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Little White Coats

Welcome to Little White Coats!
Little White Coats is the brainchild of Richard M. Pescatore II, DO, the chief resident in the emergency medicine program at Cooper University Hospital in Camden, NJ. He is a 2014 graduate of the Philadelphia College of Osteopathic Medicine. Follow him here as he finishes his residency.

Dr. Pescatore has served as an EMS and law enforcement medical director and advisor throughout New Jersey and Pennsylvania. He was graduated from the U.S. Naval Academy with a degree in aerospace engineering, and had planned to pursue a career as a nuclear submarine officer until an EMS run five years ago took him to a familiar but unexpected place. That call made him realize that EMS was more than a hobby and that his future was in medicine.

Read more about how Dr. Pescatore ended up as a "little white coat" in his first blog post, "Changing Course," and don't forget to sign up for the RSS feed for this blog to read his new entries.

Tuesday, November 1, 2016

The patient in room two had the look I've come to associate with years of hard living — nights spent on the street and days spent searching for another high. Her chart held the results — a litany of conditions sprung from dependence and the use of dirty needles. Her chief complaint had always been neck and back pain.

Her second visit was for the same thing, with the Prescription Monitoring Program (our newest tool in the opioid fight) indicating we weren't the only place she had visited with this problem. She had walked away more than once with frustratingly large prescriptions of opioids and muscle relaxers. I braced myself for what I anticipated would be a difficult encounter.

She had little new information to share. Her shoulder and back were firm and tender beneath my fingers and shot lightning bolts of pain toward the back of her head. Every motion caused her agony, but she put on a brave face for the 6-year-old grandchild at her side. The dynamic was different from what I'd expected, and every minute I spent in the room, I learned something new about this woman's struggles. Far from seeking medication for an imagined complaint, I realized she only wanted relief from debilitating pain.

I gave her an injection, and almost immediately, it abated the agony with which she had struggled for weeks. I watched, satisfied, as she turned her neck from side to side, enjoying the movements and motion that just seconds ago had brought immense pain. Tears fell from her tired eyes, and she grabbed me in a hug, grateful that someone had "taken the time" to fix the pain rather than sprinkling more morphine on the ache. "We can finally take our morning walks again," she whispered tearfully to her granddaughter as they made their way to the door, discharge papers and no prescription in hand.

It was just another encounter that I've found to be the most unexpected of escapes from the routine of the emergency department. Despite once despising the minor complaints and rote care of the Fast Track, I discovered a love and enjoyment that I hadn't anticipated in urgent care. Every day has brought new challenges, enhanced and focused by the experience of working without the safety nets to which I've become so accustomed. Like any new attending, I find myself laboring over every x-ray and prescription, taking extra steps with each diagnosis and operating with a conservativeness that starkly contrasts with the aggression and speed in the emergency department.

Urgent care makes it possible. The slower pace gives me the opportunity to walk away from each case with greater confidence while also allowing me to connect with patients in a way I haven't since I've accelerated in the ED and taken on the additional responsibilities expected of a rising resident. The patient encounters in urgent care reinvigorate me for the ED shifts to come, with problem-solving as frequent as it is refreshing.

But it's being an emergency physician that makes me a good urgent care doctor. My sick/not sick radar is what helps me triage what is appropriate for urgent care and what is best sent down to the resources I so regularly use. The tips and tricks I've learned in the department translate well to the minor emergencies in urgent care. Wound repair and splinting are regularly required, of course, but my most satisfying cases have been those where my ED training made the difference: a hemorrhoid excision in a truck driver, a ring removal that didn't destroy the ring of a newly widowed woman or a trigger point injection in an oft-dismissed addict with neck pain.

At the same time, urgent care has made me a better emergency physician. I've learned to trust and rely on my physical findings in a way I haven't needed to before. I've learned how it feels to have the buck stop with me — to hold the responsibility and accountability that have been shouldered by my attendings for so long. I read about the cases I see in urgent care and bring those lessons with me into the ED. I listen each month to the pearls and wisdom of Urgent Care RAP, and am amazed at how often the teachings and knowledge become integral to my work in the ED.​

As my final year of residency churns on, it's incredible to take a step back and see where I am and where I've been. My training has given me the tools to make a real difference in urgent care and the emergency department, and I'm so grateful to have the opportunity to play such an important role in peoples' lives. I never anticipated that minor complaints and weekend emergencies could be such an important addition to my clinical practice, but I look forward to including more urgent care experience in my career.


