PEM Rules

Though teaching is something I love doing, sometimes teaching PEM to an ED resident is challenging (for many reasons). Dr. Steven Nazario has been a physician and an educator for many years which is why I invited him on the show to talk about the challenges of teaching PEM to EM residents.  Here is the link to the Video Stephen was referring to. The EKG Changes of hyperkalemia.  https://pemrules.com/hk/   Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com  Copyright PEM Rules LLC DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.  

Newborns are small and examining them the “right way” does not take much and is worth doing, and why it is important (and helpful) to look at Pediatric Emergency Medicine as Simple.

The further away I am from my general pediatric training the more I forget how to manage chronic complaints and “primary care like” presentations. That is why I brought Dr. Noah Makovsky again to help us (PEM clinicians) do a better job with those patients.  

Sometimes enemas are not just for treatment only. Why is it important to keep making decision and not dwell and contemplate for too long and what is the best thing to do after intubations.

We all meet some people in our life that inspire us to do better. For me Dr. Ellen Fitzpatrick is one of those people. Listen to her truly amazing life story. 

Why is it useful to sometimes “consult” with your patient's parents. What tests you should really never do and why cant we just make everyone happy

In this new segment of PEM Rules Dr. Jay Fisher, who has been practicing PEM since 1992 is back to discuss intussusception and how can we all do a better job identifying those children among the sea of children with constipation.  

With the exception of corneal abrasions and conjunctivitis, ophthalmological presentations always make me a bit nervous. That is why I invited Dr. Mitchell Strominger to talk about some common ophthalmological emergencies.    Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com  Copyright PEM Rules LLC DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.  

Distracting injuries can be tricky but should always be taken into account. What should you think about in a child with LLQ abdominal pain and odd Neurological complaints and more about giving yourself a break. 

Thank you all for listening and supporting PEM Rules. I will be taking a short winter break to collect more material and enjoy the cold Nevada Winter (which I love). PEM Rules will be back in four weeks with more information, more medicine, more rules and, of course more music. 

I (finally) got a pediatric surgeon to come and talk on the show. Most importantly I was curious to know what he thinks about my Rule of 6. Listen to Dr. Erik Pearson and his wonderful advice. Here is the link to Erik's Website https://www.citizensurgeon.com/recourses     consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com  Copyright PEM Rules LLC   DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.  

How prepared should you be? Maybe Over-prepared? What to do with your trainees and why it wise to buy time (if you can).

It seems to me that due to the obesity epidemic more and more children suffer from "adult problems" such as Type 2 diabetes, hypertension etc. That is why I decided to bring Seth Ball, a PEM physician who is also trained in General EM to the show to discuss the management of those children.    Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com  Copyright PEM Rules LLC   DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.  

So apparently I am not the only one with "rules". Dr. Rammy Assaf contacted me via the PEM Rules website and wanted to share some of the rules and wisdom he has learned over the year. Thank you Rammy for coming on the show and sharing you knowledge. 

The goal of our long (and exhausting) training is to find the ultimate job. Here are some tips from Dr. Rick Saladino (my fellowship mentor and the inspiration behind PEM Rules) on the process.

What is the “best way” to take history, talking about patients expectations and what you must do before calling your consultants.

Children with Neurological complaints represent a significant portion of what we see in the Peds ED. From Status Epilepticus to febrile seizures to the child who (maybe) had a seizure at home. This is a discussion I had with Dr. Amy Goldstein, a Pediatric Neurologist at CHOP.   Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com  Copyright PEM Rules LLC DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.  

There are many “unanswered” questions in Pediatric EM where the scientific literature does not have a good, definitive answer. Whether to use or not to use steroids in anaphylaxis is one of them. Sophia Wang (our PEM fellow from previous episodes) looked into it.   Here are some of the articles Sophia used in her research  Alqurashi W, Ellis AK. Do Corticosteroids Prevent Biphasic Anaphylaxis?. J Allergy Clin Immunol Pract. 2017;5(5):1194-1205. doi:10.1016/j.jaip.2017.05.022 Gaffney LK, Porter J, Gerling M, Schneider LC, Stack AM, Shah D, Michelson KA. Safely Reducing Hospitalizations for Anaphylaxis in Children Through an Evidence-Based Guideline. Pediatrics. 2022 Feb 1;149(2):e2020045831. doi: 10.1542/peds.2020-045831. PMID: 35059724; PMCID: PMC9250079. Lieberman P, Nicklas RA, Randolph C, et al. Anaphylaxis--a practice parameter update 2015. Ann Allergy Asthma Immunol. 2015;115(5):341-384. doi:10.1016/j.anai.2015.07.019 Michelson KA, Dribin TE, Vyles D, Neuman MI. Trends in emergency care for anaphylaxis. J Allergy Clin Immunol Pract. 2020;8(2):767-768.e2. doi:10.1016/j.jaip.2019.07.018 Shaker MS, Wallace DV, Golden DBK, et al. Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol. 2020;145(4):1082-1123. doi:10.1016/j.jaci.2020.01.017   Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com    Copyright PEM Rules LLC DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.  

