Medical emergencies

Mystery on a Train: The Value of Debriefing

Jo Ann L. Nicoteri, PhD, CRNP, FNP-BC

Nicoteri JAL. Mystery on a train: the value of debriefing. Consultant. 2018;58(6):e183.


We clinicians use critical thinking skills each day when a person presents for health care. Debriefing, whether by ourselves or with others, is an important aspect of this experience, even for seasoned health care professionals. Essentially, debriefing is active reflection; behavior is either reinforced or changed based on a new experience.1 Debriefing may be formal or informal. In practice, we do replay our actions particularly at the end of the day on the ride or walk home, but generally we do not recognize the importance or value of this introspective, self-reflective step in the decision-making process. Sometimes we agree with the way a patient encounter progressed, while other times we find room for improvement.

Students often participate in debriefing sessions after a simulation exercise. One such process, Debriefing for Meaningful Learning, may be used to promote students’ reflective thinking and learning.2 It is just as important for students to receive this feedback as for health care professionals in practice. A recent incident brought the value of debriefing to the forefront in my career as a family nurse practitioner and a nurse educator.


One summer, my husband and I decided to be adventuresome and to travel by train to a nursing conference. On the second evening of the ride, the train stopped, and the conductor made an announcement asking for medical assistance from any health care professionals on board. Apparently, a woman had fallen and was incoherent and dazed.

I headed toward the rear car and was soon followed by a physician. I stated that I am a family nurse practitioner and that my primary practice is in college health. The physician said that he would defer to my judgment, because although he was an internist, he practiced in infectious disease, and I was probably more experienced with such a situation. As we made our way to the scene, the conductor told us that a passenger had alerted the staff that the woman had fallen in the aisle and needed assistance getting back to her seat. The snack bar attendant also told the conductor that the woman had purchased alcohol during the evening and conjectured that the woman most likely was drunk.

When the physician and I arrived, the woman was sitting upright, but her speech was slurred and her movements were slow. I sat down next to her, introduced myself, and explained why I was there. She was cooperative, telling me her name and birth date—she was in her late 50s—and that she was traveling alone to visit relatives. She did have difficulty telling me her age, however. She said she was taking no medications and had no chronic illnesses. She allowed me to look through her bag and open her water bottles. None of the bottles had an alcohol odor, but the woman did have a fruity odor to her breath. Her grip strength and pupils were equal, but she was having difficulty with memory and coherence. She had a slight red mark on the left side of her forehead, which she had struck when she had fallen. She denied having had alcohol but added that she had not had anything to eat. She did not have a wallet or any other identification in her bag. She said that she had another suitcase on board, but the conductor could not find any luggage bearing her name. At times her affect was very personable, but she was easily agitated, using profanities.

At this point, the train had been stopped for approximately 30 minutes while the woman was assessed. Another conductor came on scene and said that a decision had to be made as to whether the woman could travel to the next stop, 1 hour away. As in any emergent situation, several critical factors played in the decision. The woman’s condition could not just be chalked up to “too much to drink,” although that would certainly be in the differential diagnosis. If the train continued with her on board, someone would need to sit with her and monitor her situation. Transient ischemic attack, cardiovascular accident, diabetes-related illness, and neurologic problems could not be ruled out and in fact were likely scenarios given her age. What would happen if her condition deteriorated during that hour? The train would be traveling through some desolate areas to the next large-city station.

I looked at the physician and said I believed that the woman required further medical attention immediately, and that she should be removed from the train at that point. He concurred as the conductor listened. We waited with the woman until local emergency personnel arrived. Her vital signs were stable, but when the emergency medical technicians arrived, she spoke very hesitantly to them and was unable to correctly answer their questions as to the day, date, and year, so she was transported by ambulance to a medical facility.


The physician and I returned to our seats and, of course, I reviewed the situation and debriefed myself. If the woman were my relative, would I want the same course of action and referral? If the diagnosis had been alcohol intoxication, what would have happened if she had left the train in that condition? I did not learn of her final destination, but she had been escorted off the train sooner than had been expected. Would her family come to get her? Was this her usual behavior? Was there an important clue in the supposed other luggage?

As my thoughts raced for the next hour or so, the conductor appeared in the dark with a flashlight, checking on passengers. When he reached my berth, he said he was so glad he had found me again. He needed documentation as to why the train had been delayed. We walked to the now-empty dining car, where I hand-wrote an explanation of the events and my credentials for making the critical decision of removing the woman from the train.

At first, I felt anxious about having to rationalize my decision officially. As I wrote and proofread my explanation, I realized this self-debriefing actually had started occurring as I returned to my seat. It seems second nature, but how many of us consciously realize how renewing and self-validating debriefing can be? Whether conducted formally or informally, the introspective review is necessary in the evaluation of patient care.

My husband and I definitely had a story to tell about how I had unexpectedly “held up” Amtrak on our journey. We never did learn the outcome of the woman’s case; however, in retrospect, I would make the same decision in a heartbeat.

Jo Ann L. Nicoteri, PhD, CRNP, FNP-BC, is an assistant professor in the Department of Nursing at the University of Scranton and a family nurse practitioner in the University of Scranton Student Health Service in Scranton, Pennsylvania.


  1. Werry J. Informal debriefing: underutilization in critical care settings. Can J Crit Care Nurs. 2016;27(4):22-26.
  2. Dreifuerst KT. Getting started with Debriefing for Meaningful Learning. Clin Simul Nurs. 2015;11(5):268-275.