Tuesday, August 9, 2016

I've thought about mentorship a lot recently. After four years of medical school and two more in residency, I've had the opportunity to meet dozens of teachers, guides, and tutors who have served as role models and sounding boards. There were the senior students and junior residents who showed me a clinical light at the end of a long didactic tunnel in medical school, just as now freshly minted attendings tell me tales of full nights of sleep and entire weekends away from the hospital.

More than a handful of nurses helped me grow into the doctor I am now, reliably present after a difficult case with their years of experience helping to draw perspective or lend objectivity when emotions ruled the moment. The list stretches on, with so many mentors likely never realizing their daily impact — a senior resident with a son who served as reassurance that I could survive having a baby in residency, colleagues with such dedication to wellness and healthy living that I couldn't help adopting some of their habits.

And the more I think about it, the more I marvel at how much of my journey has been guided by those who I never stopped to recognize. How could I, really? Only years later can I see that the calm confidence of my corpsman Chief Petty Officer would lead me to medical school or that a flippant admonition from a surgical resident about the importance of self-education would start me on a career rooted in evidence-based medicine. So often we model ourselves based on the examples set by those around us.

Dr. W probably doesn't know how much her perpetually sunny disposition sets an example for optimism, just as Nurse S is simply doing his job, unaware that his compassion for even the most routine cases reminds all around him of the special roles we play. Through their dedication to patients and our profession, it's people like this who unwittingly provide reassurance and guidance to all who surround them.

​As I've advanced through the years of residency, I like to think that I now fill a mentorship role like so many others before me. Whether it is for our rotating medical students, eager young researchers, or even the newest wave of interns to hit the hospital doors, I hope that the standards I set and actions I take are as welcome and exemplary as the models set for me. I've already seen instances in which I've failed — allowing my biases against certain approaches, therapeutics, or thoughts to be portrayed as fact, letting a difficult shift interfere with an obligation to teach, or standing back as others learn their own way. But I beamed with pride recently when a learner harnessed our shared experience at his next patient encounter, and I smile whenever I see a championed cause being adopted by a colleague or student.

And, just as the proverb says, it seems that lighting the path for others always brightens one's own. The satisfaction of teaching, writing, and learning alongside the bright minds of emergency medicine is fulfilling and inspiring, and I quickly realized the importance of retaining that experience as I prepare to move on from residency. It was, natural, then, that I would look to home when the time came to plan for the years to come, toward the mentors and educators who started me on this incredible journey.

And so my career as an attending physician in academic emergency medicine will start back where everything else began, in my hometown of Vineland, NJ. For 30 years, I've watched with pride as Inspira Health Network has grown and developed, bringing ever-improving care to my family, friends, and neighbors. I couldn't be more excited to begin next July, serving as a residency educator and clinician alongside the men and women who taught me from the very start and serving the population closest to my heart.


Friday, June 3, 2016

It's 2:18 a.m. on my last trauma call of the year, and the Memorial Day celebrations seem to have started early. More than a few gunshots have echoed in the humid night, their victims brought in by screaming police cars or their own family's rusting minivan. On the other side of the trauma bay doors, the slurred screams of intoxicated revelers occasionally pierce the otherwise dull roar of our busy department. The end is in sight, and I'll again likely forego some sorely needed sleep in exchange for the moments with my daughter that seem to be passing faster than I ever expected.

Things seem to be falling into place. I once again look forward to every shift in the emergency department, and find enjoyment in the critical and the routine. It's exciting to see how far the interns have come, clearly now ready to take on the challenges of their second year, one that I definitely found more difficult than the first. Publication decisions have come and gone, removing some of the stress of uncertainty from the day, and once-nebulous career plans are coming more sharply into focus. Every day brings with it new opportunity and possibility.

