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Tips and Tricks

Hairtourniquet Wikimedia James Heilman Hair_Tourniquet_after Photos before & after release from Wikimedia Commons Hair tourniquets (and sometimes thread tourniquets) can occur on toes (most common), fingers, and more rarely the penis, clitoris, or uvula. Peak occurrence is at age 2-6 months, corresponding with maternal postpartum hair loss. Edema may progress to vascular compromise; ischemia and autoamputation have occurred. Tips for removal:
  • Magnifying loupes can be helpful
  • Consider topical anesthesia with EMLA or viscous lidocaine (avoid LET w/epinephrine so as to not confuse discoloration due to the tourniquet vs due to temporary epinephrine effect)
  • If definitely a hair, depilatory cream (eg Nair) can be applied for 3-10 minutes on unbroken skin; repeat once if not successful (the product can irritate skin, however)
  • AliEM describes use of a cutting needle to get under the hair and cut it https://www.aliem.com/2012/06/trick-of-trade-hair-tourniquet-release/
  • If the hair is too deep / not visualized, the cutting needle can still be used to lift the tissue and constricting band, and a scalpel then used to cut the hair and superficial layer of tissue
  • Severe tourniquets may require perpendicular cuts to the bone, best done at 3:00 and 9:00 positions
  • Look for improvement in swelling and color with release. If the hair cut deeply, it may be difficult to see if release is complete. At least one author has studied ultrasound for identification https://www.ncbi.nlm.nih.gov/pubmed/29341258.
  • Consult a urologist for deep penile tourniquets
  • Consider child abuse, particularly with genitalia involvement
Part of the new AAP BRUE algorithm’s definition of low-risk BRUE (Brief Resolved Unexplained Event) is that the event duration was < 1 minute. I always ask the caretaker to walk me through what happened step by step, using “and then what” prompting. I have had parents that told me the event lasted 2 minutes whose step-by-step description varied from “I picked her up, called for my husband to call 911, and blew in her face and she started coming around” (probably < 1 minute) to “I picked her up, ran to my neighbor’s house, she was still blue, we laid her on the couch, my neighbor gave mouth-to-mouth, and I called 911” (probably > 1 minute). Another trick I use is to say, “OK let’s say it starts when I say “now”, let me know when you think it stopped… now,” while timing with a stopwatch (available on your phone) – when your baby’s not breathing, 15 seconds can seem like 5 minutes; this helps get a more realistic estimate.
With the rise in legality of cannabis products, ED (and even PED) clinicians are seeing a big rise in cannabis hyperemesis syndrome. Topical capsaicin 0.025-0.075% is a known reliever of symptoms, as outlined on AliEM here. But who stocks topical capsaicin cream in their ED? Turns out hot sauces can be used as outlined here. Hot sauces are graded in Scoville units, and the equivalent to capsaicin cream is a hot sauce with 4,000-12,000 Scoville units. Avoid hot sauces that go higher than that - they can burn the skin. Tabasco original red sauce has a Scoville rating of 2,500-5,000 units.
When resuscitating neonates vascular access is often a challenge. While IV and IO attempts are ongoing, the ability to obtain a small amount of blood for point-of-care testing of, for example, glucose, hemoglobin, electrolytes, and venous blood gas, can be valuable. One method is the "blind stick", attempting to hit a venous plexus in the upper volar forearm blindly. Note: this method should only be used in emergent resuscitation conditions, as complications such as hematoma formation can occur. Blind Stick
Here's a quick and dirty method to recall developmental milestones Development See the zero 0 as the "o" in tone, as the eyes for gaze, and as the mouth for strong suck The word two (months) is a combination of track and coo At four, the baby finds things funny (laughs) and pushes up on forearms to roll At six, the baby sits and makes sounds Picture the number 9 in a standing position and making a pincer grasp The w in twelve is for words and walks At 2 years old, the child has 2-word sentences and runs on 2 legs
The Coach at PEMPlaybook.org has a great podcast on using the VBG in situations where we used to try to get an ABG (which was never fun to do in small children). From the podcast: the rule of 4’s: (note ABG values are always higher): VBG pH is 0.04 lower than ABG pH VBG pCO2 is 4 lower than ABG pCO2 VBG pO2 is approximately 40 lower than ABG pO2 The bottom line is that for most of our clinical concerns, we can use VBG to assess pH and pCO2, and O2 sat to assess oxygenation. VBG may be less reliable in shocky or hypercapneic patients (but end-tidal CO2 will be useful in hypercapneic patients). When do we really need an ABG? When we want to calculate the Aa gradient, looking for e.g. VQ mismatch, shunt, or a diffusion problem.
