D: “The dragon’s breath licks across Del’s robes and arms, singeing them, dealing 5 points of fire damage”
P: “I’m about to go down, I’m all out of healing potions, and I’m sitting at 7 hit points. I cast Earth Tremor on the cracks below the dragon. If I’m going down, I’m taking her with me. I rolled an 18 to hit.”
D: “The spell strikes true, and the cracks below the dragon begin to open as the ground trembles around you. The dragons is struck by a displaced piece of earth as she begins to fall. She takes 14 damage. The cavern floor crumbles around you, and the rest of the party watches helplessly as you are both swallowed by the abyss….”
The intersection of literature and theatre with medicine is a critical approach to the pursuit of medical humanities. Interactive media, namely table-top roleplaying games as a media form have largely not been examined in the context of medicine, in my opinion largely due to the lack of overlap in their circles of practice. Doctors studying literature or attending plays is commonplace, while doctors sitting around in a basement chucking dice may seem strange. Given the conversational and narrative focused nature of medicine, examining interactive narrative activities through a medical lens is certainly a worthwhile approach. In this piece, I aim to deconstruct one crucial trope in table-top roleplaying games, and examine how we might better portray injury and illness.
For the uninitiated, Dungeons & Dragons is a fantasy roleplaying game, in which players sit around a table and collectively tell a story. They each play a singular character, and interact with a fantasy world through the Dungeon Master (DM). The DM acts as a window into the world, answering questions such as “What does the inside of this cave look like”, or “what do I already know about this town?”. The DM will typically guide the players through a narrative experience, be it a quest to save a doomed kingdom, or a delve for riches and fame. The success or failure of various actions hinges on the rolls of dice, and interactions often occur with “in character” discussion, meaning that you say exactly what you think that your character would say. This othering of the self has parallels in medicine, as we are often asked to use our words to paint the picture of a patient’s experience.
“As you step into the tower, you are hit by the smell of dust and stale air. The unfamiliar stonework suggests a long forgotten civilization. An eroded staircase leads down into the darkness below. As you approach, you hear the faint sound of claw scraping stone. Perhaps this tower isn’t as abandoned as you thought…” ”
Health and vitality are key to a good table-top roleplaying narrative. Typically the adventures that you send your characters on are fraught with danger to life and limb. However, most often these dangers equate to numbers on a piece of paper, rather than interesting narrative development. As medical students, we are becoming increasingly familiar with the way that people cope and recover from injury and illness. The human response to physical and mental hardship is so varied, it seems a shame that this element of humanity is often tossed aside in favor of convenient book keeping. The stories that we tell about health are incredibly powerful in our understanding of the hardship that our patients face, and interactive fiction is no exception. This raises the question, is it possible to examine injury and health in an interesting way through interactive narrative?
In many tabletop roleplaying games, Dungeons & Dragons included, the health of a character is represented by one number, that being their hit points. This is a static number that is a rough gauge of your character’s vitality, and their ability to keep adventuring. However, this mechanic is rarely developed any further than that. Whether your level 5 Wizard has 34 hit points, or 1, they are equally capable of casting spells, exploring dungeons and finding treasure. This is a trope that has transcended the table-top medium, and has permeated into board games, video-games and most interactive media as a method of tracking vitality. Once a character hits 0 hit points, they find themselves clinging to life, their only hope healing magic, or a lucky roll of the die on a death saving throw. This strict dichotomy is a shame, because a barbarian, bloodied and barely able to stand, desperately swinging his battle-axe with his injured arm is a far more interesting vignette than the same barbarian finishing a battle appearing unscathed, despite being on the brink of death.
“I may be a little light-headed, but I’m not about to let a silly little thing like a hemorrhage get in the way of crushing orc skull!”
Most often, when a character takes damage from a spear to the side or a dragon’s breath, they are up and ready to continue with a swig of healing potion, or a quick prayer to the cleric’s deity. No matter how damaged someone is, there are no permanent consequences to these injuries once they get them patched up. Anyone who has seen the inside of an ER, or an ICU knows that this isn’t the case. A concussion could require careful monitoring, and avoiding any risk of physical trauma while a simple broken arm would require weeks of immobilization within a cast to heal properly. More permanent injury is a tricky thing to try to implement in interactive narrative simply because it often isn’t interesting. It’s frustrating to roleplay a character that isn’t able to do everything that you want them to do. Dragging a broken leg through a dungeon means you are slowing down the rest of your party. The same goes for sitting in the inn laid up, waiting for your punctured lung to heal while the rest of your friends are off saving the world from the newest Lord Skulldeath.
So how is any of this relevant to practicing medicine? Consider taking a patient’s history, when characterizing a the chief complaint, we are often most interested in how the complaint is affecting an individual’s life. What daily activities does it limit you from? How has it affected your functioning? These sorts of questions are often the most telling, and interestingly enough, are also the sorts of questions that one might ask the DM about something that has happened to their character. In my practice, this has lead to a couple of interesting revelations.
Firstly, in the clinic room I find myself asking the patient questions that I might ask a DM, as they both represent a window into an experience that I am not able to see with my own eyes. D&D is about telling stories using our words, and working with each other to develop a interesting narrative. Using the mind’s eye to put together the imagery of a fantasy setting informs lines of questioning in the same way that we use lines of questioning to develop a comprehensive history of a patient’s illness.
Secondly, when sitting at the table-top, I ask myself what sorts of things would my character be concerned about when dealing with illness and injury if they were a patient. Neither patients, nor Grognar the barbarian are very interested in the inflammatory markers that would underlie their recovery, but they would both likely be very interested in how their mobility would be affected, and what they should avoid to prevent it from worsening. Also, neither Grognar, nor my patient are medical students. They don’t have the same vocabulary, the same background or the same ways of understanding their illness. Putting myself in this different mindspace influences both my role-playing and my patient rapport.
Applying medicine to media where it is not normally applied gives us a very interesting opportunity to be introspective about the nature of disease and injury. Being able to apply our experiences in such different ways, and to imagine how certain afflictions might actually affect an individual trying to traverse fantastic situations is an incredible exercise. Roleplaying a character can require quite a lot of empathy to see things from their perspective, and this is no difference in the context of debilitation. How does Grognar feel about his severed arm, and how does it affect the way that he interacts with the world around him? In a way, placing ourselves in this mindspace can be an interesting exercise in understanding our patients. It can be difficult to imagine how ataxia may truly impact one’s lifestyle, but roleplaying experiences of disability may help to open our eyes to potential struggles.
P: “On the way down, I want to cast Hold Creature on the dragon’s wings, to prevent her from flying away”
D: “The dragon’s writhing becomes more laboured as she falls into the darkness below. The soft glow of your torch illuminates the cavern floor fast approaching.”
P “I cast Feather Fall to try to slow my descent”
D “The dragon corpse crashes into the ground below and stops moving. Your descent starts to slow, but not quite fast enough to prevent you from falling. You hit the ground shoulder first, and hear a sickening crunch. You take 6 points of damage, and have difficulty moving your left arm when you try. You are otherwise unscathed”
P “I call back up to the rest of the party: ‘If any of you want a split of this dragon’s loot, you better get down here!”