Tracking stats with fish bones: How a nursing shorthand for lab values can help a dungeon master
In this episode, Keith walks us through the fish bone diagram, a nursing shorthand for lab values.
A portion of the nursing report sheet Keith uses, showing the fishbone diagrams
When information changes frequently, having a consistent system you can quickly refer to can literally save someone's life.
As a dungeon master, the stakes are lower but tracking changing numbers like HP and Spell Save DC can drain your brain and the game's pacing. That's where a system like fishbones can help!
You can download ad use the Dungeons & Dragons version, made by Keith to quickly reference PC and NPC stats so you can speed up combat and roleplaying checks:
Episode Transcript
Sara [00:00:01] Hi. I'm Sara Shepard.
Keith [00:00:02] And I'm Keith Hazen-Diehmn.
Sara [00:00:03] And this is.
Keith [00:00:04] Dungeons and documentation.
Sara [00:00:13] Hey, everyone, this is Sara and welcome to Dungeons and Documentation. Today I'm interviewing my co-host Keith. Welcome to the show, Keith.
Keith [00:00:22] Hi. Thanks for having me, Sara.
Sara [00:00:23] Now, Keith, what are we going to talk about today?
Keith [00:00:26] So today we're going to talk a little bit about my organization system that I use in my work as a nurse.
Sara [00:00:34] So this system is called Fishbone. Did I get that right?
Keith [00:00:37] Yeah. I mean, it's not so much the name of the system as it is the name of the, you know, layout.
Sara [00:00:42] So it looks like a fish's bones.
Keith [00:00:44] Yeah, it looks like a fish's bones.
Sara [00:00:46] And when are you using this?
Keith [00:00:47] So this is a system I use in my work as a nurse for recording medical labs for. For fast reference.
Sara [00:00:55] Maybe you should tell us what's on these fish bones first.
Keith [00:00:57] Yeah, sure. So, fish bones. There's two different fish bones at once for electrolytes. So it gives you sodium, potassium bicarb and chloride, and then bone and creatinine, which are measures of kidney function and then blood glucose. And then the second one is for a complete blood count or a CBC. And that tells you the patient's white blood cell count to measures of their red blood cell count and then platelets. So those are all important measures.
Sara [00:01:35] Okay. And just for the listeners, we will have fish bones up on the episode page if you're having a hard time picturing it. We'll have one. Okay. And why are you recording these numbers over and over again? Is it something that you're supposed to know? The doctor's like, oh, my gosh, what's this potassium level?
Keith [00:01:50] Sometimes.
Sara [00:01:51] Yeah. Okay.
Keith [00:01:53] Understanding what someone's electrolyte levels are and blood counts can tell you a lot about what's going on for that person. Are they dehydrated? Are they over hydrated? Are they bleeding? Are they, you know, any number of things? If their electrolytes are out of scale with each other, then it can indicate different disease processes that are going on for that person. So, um, you know, although the labs that we draw have a lot more information, using these fish bones is sort of our fast reference to give us a lot of information very easily. In my job, I record this on every single patient that I have over the course of the day, and I have it on my person. So if I need it for fast reference, if, you know, for a just a casual conversation with a doctor or something or with if there's an emergent situation for that patient, then I have that information available and that can be used to help understand what's going on for that person.
Sara [00:02:52] So yeah, because I was thinking this sort of information would probably be in a computer, right? Like up on the screen with the beep beep.
Keith [00:02:58] Yeah.
Sara [00:03:00] That thing.
Keith [00:03:01] Yeah. No, it's not on the beep beep beep thing. It is in the computer, it's in the, the, what we call the EHR the electronic health record. But, you know, sometimes it's just it takes 5 minutes to access that.
Sara [00:03:12] And you're like "ah what's the password?"
Keith [00:03:14] Right, exactly. Exactly.
Sara [00:03:16] Yeah. A system that nurses use because it's fast, because it's information you're referencing consistently for for all these people with important information. That's good to know.
Keith [00:03:27] Yeah, that's exactly right. And it's part of a report sheet that I use to organize my day. So on my report sheet, I have fish, the fish bones with the labs, and then I write down any other, you know, pertinent labs. And then I have a sort of a quick assessment of my patient. So I'm, you know, looking at each body system, neurological, cardiac. All that stuff. Then I also have a little time layout for the day so I can track what meds need to be given at what time. When I do certain things through the course of the day, I can make notes on that piece of paper and then I can go back in and add it into the electronic health record later, because sometimes it's just takes too much time to log in and and put in those notes. So yeah, the fish bones are sort of part of this organizational structure that I use to make sure that patients receive appropriate care and make sure that that appropriate care is documented for posterity.