Still, residency is difficult, and it's a lot tougher with a 5-month-old at home who demands attention and has an uneasy relationship with her crib. Before Eloise was born, a 4:30 wakeup would have meant time for a run or a trip to the gym. Now it's barely enough to get her to the babysitter and make it to the hospital on time. It breaks my heart to wake her from hard-won sleep and have to transfer her immediately to the car seat. All too often there are only a few seconds of wakefulness for me to steal before saying goodbye for the day. Desperate to enjoy every moment of these first months, it means that the baby accompanies me whenever possible. She has been to borough council meetings and spent her fair share of time in the hospital while I finish backlogged paperwork. I've snuck her alongside the treadmill at the gym, only to be subsequently tossed out by an irate employee.

So my goals have shifted, and with them my productivity has waned, or at least transformed. As an intern, I pumped out projects and manuscripts at a regular clip, a pace that is neither possible nor prudent as the final year of residency begins. Energy not spent on baby duty is poured into bedside and didactic education to strengthen the foundations of our younger learners. Instead of writing cover letters and reference sheets, I write post-shift emails and whiteboard cases. Perhaps the most compelling part of that adjustment is that it doesn't bother me. Before such a lull would have driven anxiety and angst, but now I seem to have found contentment with my new normal. The drive to prove oneself takes on a different meaning as a family grows.

​I am repeatedly fascinated by how so much of what makes an emergency physician is defined by pursuits outside of the department. Bedside compassion and clinical practice often seem driven by experiences personal and professional, just as extracurricular involvement is so frequently a consequence of passions learned inside the ED walls. The few months I've spent as a father have had a profound impact on my clinical practice and professional pursuits, with every patient encounter and each midday meeting held with an eye toward my family and our future. As summer begins and long days under fluorescent lights beckon, I look forward to engaging my final year with a hard-won realignment of priorities.


Tuesday, April 19, 2016

Years ago when I finished Plebe Summer — the training program required of all incoming freshmen to the United States Naval Academy — my grandfather presented me with what has become my most prized possession. It's valuable to me not just for its probable auction price and its unique place in history but for the incredible story behind it.

A young, first-generation Italian American, Frank Pescatore reacted like so many others to the events that took place on Dec. 7, 1941. He beat down the door of the U.S. Navy recruiter's office as the sun rose the morning after. Bags already packed, full of patriotism and indignation, and hair cropped low (a harbinger of alopecia to come, maybe?), my grandpa was eager to join the fleet and strike a blow for Uncle Sam. With the hard-won blessing of my great-grandmother, he shipped off for the accelerated boot camp the Navy had started. A tinkerer by habit, it was little surprise to anyone that Frank Pescatore was assigned to a naval construction battalion, the Seabees.

Grandpa plied up and down the Pacific as Admirals Chester Nimitz, William Halsey, Raymond Spruance, and Ernest King fought the world's greatest sea war against the Empire of the Rising Sun. Rising to the rank of Petty Officer, Second Class (the Navy's version of an Army Sergeant), he was lucky enough to have his own Jeep during the Battle of Okinawa and its aftermath. It was this simple privilege that brought me my prize and this story.

Sitting in his rusty Jeep one morning on some unnamed beach in Okinawa, an army intelligence officer — a captain to my grandfather's recollection — approached Petty Officer Pescatore. He gave a lazy salute, then tossed his dirty boots and weary feet back on the dash where they had been resting. "I need your Jeep, sailor," Grandpa remembers the young officer saying. My grandfather was less-than-compliant and continued his supine post. Another order from the officer, another chuckle from the enlisted man. Ultimately, the IO must have realized he was up against Italian stubbornness, and began to bargain. "What'll it take for you to give me that Jeep?"

And that's how I ended up with one of the original copies of the Japanese surrender on Okinawa. I have the urgent dispatches the officer had just carried away from the armistice table. Taking custody of the calligraphed parchment, Grandpa whipped out his own pen and scribbled a few words to his mother that put a poignant closing paragraph to his wartime adventure.