My husband the internist likes to say that we peds MDs are pretending to see the TM, but I say the MDs for adults are pretending to hear diastolic murmurs. Kidding aside, you really can get good at seeing TMs in kids - a useful skill since 60% of kids will have AOM by age 4 years. Tip 1: Positioning: my most successful position is with the child sitting on parent’s lap, turned 90 degrees to one side, legs held between the parent’s legs, parent restraining child with a “hug”. Rotate the child 180 degrees to face the other way to look at the other ear. Even though the below picture shows a child getting a shot, this is the basic positioning. Don’t let the child face forward, make sure they are turned to the side. Ear Exam PositionDHS Comforting Restraint for Immunizations 2001 Tip 2) Specula: Our ED has just two size specula – 2.75mm “pediatric” and 4.25mm “adult”. If the child is 1yo or more, start with the larger specula. You can always go down in size if it’s too big or you need to push through or around wax. Don't be afraid to push the speculum in a bit - it is tapered so you are unlikely to reach the tympanic membrane with the tip. Tip 3) Otoscope: Grasp the helix of the ear and pull posteriorly and slightly outwards. Brace the fingers of your otoscope hand against the patient’s cheek so you can move with the child if he moves. Angle the speculum anteriorly as you enter – a common pitfall of trainees is seeing only the canal because the TM is angled more anteriorly in a young child. The best visual I could find of this positioning is a screen grab from the video below: Ear Exam Position 2 Regarding the video, to examine the patient's left ear, I prefer to keep the otoscope in my right hand and bring my left hand up and over the ear to pull on the helix, rather than switch hands https://www.youtube.com/watch?v=FE0sot4OoAE    
Two tips for intubating the obese patient:
  1. Position the patient: build a sizeable ramp to position the patient such that his/her ears are at the level of the sternal notch, and his/her face is parallel to the ceiling
  2. Position yourself: keep your back straight, your left elbow in, and lift (don't crank). If you're having difficulty summoning enough muscle, try straightening your left arm at the elbow to make use of your stronger upper arm muscles, rather than just your forearm.
Two great resources: Obese Difficult Airway Airway Jedi Step by Step (scroll down to the "How you lift matters" section)
It is commonly taught that a patient’s palmar hand represents approximately 1% of his/her body surface area (BSA), a useful tool when estimating the BSA of burns. But does one use the palm including or excluding the fingers? Adult studies support that the palmar hand including fingers actually represents about 0.8% BSA. Despite this widespread teaching, there are surprisingly few pediatric studies. Pediatric studies support the palmar hand without fingers to = 0.5% BSA, and with fingers close to 1% BSA. What is considered pediatric for using this estimation method? One original study included children to age 13 years, and another to age 17 years; puberty may be a useful cutoff age. How well the palm estimates BSA may also vary by gender, race, and degree of obesity. Ref: Thom D, Burns 2017 Feb; 43(1):127-136.
Success rates in infant lumbar punctures may be declining as we do fewer and fewer (doing fewer is a good thing, except that we get less experience). One thing that can improve success is early stylet removal. The stylet is kept in when entering the skin in order to avoid the very rare complication of intraspinal epidermoid tumors. However, once the needle is past the epidermis and dermis, such that a plug of skin tissue cannot be cored out by the hollow needle and deposited into the spinal canal, the stylet can be removed. Here are two excellent FOAMed discussions of this practice and the advantages: http://pemcincinnati.com/blog/wwdwwd-early-stylet-removal-lp/ and https://pedemmorsels.com/spinal-needle-stylet/
There are several techniques for removing a ring that is stuck on a patient’s finger, starting with the simplest – using ring cutters to cut it off. However, if the patient doesn’t want the ring destroyed, the string technique has been advocated, where a string is wrapped around the finger to compress the edema, then passed under the ring and unwound for removal. An oxygen mask strap works well for this purpose because of its elasticity and flatness; check out this AliEM trick of the trade post https://www.aliem.com/2012/08/trick-of-trade-ring-removal-using/. Also, this site provides a nice overview of the numerous methods https://aneskey.com/ring-removal/. Remember that tungsten and ceramic rings are usually hard to cut, but easy to break using vice or locking pliers.
