Thread by @gradydoctor

1/
July 1, 1996

Her: “This one looks straightforward. Ran out of meds, feels short-winded.” *stares at index card* “Vitals underwhelming.”

I stared at her trying to look cool. Although cool is not what I felt.

Her: “You know where the Red Zone is, right?”

2/
I mean, yeah. Technically I did know where it was from our orientation week a few days before. But I didn’t KNOW know.

She must’ve read my mind.

Her: “Don’t worry. There’s only 2 zones. I’ll be right down. Just go do the H&P and start the work up while I finish up here.”

3/
She stomped her feet back into her clogs and walked off.

I turned her words over in my head:

“Do the H&P” — okay, that I could manage. But that other part? That’s what scared me to death:

“Start the work up.”

I wiped my face with my palm and bit my lip.

Oh no.

4/
Honestly? I never quite knew what was meant by the term “work up.” It always sounded so mysterious and abstract. The only thing I knew how to “work up” was a sweat. Or myself.

Uggh.

I pushed the elevator button and tried to find “work up” in my Washington Manual.

No cigar.

5/
The elevator opened and I saw Dottie one of our chief residents.

Dottie: “Hey Kimberly! I was just coming to check on the interns. You good?”

I wanted to cling to her ankles. Good? No.

Me: “Umm yeah. So far, so good.”

She nodded and asked if I needed anything.

Ha.

6/
Ma’am, I need all the things. Starting with where to file a complaint to the Washington Manual about the absence of “work up” in the index.

But I didn’t want to get marked as needy. Or incompetent. So I lied.

Me: “I think I’m good.”

And with that, she was gone.

Uggh.

7/
I got turned around a bit but finally found my patient in the Red Zone. It didn’t help that the unit clerk told me that “blue” was lower acuity and “red” was the area for the sicker patients.

Uggh.

I did feel slightly better when I met the patient—a cheerful octogenarian.

8/
Mrs. Parker had lost her meds while on a cruise.

Mrs. P: “You been to Alaska?”
Me: “No ma’am.”
Mrs. P: “Ooooh you GOT to go. Them glaciers was a sight!”
Me: “Was your cruise in Alaska?”
Mrs. P: “Mmm hmm. Other than losing my pill bag it was great.”

She laughed. I did, too.

9/
Her pill bag included inhalers, blood pressure medicines, and diuretics. When I listened to her lungs, I thought I heard some crackles. But maybe a wheeze, too?

Uggh.

All I knew was that she needed to get back on her meds. And maybe get an X-ray?

Oh, and a “work up.”

10/
I finished up and walked out to the nurses station. Now it was time to do this elusive “work up.” Except I still didn’t know what that was.

Uggh.

“Kimberly? Hey!”

I swung around and there was Dottie again. She held out her hand and offered me a Jolly Rancher candy.

11/
She leaned an elbow on the counter and began talking.

Dottie: “You know? On my first days, I had questions that I thought were too basic to ask. So I promised myself that I would find interns and make sure they don’t feel like I did.”

She popped a candy into her mouth.

12/
I straightened my spine and tried to look confident. But just as I prepared to say “I’m okay” I remembered Mrs. Parker.

This wasn’t about me.

Me: “Ummm. . . “
Dottie: “Ask me anything.”

*pause*

Me: “What is . umm . . . a ‘work up?’”

*silence*

Me: “Nevermind.”

13/
Dottie: “No—it’s fine. What’s . . - a ‘work up?’”
Me: *face getting hot* “Yeah.”
Dottie: “Hmmm. It’s . . . like. . . what you do to figure out what’s going on with the patient.”

I still looked perplexed,

Dottie: “Let’s do this. Tell me about your patient.”

And so I did.

14/
Dottie: “So what do you think caused her shortness of breath?”
Me: “Maybe volume overload from no Lasix? Or a COPD exacerbation? Or . . .both?”
Dottie: “Okay. So what do you want to do?”
Me: “Get a chest x ray. Check an EKG and cardiac labs. And chemistries?”
Dottie: “Okay.”

15/
Me: “And a CBC. She has normal oxygenation so I don’t think she needs a blood gas.”
Dottie: “Sounds good.”

She pulled out an order sheet and wrote: ADCVANDALISM vertically down the page.

Dottie: “Okay. Now for your orders.”

And so I wrote them as Dottie coached me.

16/
Just as I was finishing, my resident walked up.

Her: “Oh awesome! Looks like you already got the work up going.”

Wait. Huh?

Dottie: “Yup. Kimberly was all over this work up.”

She gave me a tiny wink.

17/
Mrs. Parker did fine. My work up didn’t yield any surprises & she left the next day.

But.

I always remembered what Dottie did for me that day. I’ve paid it forward, too. To this day, I do my best to check on new interns. (And as a chief resident I had Jolly Ranchers.)

18/
And every year I admit I didn’t know what a “work up” was.

Mm hmm.

Let’s create space for trainees to ask anything—especially system related and patient care things.

Also—instead of “work up,” now I just say “what you want to do to figure out what’s going on.”

Yeah. 👊🏽