Sara [00:04:24] Okay. So if I'm understanding you correctly, Fish Bones is a supplemental method that you use to quickly access important information. Yeah, right. Okay. Interesting. I can see why you would want to talk about this system because I mean, I've never been an emergency nurse, but the pressure of having to know information in my campaign is probably equal.
Keith [00:04:48] Yeah, I mean, really, you make a roll and you've got to figure out how it's going to come out that can really make you sweat. Or if you don't, if you don't have it lined up just right.
Sara [00:04:58] And how is this something you learned in school or is this something that was like passed on with the nursing staff? And then you have to practice it? Like, is it taught? Is it standard?
Keith [00:05:08] You know, actually, I had a teacher in school tell me specifically using this was an antiquated tool that some old timey doctors used, but no one really used it anymore. And then, you know, as soon as I got in a nursing practice in, you know, a critical care setting, as it turns out, everyone uses them. It's a very standard tool.
Sara [00:05:30] And if you were to go to a different ward of the hospital, are there different varieties of fish bones? Like, I'm thinking you go to the maternity ward and there's a little baby fishbone and the mommy fishbone, and you're recording different things like contraction fishbone or is this like it's the standard we use this for electrolytes and we use this for?
Keith [00:05:48] Yeah, yeah. Blood counts. Yeah. This is a pretty standard layout. So, you know, the basic metabolic panel, which is your electrolytes and then the complete blood count are two very basic panels that are used for diagnostics. I don't know if you went to the maternity ward, if they would have some other kind of layout.
Sara [00:06:06] I'm guessing they would have their own sheet. Right? Like it sounds like you have these computer systems and then you have.
Keith [00:06:12] Yeah, absolutely. So like my report sheet that I use on a daily basis is very much catered to my specific area in the hospital. And yeah, if you were working in the so I work in a critical care unit. If you worked in the emergency department or if you worked on, you know, mom, baby or delivery, then you've got a very different set of information that you're most interested in. And so you definitely have a different layout for your for your sheet to organize that information.
Sara [00:06:45] That's great. Hmm. Do you want to talk about D&D?
Keith [00:06:52] Yeah, let's talk about D&D. Okay.
Sara [00:06:59] I think that Fishbone makes a lot of sense because you're talking about you have the system is the computer system for the hospital and you're charting. But then you have this extra one that all the nurses are saying, "hey, you should probably use this too, because it's just so much to keep track of and you need something really fast to keep track of the numbers that are changing throughout the day." That sounds like a Dungeon Master being like, "Cool, I've got the player sheets, I've got my monster stat block. I just I need something else to like quickly." See, I'm thinking during combat, write these numbers. And so you had an idea of how fish bones would be translated for a DM.
Keith [00:07:36] Yeah. So I used to play with a dungeon master who would make all the rules for the entire game. So he basically took care of 100% the mechanics and yeah, and then all the players would roleplay and they'd say what they were doing, and he wuld ask what attacks they wanted to make. And then he would roll and resolve them. And he was pretty good at it. I mean, he was pretty efficient and I never really understood his system. But, you know, since then, I've sort of wondered like, how did he organize all that information? Because he really did have it all down really well. So, I mean, this this system having this sort of like report sheet for your characters with this sort of like fast data layout in this in this format, like, like fish bones seems like it'd be a really effective tool for if you want to make checks for your players, not necessarily advocating that every DM out there run all the mechanics, but.
Sara [00:08:37] No one else is rolling. Only me.
Keith [00:08:39] Right, exactly. Yeah. But if you say have a NPC who's trying to charm a player, it might be more advantageous to the storytelling aspect of the game for you to just be able to roll that check without having to clue your player into the fact that they're trying to cast a spell on them.
Sara [00:08:59] I see. And so in this instance, you would have a fishbone for every one of your player characters. And then when the NPC wizard is casting charm person, you're making the saves for the player characters. Then as the DM you're seeing the results and tell your players, that you all think he's so charming, right? He's inviting you to dinner. It seems like a good idea. No one's concerned about the skulls.
Keith [00:09:24] Yeah.
Sara [00:09:25] That's great. Or I'm thinking like they're frightened, like a dragons frightening presence.
Keith [00:09:30] Sure. Yeah, exactly.