Hyperemesis due to cannabis use is on the rise, particularly in areas with marijuana legalization. While classically it is seen in chronic, daily users, affected patients sometimes have been using cannabis for less than a year, and may be using it as infrequently as once a week. Patients present with bouts of severe nausea, vomiting, and abdominal pain. A classic symptom is relief with hot showers (due to activation of the TRPV1 receptors). Symptom relief in the ED involves fluid rehydration and ondansetron (although this often no longer works for the patient after multiple bouts). There are also many reports of successful resolution of acute symptoms with benzodiazepines, haloperidol, and topical capsaicin. Curative treatment involves convincing the patient to stop cannabis use. Therein lies the tip, which I just learned from a colleague – a good way to help the patient understand is to tell them they suffer from an “allergy” to marijuana– while some people may be able to use marijuana chronically, they cannot, as it will cause these symptoms. Cessation of cannabis use can result in symptom relief as soon as 12-24 hours but sometimes not for as long as 3 weeks. So let them know how long that “allergic reaction” can continue!
Improve success of vagal maneuvers for patients in simple SVT by adding the "REVERT" maneuver: the patient performs valsalva maneuver in a semi-recumbent position, then the practitioner immediately puts the patient into a supine position with legs passively raised at a 45 degree angle. This maneuver improved conversion to NSR at 1 minute from 17% to 43%, for a NNT of 3.8. A simple way to have a patient perform a valsalva maneuver is to blow on the tip of a 10cc syringe hard enough to move the plunger. For an excellent discussion of the trial and a video of the maneuver see http://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/ REVERT for SVT
It's July, so good time to review the basics. For pediatric resuscitations of any type, the mnemonic ABCDEFG is great - Airway, Breathing, Circulation, Don't Ever Forget Glucose. Children have lower reserves and become hypoglycemic more easily than adults when stressed. This mnemonic also came from a fantastic quick review of pediatric congenital heart disease presentations from the awesome folks at emergencymedicinecases.com
Disclosure: I have no ties whatsoever to GoodRx When prescribing a medication to a patient who may need to pay out of pocket, use the GoodRx app or website to compare the prices at local pharmacies nearby, and sometimes, to find coupons that patients can use. This article explains how GoodRx makes money and why it exists.
Staying with the topic of urine... investigators at University of Pittsburgh have derived and validated a UTI risk calculator for patients aged 2-23 months. The calculator (UTICalc) is linked from the On Shift page of PEMsource under the heading Neonatal / Infant, and can be found at https://uticalc.pitt.edu/ The study by Shaikh et al was published online on April 16, 2018 at JAMA pediatrics here. Some highlights: derived on consecutive 2-23mo old febrile patients evaluated in ED for UTI, 542 with UTI and 1144 matched controls without UTI. Validated on a dataset of 380 patients, 30 with UTI. Investigators estimate sensitivity of UTICalc at 95-100% and state that use of the calculator results in approximately 10 patients tested for every 1 UTI found; UTICalc outperformed the current AAP algorithm in both of these outcomes. Users can also enter urinalysis dip, micro, and gram stain results to obtain post-test probabilities. Investigators suggest testing when pre-test probability is 2% or higher, and treating when post-test probability is 5% or higher. Further validation is warranted, but UTICalc may be useful in shared decision making with parents to give a ballpark risk estimate.
Nothing slows down the ED flow like waiting for the urine flow of an infant or toddler. Whether or not to screen for UTI with a clean catch urine vs obtain a catheterized specimen will be left for another discussion, but here are some of the latest techniques described for obtaining clean catch specimens. (For all, clean genital area thoroughly first) "CCU" procedure, first described by Herreros Fernandez et al, Arch Dis Child 2013;98:27, 80 infants aged < 30 days. Patient held under armpits with legs dangling in upright position. Suprapubic area gently tapped at 100 taps/minute x 30 seconds, followed by light circular massage of the lower back x 30 seconds. Repeat these maneuvers until urine collected. Successful in 86% of the infants with median time to collection 45 seconds. Labrosse et al, Pediatrics 2016;138(3):320160573 studied this CCU method with the addition of another person flexing the hips of female children, 126 infants < 6 months old. CCU method successful in providing urine sample within 300 seconds in 49%, median time 45 seconds. More successful in < 3 months old than 3-6 months old. "Quick-Wee" method, Kaufman et al, BMJ 2017;357:j1341, 354 infants aged 1-12mos With patient supine, suprapubic skin was rubbed with gauze soaked in cold saline. 31% voided within 5 minutes using Quick-Wee vs. 12% in the standard collection group. Finally, Naimer in Pediatr Emerg Care 2017;33:446 describes cutting a slit in an infant's diaper to push the urine collection bag through when obtaining a bag urine. This both helps to secure the bag and allows parents and nurses to see when the specimen has been obtained.
