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.

Wednesday, March 22, 2017

It had been a rough night. The crowd in the waiting room never seemed to shrink; each patient brought back was only replaced by the never-ending flow of ambulances bringing another wave of the ill or injured. Our team had endured the devastating blow of a child injured beyond repair, pulled countless overdose patients away from the brink of disaster, and brought thoughtful and compassionate care to the bedsides of dozens of the city's residents. Some were sick, requiring extra attention. Most were simply scared, yet caring for them still required time that was already at a premium. Everyone was doing his best, working ceaselessly to bring some comfort to the endless tide of patients rolling through our doors.

Then the shouts of an angry family member broke through the dull roar of the early morning hours. Upset at the wait and offended by the hallway bed hurriedly prepared for his loved one, he hurled accusations and threats at anyone within earshot, including empty promises of lawyers and news reports. He demanded attention but could not be satisfied, even as our exhausted and weary team tried in vain to address his concerns. Tensions continued to rise. Fists flew.

The emergency department is a high-stress environment ripe for passionate interactions and fervent fury. Pain and fear concentrate in a cauldron of uncertainty, and the simplest of misunderstandings can devolve into fist fights in a moment. Growing censuses and worsening throughput provide the perfect fuel for an explosion of personalities, and ED nurses, techs, and EPs are well acquainted with the dangers posed by unruly and uncooperative patients.

Recently, Psychology Today published an article detailing one physician's experience with his mother in his local emergency department. When his mother manifested some brief neurologic deficits concerning for a TIA, Peter Edelstein, MD, (a colorectal surgeon and author of the article), brought her in for evaluation. He provided a detailed timeline of their experience, including a rapid evaluation and head CT immediately upon presentation. The story quickly descended, however, into (odd) accusations of inadequate care and criticism of those in nonsurgical specialties. The author wrote in detail about his castigations of the nurses and doctors doing the best to care for his mother, and advocated for the reader to replicate this behavior — going so far as to title the article "If You Go to the ER, Get Ready to Yell." (The headline on the article has since been changed, but you can read it here: http://bit.ly/2mU79lN, and here is Dr. Edelstein's response: http://bit.ly/2ntpw1N.)

It is frustrating that anyone would write such an inflammatory and ill-informed impugnation of a team that clearly was trying to do nothing more than provide the best care possible in a resource-limited environment. It is infuriating that such a piece could be produced by a physician, one who ostensibly is well aware of the difficulties faced by all those who provide patient care on the frontlines and who almost certainly has encountered the dangers of an unhinged patient or family member.

Advocating hostility toward fellow medical professionals is reckless. To suggest that yelling, screaming, and arguing with a family member's care team is the best way to champion their care is a dangerous contributor to the pressures and uncertainties that plague acute and emergency care. It is also an intolerable violation of professionalism. Dr. Edelstein's article is nothing more than a poorly informed slander of hardworking medical professionals who labor tirelessly to provide the best care for all who pass through the emergency department.​


Wednesday, December 14, 2016

The role of a senior resident is a paradox, at once a veteran learner and a neophyte teacher. Each shift is spent suspended between scholar and student, and we are tasked with striking a delicate balance between familiarity and inexperience. Often, this is difficult, ripe for the trap of the Dunning-Kruger effect. (http://bit.ly/2hghFUf.)

It's an emblematic interval, a year of evolution from student to teacher. We have committed ourselves to studying, learning, and acquiring knowledge for so long, stopping along the way for dedicated instruction not just in our topics of interest but in learning
how to learn. Message boards and medical school libraries are replete with discussions about the superiority of blue highlighters or the farce of the lecture hall. FOAMed sings the praises of spaced repetition (http://bit.ly/2gLZGoh) and critically evaluates learning tools (http://metriqstudy.org/). Given so much focus on the science of learning, it is striking that so little attention is paid to the art of teaching. Senior residents and junior faculty are often expected to learn by example, to develop excellence in guiding the following generations by building on the best and worst of those who have come before.

Recently, leaders in our field have tried to change this disparate culture. With forward-thinking opportunities like the Teaching Institute (
https://flippingmeded.com/#about) and the ACEP Teaching Fellowship (https://www.acep.org/tf/), a light is shining on the critical importance of developing educators while our specialty continues to lead the way in evidence-based medicine and medical education. Just as we celebrate the pioneers in emergency medicine who made education and learning so fundamental to our progress (http://bit.ly/2hFYwbg), we now turn to this new focus on teaching, a critical next step in ensuring the emergency medicine tradition of excellence in education continues.

Poised to graduate and further my transition from student to teacher, I now look to these courses and classes to help me become the educator I aspire to be. I have been fortunate throughout residency to learn from wonderful lecturers and bedside mentors, but I hope to learn the strategies and innovations that distinguish the greatest clinical teachers.

Recently I had the opportunity to attend Keynotable (
http://keynotable.net/), a two-day workshop designed to help its attendees develop inspiring and elegant presentations that break the mold of the ubiquitous bulleted slides that darken every residency conference room. Under the tutelage of some of the best teachers in emergency medicine, I learned intricacies and techniques that can't be gleaned from simple observation and osmosis. Just months from graduating and having residents of my own to teach, I've learned a whole new way to translate knowledge and help others share my passion for our field.

Learning is a lifelong process, and while we never abandon our roles as students, our responsibilities as educators and teachers only grow with time. Just as we are taught how to learn, dedicated instruction in the art and science of teaching is a critical element in academic development.


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.