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Little White Coats

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

Dr. Pescatore also serves as an EMS medical director in 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, July 21, 2015

Intern year is over, and I’m left wondering how to measure the past 12 months. In patients seen? Duty hours logged? Lessons learned or mistakes made? Can I gauge my progress on documentation prowess and infrequent saves, or is the path best described by M&Ms with my head held low? I’m not sure what this past year means for the future, but I know what it was. It was harder than I thought it would be — much harder, in fact. These months were a marathon for which I was unprepared — a clinical gauntlet I had underestimated from the start.


I started intern year with, for lack of a better term, a confident trepidation. I tiptoed into my first patient encounters and began to learn the ins and outs of patient care from seasoned attendings and senior residents. I congratulated myself on correct diagnoses and agonized over bouncebacks. Kept on a short leash by my teachers, my confidence grew. My September EMN post exhibited my budding boldness, and I charged forward into the autumn months.


It wasn’t long before my newfound audacity led me astray. I began to mistake luck for skill, and confidence quickly gave way to overconfidence. Armed with the cutting-edge knowledge of #FOAMed and mythbusting facts that so frequently comprise its syllabus, I misapplied my education. Rather than perpetuate the dissemination of information in the collaborative vein of emergency medicine’s evolving knowledge translation, I stalked the halls with “gotcha” facts about NG tubes, orthostatics, and Kayexalate. I haughtily hyped the Tale of the Seven Mares at the slightest mention of central venous pressure.


It caught up to me. The winter arrived with more than gray days and frigid temperatures. It came with my most egregious errors, my deepest regrets, and the hardest lessons I’ve ever learned. My zeal for discussion of the ever-evolving emergency medicine knowledge was too frequently interpreted as overadoption or, even worse, academic arrogance. My luck ran out, and the names and faces of those patients I could have — should have — done better for are unlikely to ever leave my idle thoughts. I didn’t like the physician I’d become, and I didn’t know if I could continue.


Eventually, things began to change. My hardest moments became my best lessons. As the spring months bore on, I slowly learned the value of experience and that there is no greater teacher than the patient. I came to realize that listening to podcasts and highlighting articles can’t replace the permanence of the clinical encounter. I slowed down. My patients per hour fell alongside my stress level, and I worked to balance quality of care with quantity of the same. I still indulged the open-access evidence, but endeavored to temper it with the irrefutable value of experience, the hard-won lessons of my own mistakes and my attendings’ years at the bedside.


The start of second year has me out of the department. I’m rounding in the ICU with an internal medicine intern at my side, and it’s hard to believe it’s been a year since I stood in his shoes. While the hours are long, it’s a gentle ease into the year, and it remains to be seen, I suppose, what kind of “junior” I’ll be in the ED. I hope I can find the balance it’s taken me a year to know is needed.


So, in the end, how do I measure intern year? I’m still not sure, but I think it has more to do with my failures than my accomplishments. I have a sense that it’s only in the depths of disappointment that we make our greatest leaps forward, only when it all seems too much that we can learn, adapt, and grow. I’m eager to get back to the task of caring for the ill and injured in my hospital’s emergency department, and I know that my future patients will be best served by all those who came before.



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Thursday, May 14, 2015

I’ve spent the last month sequestered in the separate treatment area that makes up our pediatric emergency department. With eight rooms designed specifically for the care of infants and adolescents in mind, it’s a formidable addition to our educational process, a key experience that cannot be overemphasized when considering that up to 20 percent of ED patients are under 18.


Like most pediatric emergency departments, the flow of respiratory and gastrointestinal viruses seems unending. Tylenol and ice pops are critical to patient flow, and where my adult emergency experience might be defined more by my comfort with managing illness, it’s reasonable to argue that my time in pediatrics is based on my understanding of wellness. New parents so frequently turn to this health care safety net when they are overwhelmed or confused, and the emergency pediatricians regularly take on the simultaneous roles of emergency provider and primary care mentor.


I anxiously await the critical and crashing patients in the adult emergency department. I’m still new enough to be excited and challenged by the patients being rushed into our resuscitation rooms, and I enjoy bedside procedures and critical care. Indeed, more than a few mentors and colleagues have chastised me for being perhaps overeager, eschewing my patients with minor complaints and spending too much time locked in the struggle against sickness in our more precarious patients.