Sometimes it is good to give your patients (or parents) some options regarding their care (some people call it shared decision making). How a short conversation can help you better understand your patients and their needs.

After many months of work and some requests I am excited to open my online PEM Rules Store where listeners can order some fun PEM Rules merchandise. Please click the link below to check out the store and maybe purchase a T-shirt, a hat or whatever product you like.   Thank you for all the support, the downloads, comments and requests. Yaron Ivan   PEM Rules Online Store. https://www.redbubble.com/shop/ap/164385928 www.pemrules.com      

Every once in a while I meet a physician who does a great job “taking care of himself / herself”. He or she are engaged in multipule activities or hobbies and don't seem to be suffering  “burnout”. Listen to my discussion with Dr. Snow and his advice on how to achieve wellness.   

Having a goal before you see the patient is crucial and it should not be to find a diagnosis. It is ok to fail but not so ok not to try and what about the patient's mental status? 

If you are like me you probably do most of your guitar learning online or using videos. So here is an opportunity to learn some classic guitar riffs and get a discount via this link. Check out Guitar Coach and all the resources they have and use the link below to get a discounted price for the 42 All-Time Classic Guitar Riffs program using muscle memory.  It's a great way to up your guitar playing game. bit.ly/3Wv6R72     Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com  Copyright PEM Rules LLC DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.    

Like most professionals, physicians and clinicians can always use a good advice. Especially on approach to the challenging patient when you seem to be doing everything right but nothing seems to work. That is why I invited Josh to the show. Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com  Copyright PEM Rules LLC DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.

Why knowing statistics is important for us EM providers, what is the “best” way to treat the patient and being curious. Here are the studies I speak of in the episode https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359077/ https://pubmed.ncbi.nlm.nih.gov/20627219/ Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com  Copyright PEM Rules LLC DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. 

On episode 100 coming this November, Dr. Saladino will be discussing his advice on how to maximize your chances of finding the best job in PEM, EM or just in medicine. Please take a minute to fill up this survey so Dr. Saladino and I can have a beneficial discussion for the listeners.  https://www.surveymonkey.com/r/8WP7DQB     Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com  Copyright PEM Rules LLC   DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.  

None accidental ingestions and overdoses are common scenarios in the Pediatric Emergency Department. Now (unfortunately) driven by some social media posts. Knowing how to recognize and manage these patients is critical. That is why I invited Dr. Daria Falkowitz to discuss some of these common Tik-Tok Challenges

Please check out PEM Rules on Facebook and become a follower. I finally found the time to put some educational material for you to learn from. https://www.facebook.com/PEMRules  

Toxic ingestions are always on my differential diagnosis of any child with acute onset "odd symptoms". That is why I invited Dr. Brian Schultz to discuss this important (and often challenging) topic.

Sometimes (it is not often), a normal physical exam is actually more concerning, why it is a good idea to be pessimistic? and how to be comfortable with risks?    

What do our “future bosses” look for in their candidate and how can we become a more competitive applicants for our next job?. I discuss that and other important questions with Dr. Todd Zimmerman a PEM attending in Las Vegas.  

Sometimes there are "odd reasons" for using a test, Getting a good history is key and some questions are more important than others and a bit about knowing what not to do.        Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com    Copyright PEM Rules LLC       DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.  

Just like I lost many of my “primary care” skills many primary care pediatrician feel uncomfortable treating emergencies or urgencies in their office. That is why I had a discussion with Dr. Noah (from a previous PEM Rules episode) about what to do when these situations arise.     Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com    Copyright PEM Rules LLC       DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.    

What do you do when the patient in front of you has no symptoms (at the moment). Why you should enjoy being in training and what all of us PEM clinicians should know very well.    Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com    Copyright PEM Rules LLC     DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.  

What do you do when a teenager with odd (and concerning) neurological symptoms walks into you ER and how do you apply the PEM Rules to work him up step by step?