Sara [00:09:31] To determine that. And just like it sounds like the DM who is rolling for everybody, that's an extreme level, but I imagine the pacing of the game was pretty fast because people aren't having to be like, "Oh, what's my spell save? Do you see? I don't know. What's my agility modifier? I don't know."
Keith [00:09:45] Yeah, for the most part. Every once in a while he would have to sort of pause and look through things and and then pick things back up. But the cool thing about that was, you know, if like, if you say you just have an NPC that's trying to convince you of something, you know, if the DM rolls and they do a good job of it, you know, if they do, if you do opposing, you know, charisma checks, say, and the NPC wins, then, then the DM can just tell that story by what they say. So, you know, they, they do great. And then they say something suave like, you know, "oh, why don't you come to my bedchamber" or whatever? Or they fail. And yeah.
Sara [00:10:25] I don't question that at all.
Keith [00:10:27] Or they feel and they're like, Hey, want a bone or what.
Sara [00:10:32] You and spills their drink all over.
Keith [00:10:33] You. Yeah, exactly. Exactly. Yeah. So rather than like, you know, saying the text and then resolving whether that's effective or not, you can you can storyteller a little more effectively.
Sara [00:10:43] Yeah, I like that because we often do that for player roles. Like a player might say, I want to seduce this man. You say, make a check, and then it's hilarity ensues. But we don't always do that for like NPC PC encounters from the NPCs perspective. Mm hmm. Sure. Yeah. That adds a whole level of it and certainly allows you to be. To embrace the unknown for the NPCs you've created and then experience the fun as a DM because often it's just the players that get to have fun.
Keith [00:11:11] Sure, sure.
Sara [00:11:13] So you're thinking your fish bones would be like the player character's stat block, or maybe just the modifiers?
Keith [00:11:19] Yeah, it could either be. Yeah, probably just the modifiers or just the saves.
Sara [00:11:24] Maybe even to go back to the your fish bones at the hospital, you had to fish that you use for patients. So maybe you have the stat block on one of the fish bones. Yeah. And then we have things like I as a team and interest in hit points. I want to know if this. Like sometimes a dragon's breath, a weapon will just insta kill a player. And I might want to know if that's going to happen before I tell them either because I'm going to change so, or I'm going to say, you know, you fall dead, make a death saving throw to kind of like keep that momentum going, like you die.
Keith [00:11:56] Hold up, Sara. You changed the role to to alter the outcome of your game??
Sara [00:12:03] Everybody does that. I mean, like, one of the first games I ever ran, my player character, Tim was just instantly killed, and I knew he he wasn't going to be able to handle that because he was new to die and he was going to think his character was dead forever.
Keith [00:12:16] He was not emotionally prepared for that.
Sara [00:12:18] I was like, "Oh, you drop to one point."
Keith [00:12:20] I Sure, yeah. Yeah.
Sara [00:12:22] You know, in retrospect, I wish I would have killed him because now he's got way too much confidence.
Keith [00:12:25] He would have learned a valuable lesson. Yeah.
Sara [00:12:27] Don't try to fight a dragon at level one... Okay.
Keith [00:12:29] But to go back to what you're saying, it is super useful information to have. So that I mean, just organizing that information, I mean, a lot of a lot of Dungeon Masters will do that. They'll have at least, you know, acres lined up.
Sara [00:12:41] Oh my God. Yeah. AC That's like the biggest bog, I think, in the game that you and I are playing right now. It's just like, "I don't know my AC Oh, and I don't know my spell save DC." Yeah, that's me talking about myself. I don't really know. I should though.
Keith [00:12:54] That. Instead of the DM having to ask every time, oh what was your AC again or what was your spell save DC again. They can just have that information.
Sara [00:13:02] Yeah, I almost always better. Sometimes I run an encounter and I say it's 17 to hit to the table like so you please remember if you're hitting or not because it gets really repetitive. Like I rolled a seven. Okay, that doesn't hit. I don't know, like, do we need little cards? It's like, here's the AC. The Fishbone for the monster. I guess we don't want that.
Keith [00:13:25] Well, going back to, you know, this mythical team that I played with that role did all the roles. You know, one of the interesting things about that is, you know, if you don't know what number you have to hit, then, you know, it makes attacking a little bit more of an unknown. Right?
Sara [00:13:41] It's true.
Keith [00:13:42] Especially in the initial rounds, like if you're in a battle and you feel like you're swinging really well, but the your opponent is dodging you or parrying you, then you'd sort of know, you know, as it comes out. Like you have to you have to swing really well. You have to attack really well or, you know, you roll a.
