This week's grand rounds started off with our EMS team represented by Dr. McMullan updating us on new EMS stroke protocols, an upcoming trial for pre-hospital ketamine use, as well as a refresher on notification calls.  This was followed by Dr. Shaw, who made his grand rounds lecture debut discussing the diagnostic and clinical utility of lactate.  Drs. Harty and Toth then went mano-a-mano in another installment of the CPC lecture series, during which they discuss the presentation, workup and management of carotid cavernous fistula.  Dr. Gorder then presented her clinical soap box, using the example of NG tube placement for SBO as a platform for addressing the impact of dogma within medicine.  Our peds EM colleagues then steered the ship for the final 2 hours, discussing 2 oral boards cases (fussiness in a newborn and HSP) as well as putting on a pediatric trauma simulation.