Often times I see none verbal patients (be it newborns or children who are neurologically devastated) who come in by EMS or perhaps their parents / caregiver. In those situations, I find it important to be more conservative. How do I gain the parent's trust? Simple gain the child's first.  

Hours after last weeks episode was published I heard from Dr. Jay Fisher about a very similar (and unfortunate) case one of his APP's had in their ED. I decide to bring Jay to the show (again) to discuss the case so we can all learn from this experience.  Below is the link to the patient's Chest X rays. https://pemrules.com/pneumonia-patient/     Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com    Copyright PEM Rules LLC DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.    

What is the appropriate differential diagnosis for a well appearing child with fever for over 5 days and what is the best way to work these patients up? I discuss this important Issue with my Former colleague Dr. Fatma Levent, a pediatric Infectious Disease Attending.

There is a certain way to address the chief complaint in the ED and it is often advantageous to do it this way. Why is it important to know what syndrome the child has? and how can we all give better care to our patients?

As a PEM Physician, I get to take care of children with neurosurgical problems fairly often. Sometimes it is children with known issues such as hydrocephalus with a shunt and sometimes it is a patient with traumatic injury.  Pediatric neurosergeons are often life savers in those situations. Here is a conversation I had with Dr. Todd Hankinson, a Pediatric Neurosurgeon at Children's Hospital of Colorado.    

As a good leader there are certain ways you can work with your team to let them excel. How do we work up our patients “appropriately”? and what can we learn from our patients?

Probably the Pediatric Sub-specialists I interact with the most are the pediatric hospitalists. Not only they accept my admissions but often give advice about the work up that the patient needs and serve as an extension of the Pediatric Emergency Department. That is why I invited Jason Zamkoff, a Pediatric Hospitalist from Denver CO to talk about the relationship between PEM Clinicians and the Peds Hospitalists.    Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com    Copyright PEM Rules LLC       DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.    

It is important to communicate to your consultants and hospitalists the way they want to be communicated to and “speak their language”. Why is it important not to think linearly and when is it “Not OK” to use antibiotics.

As a PEM physician, treating pain is a big part of my life and sometimes it is easier said than done. This why I invited Dr. Alan Bielskay, a Pediatric Anesthesiologist (and pain expert) from Denver CO to talk about pain treatment in children.     Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com    Copyright PEM Rules LLC DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.

Sometimes decisions are hard to make, nonetheless, in the ED world it is important to make a decision and sometimes sooner rather than later. Why getting a blood culture (without giving antibiotics) makes no sense to me and more about going with your gut feeling.   Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com    Copyright PEM Rules LLC   DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.  

As a PEM Physician, child abuse, sexual abuse and child neglect cases are those cases I never want to miss or overlook. That is often easier said than done. This is a discussion I had with Dr. Stephen Boos, a child abuse doctor in Western MA.

Probably the best advice I got in my career was to take care of myself before I take care of any patients and how I address some over-medicalized issues.

I am excited to announce the launch of the PEM Rules Facebook page. Please visit, become a follower and communicate what you like, wish to hear or just keep in touch.  Here is the link to the page https://www.facebook.com/PEMRules Please consider contributing to PEM Rules at https://ko-fi.com/pemrules And check out www.pemrules.com    Copyright PEM Rules LLC     DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.  

What medicolegal aspects of medicine should we PEM Providers be familiar with and how can we all better protect ourselves while providing excellent care for our patients?  I discuss these question and more with Dr. Brady Pregerson an expert in the field.   Copyright PEM Rules LLC DISCLAIMER By listening to this podcast, you agree not to use these resources as medical advice to treat any medical conditions in either yourself or others, including, but not limited to, patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast or website. Under no circumstances shall PEM Rules, the PEM Rules podcast or any guests or affiliated entities be responsible for damages arising from their use. This podcast should not be used in any legal capacity whatsoever, including, but not limited to, establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website or in the podcast.  

My apologies to all of you who tried purchasing merchandise from Pickaso Guitar Bow and use PEM Rules Promo code. It came to my attention that the promo code stop working. Please be patient, check out the following link https://www.pickasobow.com , decide what you want to buy and be on the lookout for a new method of getting a discount via PEM Rules. The Pickaso Guitar Bow is fun to have and use to enrich your musical skills.   

What should you do when things don't seem to work they you want them to, what happens when a patient visits the Peds ED 3 times (or more) in a short time interval and what endorphins can potentially be.