A quick rule of thumb for estimating whether the QTc is normal is to look for it to be half the preceding RR interval (see figure below from ECG Interpretation). However, note that this rule of thumb is not accurate at heart rates < 62 bpm. Also, it is conservative at heart rates > 66 bpm. An excellent thorough explanation can be found at Dr. Smith's ECG blog here. For heart rates < 62 bpm, Dr. Smith suggests using QT < 40% of the preceding RR as rule of thumb. Also, be careful - computer calculated QTc are often incorrect - may need to get those calipers out! (or just count little boxes - each one is 0.04 sec, or 40msec). The most common formula used to correct QT is the Bazett formula QTc = QT / sqrt(RR), although this formula produces false positives at high heart rates. Here is a calculator at MedCalc that will do the math for you! QT half RR ecg-interpretation.blogspot.com
Your local hospital cafeteria can be a useful resource in managing your PED patients:
  1. Sugar liberally applied to the edema of a paraphimosis or rectal prolapse may help decrease swelling and improve reduction efforts
  2. A mayonnaise packet provides useful lubricant for removing a tight ring
  3. Tannins from a tea bag (particularly black tea) can help clotting with post dental extraction bleeding (place a moistened tea bag in the socket and have the patient apply pressure by biting down)
  4. A packet of sugar + 10 mL sterile water = make your own sucrose solution for treatment of pain associated with procedures in infants
Know of any more? Comment below!
Having trouble with bag valve mask ventilation? Don't forget to use adjunctive airways - nasopharyngeal for conscious patients, oropharyngeal for unconscious. Reuben Strayer's great video here advocates placing 2 nasal airways and an oral airway, then bagging over those, for the difficult to bag patient. You can also place an ETT adaptor (pull the adaptor off the tube) into a nasal airway and bag the nasal airway directly - see more information here. Don't forget, nasal airways are measured from the nostril to the tragus of the ear, and oral airways are measured from the center of the mouth to the angle of the jaw.
The SAMPLE mnemonic is typically used to remember the important brief history needed for trauma patients: Symptoms, Allergies, Meds, Past medical history, Last meal, and Events leading up to the trauma. Think of the mnemonic as SAMPLE-PT and add in Pregnancy (history, testing) and Tetanus status. Also, ABCDE is used to recall Airway, Breathing, Circulation, Disability, Exposure in managing trauma patients. Keep going in the alphabet and add on FAST, Gastric tube (NG or OG) and Glucose check, Hemoglobins (serial), IV (two large-bore).
Having trouble finding the ICD-10 code in your electronic medical record? Do a Google search "ICD 10" + whatever diagnosis you're looking for. For example, searching "ICD 10 parent concern" turns up "Z 71.1 Person with feared complaint in whom no diagnosis is made." Here's another useful one "R 68.11 Excessive crying of infant (baby)." Hope everyone has a Happy Thanksgiving, and no one feels the need to use "Z 63.1 Problems in relationships with in-laws."
