character with First Aid is not able to read a medical file and make sense of it. A character with Medicine is able to read a medical file automatically, and can also draw conclusions from it if s/he makes a Medicine roll. This includes medical research papers, although perhaps with modifiers.

3/. Medicine skill can be used to draw conclusions about unknown conditions- Medicine might pick up all sorts of anomalies in a character undergoing transformation into a Deep One, for instance.

4/. Both skills require some equipment for any restoration of hitpoints: 4a/. Bandages & gauze for bleeding wounds, splints for breaks, coldpacks for bruising are the bare minimum for use of First Aid. If these are _all_ that is available then Medicine skill gives the same benefits as First Aid and no more.

4b/. Medicine requires a full "doctor's bag" in the field, backed by good facilities for ongoing care. The bag would contain a number of bulky and delicate items (i.e. a stethoscope, thermometer, torch, manometer) in addition to some surgical instruments and drugs. These last would include morphine, at least one type of barbiturate, Valium, nitroglycerin tablets, antihistamine, adrenaline, broad spectrum antibacterials…

4c/. The "hospital" environment must supply 24-hour care if the injured character is going to recover at 2d3 hp/week. In addition the "doctor" meeds access to additional instruments- xray, fluid analysis, EEG (ECG in some cases!). If the place of ongoing care is not up to the standards of a really good 1920s hospital then I modify the Medicine roll- if it is failed, the character rolls again but the healing rate is as for First Aid. Equally, if the hospital is better equipped, I increase the roll.

5/. First Aid typically takes at least five minutes, during which time neither character can do anything else. Durations for Medicine start at at fifteen minutes and could go up to hours.

6/. Medicine is used for diagnosis of disease, poisoning and other illness (i.e. stroke & heart attack, radiation poisoning, or Characteristic drain by a Colour Out of Space). Assuming that the diagnosis is correct, and treatment is given (chicken soup for the Colour drain?), the sick character gets bonuses on the resistance table. The bonuses have to be made up as you go, depending on circumstances, as does the Potency of the disease or poison.

As an example, a character dignosed with malaria would get a +2 to his/her resistance table roll in a '20s game, and a +10 if in a modern hospital. Malaria has a Potency of about 5.

Finally, I made up a rule for CPR a while ago, and used it once. It is complex and clumsy, and serves to warn Keepers of what to avoid. IIRC:

7/. CPR is a special application of First Aid available only in modern settings. It allows a character on 0, -1 or -2 HP to be kept "alive" until someone arrives who can apply Medicine. CPR requires two successful rolls every five minutes: a successful First Aid roll, and roll on the resistance table against resistance 10, with the First Aider's Stamina the active characteristic.

[edit]=
When describing skills to players I would use a scale* similar to these:

First Aid 40% as equivalent to a 30 hour course backed with some ongoing use of skills: i.e. a "St.Johns" course. Police, some firemen, and ambulance officers have First Aid starting at 40% and going as high as 75%. ER staff (other than doctors) have First Aid at 75%+.

Medicine less than 50% is possessed by nurses, physician's assistants, paramedical staff (i.e. dentists). 50-60% is a pretty poor doctor. 60-70% is an average GP. 70-80% is a really good GP or a below average specialist. 80%+ are really great doctors or surgeons.

This is the first time I have written this down, but it seems about right
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Date: Mon, 07 Sep 1998 13:50:22 -0300 From: "Roberto L. Vargas"

At 01:15 PM 9/6/98 -0400, you wrote:

As a fourth year med student (considering Pathology, by the way) I agree with most of what Graeme said. Here is my take:

First Aid stays just as he suggested. The character knows how to give basic CPR, assessing fractures, how to stop bleeding, etc. If the skill is high enough, >40%, the character can be a paramedic, which means he has other techniques he can use, like knowing when to give oxygen (which you do not give to everyone who is gasping, as that may undermine his basic drive to breath), setting up casts, saline drips, and even cardioversion (that electrical thingy you do with 2 pads properly positioned in the chest… CLEAR!!!…..K-CHNK!!!!), up to the point of injecting drugs (which is, by the way, the correct treatment of asystole or the famous flatline; not cardioversion as has been engrained in urban myth by television and movies… I guess it is more dramatic than injecting atropine and pumping and puffing away, after all) If he has less, he simply took a course and can be a certified at CPR, both the actual technique (hoping to break as few ribs as possible) and the approach (for example, if you are alone and a kid is on the floor you rush and assess him as chances are that he either suffered an accident or has a foreign body and straight CPR can really help; while if the same happens to an adult you call emergency services first, 911 or whatever, and then you start CPR since chances are he needs serious help to get over the crisis).