Sara [00:14:00] Really early screwed, you should probably run away if 23 doesn't hit.
Keith [00:14:04] Yeah. And you know as a, as a character. Right you would know. Yeah, this is the best that I can do and it's not good enough and I should leave. But you wouldn't necessarily know that right off the top, right? Yeah.
Sara [00:14:18] Okay. Fish Bones, I'm preparing for a session. I'm a DM. I'm going to fish bone my player characters. I'm going to have their modifiers on one fish bone, and I'm going to have information that's important to me on the other. So I'm thinking spells ADC. Armor class, hit points. And I don't know, they're passive wisdom?
Keith [00:14:39] Passive perception. Yeah.
Sara [00:14:40] There we go. And I've got that on a sheet and I'm just kind of referencing it during combat or during roll plain. And then I guess I'm going to do the same thing for my major NPCs because it's just helpful if I know they're going to meet the Vampire this session. What's his charisma? Right? Just kind of like having it ou there as a one sheet, I'm ready to.
Keith [00:15:00] Go, right. And just keeping that information all organized. So you're not having a flip around in different pages or books or whatever.
Sara [00:15:07] Yeah. And then are you thinking that like as a DM, I'd sit down and say, okay, can everyone just remind me of your stats or Hey, can you hand me your player sheets and I'm just going to take some notes? Players get a little nervous. Kind of adds to it.
Keith [00:15:21] Yeah. Yeah.
Sara [00:15:23] "Why's she looking at that?"
Keith [00:15:24] Yeah, yeah. Initially you could just copy it off their player sheets. You know, it becomes a little tricky as you're leveling up because those things change, so you just have to make sure that you're tracking it all.
Sara [00:15:32] Yeah, well, that's the beauty of the Fishbone, is that you, even you, as you're at work, you're redrawing it throughout the day, I'm guessing.
Keith [00:15:39] Or know. Yeah. For checking labs on a person multiple times throughout the day. You're you're adding, you know, new notations for sure. Sometimes not. Sometimes it's just once a day and that's it. But, you know, there are definitely situations where you're checking labs every couple hours or 4 hours or something, and so you're definitely adding new information.
Sara [00:15:59] That's great. I'm definitely going to try Fishboning it.
Keith [00:16:03] Yeah. So we'll develop a little layout for fish bones. Um, we'll, we'll post that on the website for anyone that's interested in looking at it, using it, seeing how it works in their games, how it helps them organize information and um, you know, we're always interested in feedback as well.
Sara [00:16:20] Yeah. If you end up using it and you like it, you don't like it, just comment on the episode page or you could comment on our social media like just linked on our website.
Keith [00:16:29] Yeah. You know nice though.
Sara [00:16:31] Don't yeah. Don't be a dick about it. I mean, constructive comments people.
Keith [00:16:38] Yeah. We love you and you love us.
Sara [00:16:40] And I mean, I don't I don't know. Use it. Well, thank you, Keith, for that. That's great. And you know what? Hey, salute to you. You know, first responder during these hard years, like you are actually a legit COVID nurse, like you were in the thick of it. You brag about how great you are. I'm going to brag about you. Keith was in it everybody. When we were all staying home, he was going to work at the hospital with COVID people.
Keith [00:17:07] With COVID.
Sara [00:17:08] As they're called. Yeah.
Keith [00:17:09] Yeah.
Sara [00:17:10] Cool. All right, that's. That's all we have today.
Keith [00:17:13] Yeah. Thanks for having me on, Sara. This was really fun.
Sara [00:17:16] Yeah. Thanks for joining me. Look forward to your next episode. Yeah. Okay. Bye bye. Dungeons and Documentation is a production of Keith and Sarah's free time. Our theme song was created by Ian Post executive producer Oslo Cobblepot Underwriting provided by Shepherd Creative Enterprises, LLC. Our show is recorded and produced in the crypt of the Smiling Lich.
Keith [00:17:44] Dungeon, and documentation is brought to you by the Eugene Public Library. The Eugene Public Library. We have books and stuff if you want to check it out. Brought to you also by DM Tools. Find it online at DM Tools, dot dev DM Tools. What was that guy's name again? Dungeons and Documentation is also brought to you by Sarah Shepard. Creative Web Design. Sarah Dash. Shepard Tor.com Shepard Creative Web Design. There's no H except in the last name. There's two ages in that.
Sara [00:18:20] Today's episode was sponsored by the McNassar Health Foundation, encouraging all men in their late forties to go to an actual doctor. And we're talking to you specifically, Jack.