Use the PATCH mnemonic to remember transdermal medications Child with unusual symptoms, potential toxidrome? Look all over their body for a medication patch. Many are transparent or look like bandaids. P   Pain (fentanyl, lidocaine) A   Anti-cholinergic (scopolamine) T   Tobacco (nicotine) C   Clonidine H   Hormones (estrogen, testosterone)
Some tips and tricks for examining children's throats:
  1. Don't do it until after you've gotten your lung, heart, and abdomen exam - once you make them cry, it's game over
  2. A helpful position for young children is to sit on the parent's lap facing the parent, legs straddling the parent. Then, have the parent lean the child back so he/she is laying supine on the parent's knees with the head hanging back (the dentist chair view)
  3. Older children can be asked to pant like a dog, scream, or sing "ah ah ah ah ah" opera-style
  4. Sometimes if you do the ear exam first, the child will yell and then you can see the throat
Placing topical anesthetic (EMLA, LMX4) on skin abscesses may result in spontaneous drainage, precluding need for incision. If topical anesthetic doesn't result in spontaneous drainage, it at least provides some skin anesthesia prior to local anesthetic injection for incision and drainage procedure. In one published retrospective study, 26 of 110 patients with the topical anesthetic LMX4 placed had spontaneous drainage, 3 of whom required no further intervention: https://www.ncbi.nlm.nih.gov/pubmed/21129885
Thanks to Tim Horeczko pemplaybook.org for tube-tape-tap mnemonic Peds Sizing  
What do you do if you have a patient with a tooth avulsion and no commercial periodontal dressing? You can use the flexible thin metal nasal bridge on an N95 mask and glue the reimplanted avulsed tooth to an adjacent tooth using 2-octocyanoacrylate skin adhesive (made for laceration repair). N95 maskN95 mask, Amazon.com See this discussed in an Aliem.com trick of the trade See more on tooth avulsion management from NCEMI Common Simple Emergencies
We all know the importance of lining up the two sides of a laceration that goes through the vermillion border of a lip laceration. Injecting lidocaine or swelling from the trauma itself can make this difficult. Use a skin marker to outline the the vermillion border on each side, making this easier. Vermillion border closing the gap This photo comes from this great tutorial on Closing the Gap For lip lacerations requiring repair beyond simple alignment, consult a plastic surgeon. Here is an interesting discussion on Plastic Surgery Key
The Katz extractor is a great tool for removing nasal foreign bodies, as shown on the video here (I have no financial interests in this product). But, if you don't have one available, get a Fogarty cardiac embolectomy catheter from the O.R., and this will do nicely as well. For many many tips and tricks on removing foreign bodies in the head and neck, go to PEMplaybook
A young girl comes in c/o dysuria and the urine is stone cold normal. What else can explain her symptoms? (BTW, you must do a GU exam at this point). Adhesions (labial) Bubble bath (and other soaps, irritants) Candida (particularly if recently on antibiotics, or at risk for new onset diabetes) Detergent (harsh laundry detergent, new tight clothing / underwear) Enterobius (aka pinworms) Foreign body (typically toilet paper) Gonorrhea & chlamydia (in sexually active or sexually abused) Hygiene, poor (teach girls to wipe front to back, consider having them sit on toilet backwards to urinate, especially if they are overweight/obese, to encourage complete voiding and keep urine from collecting in vagina) Irritation (masturbation is a common normal behavior in preschoolers)
Easily remember the approximate Oxygen-Hemoglobin dissociation curve as follows: PaO2 40 corresponds to SaO2 70% PaO2 50 corresponds to SaO2 80% PaO2 60 corresponds to SaO2 90% This rule along with a lot of other handy RT knowledge can be found here Read more about PaO2 vs SaO2 at airwayjedi.com here
For minor procedures in the PED, analgesia, anxiolysis, and distraction are the most important therapies to promote cooperation and procedural success. See our algorithm for procedural pain here. But sometimes, even with all of those, physical restraint is needed. Most PEM practitioners know how to wrap a child up using a simple bedsheet folded lengthwise twice, and then wrapped over one arm, behind the back, and over the other arm, and then around the child as seen here. Another technique if you have a pillowcase is to put both arms behind the child into a pillowcase and then lay the child down onto the pillowcase, thus restraining the arms (see picture below). (This technique was published under the colorful name "Superhero Cape Burrito" here). Finally, a c-collar can be useful to immobilize the head for face and scalp laceration repairs. pillowcase-restraint