Medicine is broader, and all doctors HAVE to know first aid. The way I deal with it is, if you want Medicine, you need First Aid in 40% or more. That said, a doctor gives basic aid and knows how to give ACLS (advanced cardiac life support). BUT, to do most of those things you need to be in an emergency room, or, at the very least, have some special drugs (atropine, epinephrine, bicarbonate as basics, many more as things get messier…) special instruments, and professional help (nurses, paramedics, other physicians) so it is a bit limited in the field (possible field uses include the ever famous tracheostomy). I substitute the Med roll for First Aid in doing basic things. Poisonings have to be attended by MD's and most know the basic antidotes by heart. If you don't remember, or if the substance is rare, in every ER there is a large group of phone numbers, so you call the nearest poison center and they tell you antidote, management steps in acute poisonings and blood levels where it is hazardous.

That said, you either have to be in the ER, or steal what you need from an ER (another use for Medicine by the way; knowing what things you will need to "borrow" for any intervention). While paramedics do cast broken bones, MD's undo these casts, realign the bones (painful as hell!!) and re-cast it again, then get an x-ray to see if it is properly aligned (you can guess what happens if it isn't, yep you go through the steps again). If you don't, it will heal slowly and heal crooked. To this I add the already mentioned disease diagnoses and long or short term treatment, after the acute crisis have subsided. One last thing, in order to be an MD, characters need >60% in Medicine (otherwise they dropped out of med school or are people extremely well read, or are nurses, who by the way not only know a lot, but have special skills all of their own.) They also need equipment (even if it's just an aspirin, which is the first thing you can give someone who is having a heart attack after you ask him if he is allergic to it; it does wonders in improving mortality and morbidity and you don't have to be a doctor to do it), otherwise they will just be able to assess what is happening and pump and puff like crazy.

"but many MDs who are specialists in important-sounding fields of medicine haven't seen the inside of an ER since their Residency days, or maybe their Internship!)" Very true, but in order to keep their licenses they have to get re-certified every damned year (hell, I have to do it and I'm just in med school). And re-certification involves dummies which have pretty lights that shine when you do things right, and glare when you break the dummy's sternum.

Specialties and subspecialties, like surgery and the like: This is muddy territory. In general, anyone who wants a specialty, like general surgery or pathology, HAS to be an MD beforehand. Then there are the sub-specialties, like transplant surgery or forensic pathology. Usually, I make no distinction in game terms, except perhaps asking for a higher score in order to be a sub-specialist (and maybe getting a penalty if he attempts something outside his area of expertise, if you are that nasty). Once again, you need equipment and facilities.

Players may argue that those are a lot of points to become a Forensic Pathologist. I agree, but that reflects the preparation those people have. 4 years under-grad, 4 years med school, 5 years pathology residence, 1 year forensic pathology felowship. It's not like you can do a whole lot of other things while you study. I do wonder how old is Scully, as she needs to be a forensic pathologist in order for her autopsies to be accepted.

The difference between regular pathology and forensic? Pathologists do autopsies of people who died of "natural causes", besides diagnosing biopsies (microscope work) and they are the ones who do lab work like taking care of blood banks, and immunological and genetics labs. Forensic P. deals with autopsies of unnatural deaths (accidents, murders, suspected anything, etc.) and legal cases.

I don't know about the blood and stress bit someone else suggested, although there are substances known as stress hormones… but that is biological stress, like disease, accidents and such (and of no diagnostic value except under certain circumstances).

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