Critical Skills

Ada Winchester is a 15-month-old girl I had never met before. All I knew about this first patient of the day was that her chart listed "abdominal pain" as the chief complaint. As I approached the exam room door, I was already rehearsing my constipation speech. But when I entered the room I quickly put my timeworn pooping monologue back on the shelf.

Ada (the name is fictitious) was sitting comfortably on her mother’s lap. Her sparse, wispy hair framed a cute but slightly pale face. She was lean but not scrawny, and I could see why her usual pediatrician had at times been concerned about her weight. She was breathing easily and interacted with her mother in a relaxed manner. Although I couldn’t put my finger on the reason, my first impression was that she was a sick child.

She had not seemed herself for about 3 days, she had had no measurable fever, her appetite was down, and she seemed uncomfortable, her mother told me. Although the discomfort waxed and waned, it had never completely abated. She had not vomited. The most consistent observation by her family was abdominal tenderness. She had no prior history of constipation. And, although she had not had a bowel movement since the illness began, her mother said that this could be explained by her lack of intake. The morning of this visit, she had a large, loose bowel movement that did not seem to relieve her discomfort.

On my exam, I found that her chest was clear, and her ears and pharynx were normal. Despite her pallor, her palpebral conjunctiva were a robust red. When she cried, her skin color turned a reassuring pink. Her abdomen was not distended, but was strikingly tender to palpation. Her bowel sounds were normal and she did not complain when I asked her mother to bounce Ada on her knee.

I explained to Rhonda Winchester (not her real name) that her daughter presented a fairly common diagnostic dilemma. Did she have stomach flu? Or was she constipated? Each condition required a completely different management plan. What I didn’t tell her was that my overwhelming concern was that her daughter looked sick in a subtle way that I couldn’t square with either constipation of gastroenteritis.

I sent them down the hall for an abdominal x-ray on the slim hope that Ada was more constipated than her history suggested. The image showed a few dilated loops of bowel and a nearly airless left lower quadrant. (Later in the day, it was officially read as normal.)

When she returned from x-ray, Ada was happily exploring the room, but I was still uncomfortable with her appearance. I now shared my discomfort with her mother, but I told her she could take her daughter home. I asked her to call promptly if anything changed and that I would call her in a few hours to check on her and report the official x-ray interpretation.

Just 2 hours later, Mrs. Winchester called back to report that Ada was much more uncomfortable. Suspecting that she might have a problem requiring intervention by a pediatric surgeon, I told her to go to the tertiary medical center in Portland rather than our local emergency department. By late the next day Ada, was finally diagnosed with an infected urachal remnant, a condition that was not even at the bottom of my diagnostic list.

As I discussed this scenario with a couple of my partners, we agreed that it demonstrated the two most important critical skills that a pediatrician must possess.

The first is the ability to identify a sick child. A lay person might ask, "Almost every child who is brought to you for anything other than a checkup is sick. What’s the big deal?" Well, there is sick, and there is scary sick. And sometimes vital signs and lab work aren’t going to separate the two. In Ada’s case, her vital signs and blood work (obtained at the tertiary hospital) were normal. Identifying the scary sick patient is a difficult skill to teach. It requires that the student see a large volume of patients and compare the outcomes with their first impressions.

The second skill that must accompany this critical exercise in pattern recognition is the ability to know when you don’t know what is going on ... and then ask for help.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Ada Winchester is a 15-month-old girl I had never met before. All I knew about this first patient of the day was that her chart listed "abdominal pain" as the chief complaint. As I approached the exam room door, I was already rehearsing my constipation speech. But when I entered the room I quickly put my timeworn pooping monologue back on the shelf.

Ada (the name is fictitious) was sitting comfortably on her mother’s lap. Her sparse, wispy hair framed a cute but slightly pale face. She was lean but not scrawny, and I could see why her usual pediatrician had at times been concerned about her weight. She was breathing easily and interacted with her mother in a relaxed manner. Although I couldn’t put my finger on the reason, my first impression was that she was a sick child.

She had not seemed herself for about 3 days, she had had no measurable fever, her appetite was down, and she seemed uncomfortable, her mother told me. Although the discomfort waxed and waned, it had never completely abated. She had not vomited. The most consistent observation by her family was abdominal tenderness. She had no prior history of constipation. And, although she had not had a bowel movement since the illness began, her mother said that this could be explained by her lack of intake. The morning of this visit, she had a large, loose bowel movement that did not seem to relieve her discomfort.

On my exam, I found that her chest was clear, and her ears and pharynx were normal. Despite her pallor, her palpebral conjunctiva were a robust red. When she cried, her skin color turned a reassuring pink. Her abdomen was not distended, but was strikingly tender to palpation. Her bowel sounds were normal and she did not complain when I asked her mother to bounce Ada on her knee.

I explained to Rhonda Winchester (not her real name) that her daughter presented a fairly common diagnostic dilemma. Did she have stomach flu? Or was she constipated? Each condition required a completely different management plan. What I didn’t tell her was that my overwhelming concern was that her daughter looked sick in a subtle way that I couldn’t square with either constipation of gastroenteritis.