Mucosal atomizer devices improve administration of intranasal medications. Intranasal fentanyl 1.5 mcg/kg is a great way to give stronger pain medication (eg for fractures) without placing an IV. Intranasal midazolam 0.2 mg/kg (use concentrated 5mg/mL form to keep total volume < 1mL per nostril) can be used to treat active seizures when no IV access is yet obtained, or as an anxiolytic for procedures. Intranasal naloxone at a standard dose of 4 mg is being provided to opiate addicts to use in case of overdose. A commercial device is available, but currently some lots are being recalled (check here for recalled lots), or you may simply not have one in stock. Here's how to make an improvised atomizer courtesy of Faisal Alghamdi of KFMC Riyadh. Hook up a 3 way stopcock with the lever turned so that all 3 ports are open to 1) a 14 or 16 gauge angiocath, 2) a syringe with the medication you wish to deliver, and 3) oxygen tubing. Hook the other end of the oxygen tubing up to oxygen and turn up to 5-10 L/min. Place the angiocath in the nostril and gently & slowly depress the plunger of the medication. See picture and video below. img_1123 Click here to see a video and compare to commercial device here
You're seeing a 5 day old with a fever of 39. Attempts to get IV access have been unsuccessful. The child is alert and not toxic appearing, but you'd like to get empiric antibiotics started within the first hour of evaluation. What are your options other than drilling with an IO or embarking on a potentially long sweaty frustrating attempt at a central line in a neonate? An ultrasound-guided peripheral line is one possibility if you have the skills. Another vascular access method to keep in mind is the umbilical venous line - the umbilical vein can stay patent up to 7-10 days of life! Soak the dry cord in saline soaked gauze to soften it, use a scalpel to cut straight across at 1-2cm from the base, look for the single large vein, insert a pre-flushed catheter with gentle pressure into the vein while pulling back on a syringe until you see a flash of blood. For more info: https://blogs.brown.edu/emergency-medicine-residency/emergent-umbilical-venous-catheter-uvc-placement/ The "Fast-cath" technique advocates using a 14 gauge angiocath http://www.emsworld.com/article/10852257/paramedic-umbilical-vein-catheterization-for-newborns Find resources for born out of asepsis babies on our algorithms page, including how to make umbilical venous catheter mini kits to keep in your ED. http://pemsource.org/algorithms/boa-newly-born/
Use a glass test tube or specimen tube to press on a rash to see if it blanches - remember, petechiae and purpura don't blanch. You can also use a glass test tube as a mini-anoscope to blanch surrounding mucosa and assist in identifying anal fissures in infants. (Anal fissures are one of the many possible causes of GI bleeding in children - check out pemplaybook.org's latest podcast on GI bleeding) glass_test-focus-none-width-800 (From https://www.meningitisnow.org/meningitis-explained/signs-and-symptoms/glass-test/)  
Check out these cuties that CHOC PED physician and former Harbor PEM fellow Seth Brindis makes! See below for step-by-step instructions and more ideas for toys to make with medical supplies. Tongue Depressor Puppets Here are instructions put together by Seth, and a video of them in action. And here are some more ideas for toys to make in the PED (thanks to former Harbor PEM fellow Casey Buitenhuys for the glowstick idea): make-your-own-toys
What can you do if your patient is maxed out on ondansetron but still feels nauseated? A recent study in Annals EM found a positive treatment effect of deeply inhaling from a standard isopropyl alcohol pad held 2.5 cm from the patient's nose. Patients inhaled for 60 seconds at 0, 2, and 4 minutes (stopping if nausea resolved), and nausea was rated up to time 10 minutes. (Caveat: this study enrolled only adults). A 2012 Cochrane review also found isopropyl alcohol inhalation beneficial, although less so than standard antiemetic medications. Also, anecdotally, for dehydrated patients, rehydration and resolution of ketosis is thought to improve nausea and vomiting. For the grammar police out there, clarification of nauseated vs nauseous can be found here
Measure your fingernails to see which is closest to 1cm - now you will always have a 1cm "ruler" with which to measure lesions, lacerations, discolorations, etc. Measure nail  
Use a sterile saline respiratory ampule: wet the fluorescein strip with the saline, squeeze out half of the saline, then suck the yellow fluorescein liquid back up into the ampule. Now you can use the ampule as an eyedropper. For uncooperative kids, lay them supine and squeeze the liquid into the medial corner of the closed eye - when they open their eyes it will run into the eye. Respiratory Ampules (Amazon.com) For additional methods, see AliEM's great tricks of the trade post at: https://www.aliem.com/2015/tricks-of-the-trade-fluorescein-eye/
Cut a narrow caliber ETT short to create a semi-rigid suction catheter for foreign body removal of the nose or ears.  (From EM News September 2009, Tricks of the Trade: An Improvised, Semi-Rigid, Nasal/Aural Suction Catheter, by Timothy McGuirk DO)
For a forhead laceration, place gauze over patient's eye and hairline, cut a hole in center of a large tegaderm, peel and stick with the laceration positioned in the middle of the hole. Now you can use tissue adhesive to close the laceration without worrying about the adhesive running into the patient's eye, hair, or down the face.
Explain to parents - colds are called colds because viruses thrive in cold temperatures, so fevers are the body's natural way to fight off the cold
Use a laryngoscope upside down as a tongue blade, or use a self-lighting pelvic exam speculum (remove top half of the speculum)

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