Last year at this same time, as my last PEM Case of the Week before our seniors graduated, I listed some of my PEM Pearls.  It seemed to be a very popular one and many still ask me about this email.  I thought I may bring this back at the end of every year and maybe add a few more.  We are all continuous learners after all.

So, for our graduating residents, this may be the last email you will receive (and hopefully read) from me.  In one email, I leave you with some PEM pointers I have picked up along the way.  

Enjoy.........

A child's weight is in fact a VITAL SIGN!  Make sure it is accurate.  This is unfortunately a very common error and we need to be better at this.  Make it a habit to look at the weight just like you look at the vital signs, and make sure it makes sense. 

Placing an IV is the most basic skill in EM.  You need to be great at this.  An IV without an US is not a "blind IV"- learn to use your eyes and fingers to get good at placing IVs.  Don't rely on US.  US is absolutely a great skill to have, however, in my opinion, should be a backup plan when you can't get it the "old fashioned" way.  Don't rush.  Don't start unless you have enough people helping to hold the child, as needed.   (if all else fails, we almost all have a good vein between our 3rd and 4th finger).

Quiet tachypnea, think fingerstick - DKA

Ill appearing child - GET A FINGERSTICK!  Remember how to give a bolus of dextrose and the rule of 50s.  Remember it is not a continuous rate, but a bolus!

Progress notes are so important.  Sadly, if it's not documented, it didn't happen.  Most likely if a case ever comes back to you one day, you will not remember every detail.  Document and timestamp.

Rectal acetaminophen can be given at higher dosing for one bolus dose only.  I especially like this for febrile seizures.  Never recommend this dosing to the parents at home.

When you get a notification of an extramural delivery or a neonate coming in, get the neonatal warmer warmed up and ready.  Cold babies do not do well.  Consider using the warmer for any neonatal workup.  

Make sure you bring our children with special needs (developmental delays, autism, etc.) into their own rooms as quickly as possible, preferably not a shared room.  Often, they don't like to be overstimulated and they need less chaos and more quiet. 

Nursemaid's elbow does not always present with elbow pain, very commonly children will be holding their wrist (because rotating their wrist will also rotate their elbow).

Parent always knows best, especially when they feel something is not right with their special needs child.

For foreign body removal from the nose, a bent paperclip is often all you need.  If I didn't teach you this yet, come find me.

Do a testicular exam on every male with abdominal pain.  It's common sense really but too many skip this part.  Just make it a normal part of your exam and it will become second nature.  Don't take shortcuts because one day you will get burned.

Do a pregnancy test on every female with abdominal pain who has reached menses.  They don't always tell us the truth, so check it whether they say they are sexually active or not.

If something just doesn't seem right, it's probably not.  Don't try to convince yourself that the child is well.  Do the work-up and prove that they are not sick.  

A newborn with lethargy or fatigue with feeding is likely either congenital heart disease or sepsis.  It's always something and it's never colic!

Intranasal versed works well, if you give it properly and wait long enough.  If you don't split the dosing and wait less than 20 minutes, it's not going to work.

Intussusception rarely presents with the classic triad you read about.  If you wait for the bloody stool, you have waited too long.  Consider intussusception in a child with lethargy or AMS.

Racemic epi needs to be diluted in 3ml NS before being nebulized.

If your patient in DKA is not getting better within 2 hours of starting the insulin drip, make sure your line was not primed with NS alone.  It needs to be primed with the insulin : saline drip.

If a parent wants to stay in the room during a procedure, let them.  One day you may be lucky enough to be a parent, and you will understand.

Use shorty IVs only in neonates.  The catheter is too short in older children and will infiltrate.

Always triple check your dosing at the bedside prior to a sedation.  Look at the vial, check the concentration and do the math with the nurse.  

For calculating dosing, cross multiply and divide.  That's all you need to know.

Wherever you end up working, make sure you know where your equipment is.  You may know what to do, but if you don't know where things are, it's useless.

For a reliable respiratory rate in babies, have parents take the child's shirt off and count respirations from across the room if you have to.

Bone pain is a common complaint and could be anything from a sprain/strain to leukemia.  Know what questions to ask and when to do more.  You may be the first person who hears this complaint before they are diagnosed with a malignancy in about a year.

Know your developmental milestones, just the basic ones (rolling, sitting, pulling to stand, crawling and walking).... so you know when to consider NAT.

For sedation, you can probably get away with half the dose you calculated, so start slow and give small boluses if you need to.  You usually won't need to.

Delivering bad news about someone's child is something you need to approach carefully.  The parents will remember every word, in the order you said it, for the rest of their life.  Proceed carefully.

Advise from my daughter Brielle: "Don't be too hard on them, children are scared."

And lastly, children are not little adults, but adults may in fact be big children.

With love, gratitude and tons of luck,

Yvonne