PEM Pearls, 2026 edition
These pearls are shared each year as the final PEM Education of the Week before the senior residents graduate. They are pointers collected over 24 years of practice, and they reflect how I practice every day.
Trust your judgment
Don't talk yourself out of doing the right thing. That gut feeling is usually there for a reason. If something is not sitting well with you, do the work-up.
However long you have been doing this, a case will occasionally humble you. Let it. It may scare you, and it may even scar you. Learn from it and take it with you.
Parents always know best, especially when they feel something is wrong with their child with special needs.
Be prepared
Wherever you work, know where your equipment is. Knowing what to do is useless if you cannot find what you need. Make a habit of checking that your critical care room is stocked and that you know where backup supplies are.
When you are notified of an extramural delivery or a neonate coming in, warm up the neonatal warmer. Cold babies do not do well. Consider using the warmer for any neonatal work-up.
Vital signs and red flags
Think sepsis! If something does not seem right, think sepsis even more.
A child's weight is a vital sign. Make sure it is accurate, look at it as you do the other vitals, and make sure it makes sense.
Quiet tachypnea: get a fingerstick and think DKA.
If something does not seem right, and it is not sepsis, consider myocarditis. These cases are scary and often fool us.
In a lethargic or ill-appearing child, get a fingerstick. It is probably low. Remember how to give a dextrose bolus and the rule of 50s. It is a bolus, not a continuous rate. They look like wilted flowers; water them with some sugar and they perk right up.
A newborn with lethargy or fatigue with feeds has congenital heart disease or sepsis until proven otherwise. It is always something, and it is never colic!
For a reliable respiratory rate in a baby, have the parents take the shirt off, and count from across the room if you have to.
Don't miss these diagnoses
Atraumatic back pain in a young child is very uncommon. Do the work-up, especially with fever, and include inflammatory markers.
Do a testicular exam on every male with abdominal pain. Make it routine and it becomes second nature. Skip it, and one day you will get burned and hear my voice in your head.
Do a pregnancy test on every female with abdominal pain who has reached menarche, whether or not she says she is sexually active.
In a girl over 9 years old (and Tanner-appropriate) with abdominal pain, ask whether she has started menstruating, and think about imperforate hymen/hematocolpos. A good history may be all you need.
Intussusception rarely presents with the classic triad. If you wait for bloody stool, you have waited too long. Consider it in a child with lethargy or altered mental status.
Nursemaid's elbow does not always present as elbow pain. Children often hold the wrist, because rotating the wrist rotates the elbow. Hyperpronation is usually the better reduction technique, and the answer on your boards.
Bone pain can be anything from a sprain to leukemia. Know what to ask and when to do more. You may be the first person to hear the complaint that leads to a malignancy diagnosis a year later.
Know the basic developmental milestones (rolling, sitting, pulling to stand, crawling, walking) so you know when to consider non-accidental trauma.
Procedures and medications
Placing a "blind" IV is the most basic skill in EM, and you need to be great at it. The good veins are usually the deeper ones you feel, not the ones you see. Don't rush, and don't start without enough people to hold the child. (If all else fails, there is usually a good vein between the 3rd and 4th fingers.)
Use "shorty" IV catheters only in neonates. In older children they are too short and will infiltrate. Shorties are about ½ cm; regular catheters are about ¾ inch. That makes a big difference in a small child.
Rectal acetaminophen can be given at a higher dose for one loading dose only. I especially like this for febrile seizures. Never recommend this dosing to parents for use at home.
Intranasal midazolam works if you give it properly and wait long enough. Split the dose between both nostrils to increase the absorptive surface area, and wait at least 20 minutes.
Racemic epinephrine must be diluted in 3 mL of NS before nebulizing, unlike albuterol or DuoNebs.
If a DKA patient is not improving within 2 hours of starting the insulin drip, check that the line was primed with the insulin–saline drip, not NS alone.
Always triple-check doses at the bedside before sedation. Look at the vial, check the concentration, and do the math with the nurse. They will appreciate it, and it is the right thing to do.
To calculate doses, cross-multiply and divide. That's all you need to know
For sedation, you can probably get away with half the calculated dose. Start low and give small boluses if needed; you usually won't need to.
High flow does not fix everything, especially apnea.
To decompress a distended abdomen in a young child during intubation or bagging, consider a rectal temperature probe. It works.
For a nasal foreign body, a bent paperclip is often all you need. If I haven't taught you this yet, come find me.
Caring for children and families
Don't discharge a patient just because your shift is over. If the child needs more observation, sign it out. Observation is often necessary, especially overnight, when a tired child cannot be fully assessed.
Progress notes matter. If it isn't documented, it didn't happen, and if a case comes back to you years later you will not remember every detail. Document and timestamp. I update my progress notes as I run my list during a shift.
Bring children with special needs (developmental delay, autism, and so on) into their own room as quickly as possible, preferably not a shared room. Many do not like overstimulation and need less chaos and more quiet.
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.
Deliver bad news about a child carefully. Parents will remember every word, in the order you said it, for the rest of their lives.
And lastly
Children are not little adults, but adults may in fact be big children.
As Alex Morgan said, "Don't practice until you get it right. Practice until you can't get it wrong."