"As the bombs burst overhead and the guns fell silent, my heart turned toward you, Mom, back in the States. I will carry this paper with me for the rest of my life — for this document many a buddy of mine lies dead on Okinawa."

"They were the bravest men I ever knew," Grandpa added, a tear streaming down his palsied cheek that day in August when he handed me the yellowing scrolls.

As we laid my grandfather to rest yesterday, more than a few similar tears found their way down my own cheek. I remembered this story and thought about the many lessons this great man had taught me along the way.

What's the connection to this blog? To emergency medicine and my residency journey? I guess it's the perennial thought that our life stories are so often shaped in the moments we least expect, or by the daily grind we so rarely reflect upon. The second year of residency is nearing its close, and I'll start the next academic year just a little more experienced, a little wiser, and a lot more weary.

I'm tasked with the honor of chief resident, even though it feels like just moments since donning the long white coat for the first time. Even though those first days of intern year seem like just yesterday, it took a cold, rainy morning and a moment of mixed reflection to realize that there is no defining moment in store and no transformative event to prepare me for the year ahead.

​Every instant of residency so far has played its part in my own story, one I'm so fortunate to get to share here. Even as I said goodbye, my grandfather had left me one last lesson.


Monday, February 1, 2016

It's amazing how quickly things can change. The past nine months of residency have held all the highs and lows that one would expect, all the while underlined by a 40-week countdown. Every plan I have for the future has been qualified by the expected arrival of my family's newest member, and I've worked furiously with the knowledge that time once dedicated to research, writing, and reading would soon be spoken for.

My wife and I welcomed our daughter on Dec. 22. Eloise Jane waited for me to finish one last holiday shift before signaling her arrival, and gave us only a few hiccups on her way into our arms. The entire experience was more magical than I could have ever anticipated, and it surely has changed me as a person and as a physician.

It was an odd feeling, really, sitting in the delivery room waiting for Eloise. More than once, I felt lost — even with separate months on the OB service as a medical student and later as a resident, there were terms, plans, and medications I struggled to understand.  My superficial knowledge of fetal heart tracings was more a curse than a blessing, and I panicked with every momentary dip of the line. My wife, an obstetrician, repeatedly reassured me, but it did little to allay my perpetual worry. I watched with wonder as a team of confident experts brought my daughter into the world. The process was organized, quiet, and rehearsed in every way that an ED delivery isn't, and each hurdle was handled with ease by the skilled hands at our bedside.

With Eloise's first cry, my whole world brightened. I announced her delivery to our assembled family with the proudest of voices, and couldn't stop staring at the little miracle who slept so peacefully pressed against her mother's chest. All of the stressors of the weeks and months before melted away in the face of all of the new possibilities laid out in front of me.

Having a baby during residency has not been easy. Shifts seem to stretch on longer than ever before, with dozens of charts standing between me and home. Where before an extra hour or two in the hospital was of little consequence, now I feel the continuous pull back to the nursery. I rush home for the chance to hold her for a few minutes before collapsing into bed, only to be awakened just a few minutes later for another diaper change. I don't not think my wife has slept since Christmas, but she amazingly juggles the tasks of home, work, and infant with ease.

I've learned more in the past few weeks than in any number of pediatrics rotations or peds ED shifts.  Those 2 a.m. chief complaints I once considered lunacy — "noisy breathing" or "crying" — I now completely understand because I all but order the intussusception ultrasound with every balled-up scream. It took no time at all for me to master the swaddle with which I've struggled so much in the department, and I can change a diaper like nobody's business. They're minor lessons in the grand scheme of things, but I think they've helped me connect with my youngest patients and their parents, and helped me to understand their fears and confusion.​

Everything is different now. My plans for a post-residency future are now influenced by school districts and grandparent availability. Research projects that were well in motion have slowed until I can master chart reviewing while burping, or until Eloise completes her IRB training. Podcasts have become an integral part of my study routine, and I suspect that my daughter may come to recognize the voices of EM:RAP more than my own. I look forward to every day left in residency and beyond, all of them brighter now with Eloise in my world.