That made me anticipate a struggle with my month on the “small side.” Knowing that the pediatric ED typically packed a lower acuity, I worried that I might miss the action and adventure just a few doors down.


But with the days of my pediatrics rotation coming to a close, I realize now that I shouldn’t have worried. Every day spent with our tiniest patients was as rewarding as the one before. I learned more with each shift, and I fell asleep each night eagerly anticipating the next day’s cohort. Helping to ease a young mother’s worry was nearly as rewarding as watching a 2-year-old regain his energy after a therapeutic dose of Tylenol. I loved answering fake phone calls on the iPhone handed to me by an imaginative toddler, and took great pride each time I was able to disimpact a cerumenolytic ear without creating a 5-year-old enemy.


Most of all, though, I saw love as I’ve never seen it before. It’s hard to write, really, just how breathtaking a parent’s commitment can be. I would watch daily as fathers waited hours at a sleeping child’s bedside, keeping steadfast watch while lab tests and imaging results crawled their way back to our computer screens. It was an unforgettable privilege to witness the incredible devotion a mother would show for her permanently disabled child.


My month in the pediatric emergency department made me a better physician. I learned about pseudosubluxation and Sever’s disease, about 24-gauge IVs and the healing power of an orange ice pop. I discovered a good use for those gigantic Q-tips on the OB-GYN cart (“I need your help tracking down the elephant who needs his ears cleaned!”), and started to make sense of formula types and feeding schedules. My month in the pediatric ED taught me weight-based dosing, Salter-Harris grading, and even the value of a code sheet when everything goes wrong. Most importantly, what I learned in the pediatric emergency department is that a good doctor is not just someone who can battle death in the resus room, but also the provider who can lend a helping hand when a tired mother can’t make it through another night of crying and coughing, or who can empathize with the young father who just doesn’t know what to do. My month in the pediatric ED made me a better physician, and I owe a great deal of thanks to the patients, nurses, and teachers who helped that happen.



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Thursday, March 05, 2015

When I graduate from residency and pass the ABEM qualifying exam, I’ll be ready to start my own career as a board certified emergency physician. After four years of medical school and three more of residency, the powers that be will have deemed me ready to care for the ill and injured across the country — but not in my home state. I’ll be permitted to infuse inotropes and lead resuscitations in New Jersey, but it will be unlawful for me to prescribe laxatives in Pennsylvania. I can strive to save lives in Alabama, but I am barred from doing the same in Florida. The problem, you see, is that I’m a DO.


I should start off by saying how proud I am to have graduated from an osteopathic medical school. An institution that had no compelling reason to accept me readily brought me into their academic fold, and I thrived on every moment of their tutelage. The mornings of manipulative medicine instruction shaped my role as a physician just as the long nights of anatomy lab did. Osteopathic principles infused into every patient-centered lesson helped mold me in the vision of Andrew T. Still, MD, DO, and I truly believe that my daily patient interactions are influenced by my osteopathic education. Nonetheless, I opted to enter an ACGME-accredited program for my residency training. Many reasons led me to forgo the AOA match and enter an MD program — the same arguments that are played out daily on Internet message boards and in the minds of the thousands of emergency medicine applicants each year — but the only reason that matters, of course, is that it was the right program for me, the place where I could best learn the art and science of emergency medicine.


To maintain some measure of osteopathic distinctiveness, the osteopathic licensing boards of four states (Pennsylvania, Michigan, Oklahoma, and Florida) typically require completion of an AOA-approved internship prior to granting a permanent medical license. The remaining 46 states make no distinction between the medical degrees, but these four stand fast in their requirement. The AOA instituted Resolution 42, or the “hardship resolution,” in 2000, which grants credit for internship to ACGME trainees, allowing them to apply for licensure in the four states. Resolution 42 provides a mechanism for DO graduates to remain part of the osteopathic family, but it places perhaps onerous requirements on emergency medicine trainees, sometimes requiring replacement of elective time — designed to help residents pursue a niche interest or sharpen a relevant skill — with a rotation of questionable benefit to the emergency medicine curriculum.


My co-residents, the residency faculty, and the hospital staff treat me no differently as a DO in an MD program. Most patients are unaware of the difference or at worst simply ask what the letters behind my name mean. By and large, the only entities that force a distinction are the four state boards that would deem me unfit to treat their citizens. Graduate medical education is undergoing a long-awaited evolution toward a combined certifying organization, so it is peculiar indeed that such restrictions and requirements still exist in these states.