I sent them down the hall for an abdominal x-ray on the slim hope that Ada was more constipated than her history suggested. The image showed a few dilated loops of bowel and a nearly airless left lower quadrant. (Later in the day, it was officially read as normal.)

When she returned from x-ray, Ada was happily exploring the room, but I was still uncomfortable with her appearance. I now shared my discomfort with her mother, but I told her she could take her daughter home. I asked her to call promptly if anything changed and that I would call her in a few hours to check on her and report the official x-ray interpretation.

Just 2 hours later, Mrs. Winchester called back to report that Ada was much more uncomfortable. Suspecting that she might have a problem requiring intervention by a pediatric surgeon, I told her to go to the tertiary medical center in Portland rather than our local emergency department. By late the next day Ada, was finally diagnosed with an infected urachal remnant, a condition that was not even at the bottom of my diagnostic list.

As I discussed this scenario with a couple of my partners, we agreed that it demonstrated the two most important critical skills that a pediatrician must possess.

The first is the ability to identify a sick child. A lay person might ask, "Almost every child who is brought to you for anything other than a checkup is sick. What’s the big deal?" Well, there is sick, and there is scary sick. And sometimes vital signs and lab work aren’t going to separate the two. In Ada’s case, her vital signs and blood work (obtained at the tertiary hospital) were normal. Identifying the scary sick patient is a difficult skill to teach. It requires that the student see a large volume of patients and compare the outcomes with their first impressions.

The second skill that must accompany this critical exercise in pattern recognition is the ability to know when you don’t know what is going on ... and then ask for help.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Ada Winchester is a 15-month-old girl I had never met before. All I knew about this first patient of the day was that her chart listed "abdominal pain" as the chief complaint. As I approached the exam room door, I was already rehearsing my constipation speech. But when I entered the room I quickly put my timeworn pooping monologue back on the shelf.

Ada (the name is fictitious) was sitting comfortably on her mother’s lap. Her sparse, wispy hair framed a cute but slightly pale face. She was lean but not scrawny, and I could see why her usual pediatrician had at times been concerned about her weight. She was breathing easily and interacted with her mother in a relaxed manner. Although I couldn’t put my finger on the reason, my first impression was that she was a sick child.

She had not seemed herself for about 3 days, she had had no measurable fever, her appetite was down, and she seemed uncomfortable, her mother told me. Although the discomfort waxed and waned, it had never completely abated. She had not vomited. The most consistent observation by her family was abdominal tenderness. She had no prior history of constipation. And, although she had not had a bowel movement since the illness began, her mother said that this could be explained by her lack of intake. The morning of this visit, she had a large, loose bowel movement that did not seem to relieve her discomfort.

On my exam, I found that her chest was clear, and her ears and pharynx were normal. Despite her pallor, her palpebral conjunctiva were a robust red. When she cried, her skin color turned a reassuring pink. Her abdomen was not distended, but was strikingly tender to palpation. Her bowel sounds were normal and she did not complain when I asked her mother to bounce Ada on her knee.

I explained to Rhonda Winchester (not her real name) that her daughter presented a fairly common diagnostic dilemma. Did she have stomach flu? Or was she constipated? Each condition required a completely different management plan. What I didn’t tell her was that my overwhelming concern was that her daughter looked sick in a subtle way that I couldn’t square with either constipation of gastroenteritis.

I sent them down the hall for an abdominal x-ray on the slim hope that Ada was more constipated than her history suggested. The image showed a few dilated loops of bowel and a nearly airless left lower quadrant. (Later in the day, it was officially read as normal.)

When she returned from x-ray, Ada was happily exploring the room, but I was still uncomfortable with her appearance. I now shared my discomfort with her mother, but I told her she could take her daughter home. I asked her to call promptly if anything changed and that I would call her in a few hours to check on her and report the official x-ray interpretation.

Just 2 hours later, Mrs. Winchester called back to report that Ada was much more uncomfortable. Suspecting that she might have a problem requiring intervention by a pediatric surgeon, I told her to go to the tertiary medical center in Portland rather than our local emergency department. By late the next day Ada, was finally diagnosed with an infected urachal remnant, a condition that was not even at the bottom of my diagnostic list.

As I discussed this scenario with a couple of my partners, we agreed that it demonstrated the two most important critical skills that a pediatrician must possess.

The first is the ability to identify a sick child. A lay person might ask, "Almost every child who is brought to you for anything other than a checkup is sick. What’s the big deal?" Well, there is sick, and there is scary sick. And sometimes vital signs and lab work aren’t going to separate the two. In Ada’s case, her vital signs and blood work (obtained at the tertiary hospital) were normal. Identifying the scary sick patient is a difficult skill to teach. It requires that the student see a large volume of patients and compare the outcomes with their first impressions.

The second skill that must accompany this critical exercise in pattern recognition is the ability to know when you don’t know what is going on ... and then ask for help.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].