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Tuesday, January 06, 2015

It’s gray outside. Every day, thick clouds block the winter sun. The trees have lost all of their leaves, and the suburban lawns blend into the cracked sidewalks and streets. In college we called this time “The Dark Ages,” the seemingly endless and dreary stretch between the color and joy of the December holidays and the sunny promise of spring.


The Dark Ages seem to have come early this year for some reason. I began my ICU rotation in early December, after a November ED month marked by mistakes and frustration. I was excited. With #FOAMed heroes so heavily represented by the critical care crowd, I was ready for a revelatory experience, prepared for the first steps toward fellowship and broader horizons from the ICU. But I was never able to throw off the heavy yoke of my emergency department disappointment.


My mind would wander on rounds, always returning to the difficult cases I’d faced just a few days earlier. I questioned myself, relived the moments I could have — should have — done better. I presented my patients each morning, and was struck by how frequently their courses had been set long before they landed in their glass-walled suites. So many of their paths were determined not by vents and vasopressors in the ICU, but by the hands and hearts of the ED or by the astute ears of the responding paramedic or the experienced eye of a downstairs provider. I was simultaneously proud of my role while ashamed at my performance.


I learned a lot in the ICU. I saw disease processes I had only read about before, and managed the sickest of the sick in the early morning hours. I placed more lines than I could count and enjoyed the daily rounding I once despised as a medical student. I marveled at the depths of the intensivists’ expertise and experience. All the while, though, I wondered about the emergency department. I missed the choreographed chaos and patient-centered teamwork that defines our specialty, and I pined for a chance at redemption. I longed for the learning that comes with each patient and every shift.


The first half of intern year is over. Where the beginning bar was set low, every shift has rightly brought with it a new set of expectations, an incrementally expanding role of responsibilities, and the trust of others that we’ve fought so hard to earn. In our own minds, the once-monumental step across the threshold into a patient’s room has become routine. We’ve gained confidence, which is, perhaps, why our failures seem amplified. It’s only when you’re big enough that the fall hurts.


But it’s only at the precipice that we change, and only at the threshold that we learn, adapt, and grow. I return to the emergency department tonight after a brief respite, and I like to think it’s no coincidence that my new chance begins alongside the new year. I like to hope, at least, that the light of a rekindled passion can beat back the perennial murk of The Dark Ages.

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Monday, December 15, 2014

I first met heroin when I was a brand new medical student at the local needle exchange program. This organization provided free and clean needles for intravenous drug users. It was early March when I first set out to volunteer with the needle exchange. Cutting classes for the day, I drove downtown to search for the program offices. I made lap after lap around crumbled, aging buildings before I spotted the sign, a fading yellow placard that swung lazily from rusted chains. I pressed the lock button on my car’s keyless entry remote a few extra times.


It took a few minutes to enter the exchange office, requiring passage through three locked doors, each guarded by a suspicious, jaded secretary who needed wooing before granting access. Finally, I entered the wood-paneled cavern that the program had claimed, an aging mix of law library and crack den. A spandex-clad receptionist pulled herself out of her chair to greet me. "They're ready to go in the van out back. You'd better head out there."


I settled in for the short ride to the exchange site. The setup was simple. Nestled in an overgrown field south of the city, far from the eyes of potential businessmen and graciously ignored by the municipal police, we set up three tables. "Customers" would approach the first table and hand over a single dirty syringe. Then they would proceed to the middle counter, where a selection of BD's finest awaited, categorized by volume and gauge. A point of the finger (no words uttered here), and each would receive 200 tiny needles. The last table held the accouterments that these venous veterans required: tourniquets, alcohol wipes, and sterile water for injection.


I was amazed by the diverse clientele that shuffled through our makeshift bodega. Lady Liberty's huddled masses were present, of course, but it quickly became apparent that heroin use was much more universal than I thought. When a brand-new Jeep Cherokee pulled up with mom, dad, sister, and brother each claiming their 200, I began to see just how deep the rabbit hole went. Heartbreaking stories continued to fly through, staying only long enough to secure their supplies for the week. Brothers. Families. Prostitutes and their pimps. Sunken eyes told tales of debilitating dependence and more than a few brushes with death.


We were forbidden to ask if anyone wanted medical help or counseling. Such intrusiveness would drive the population away, I was told, and leave more users stuck with dirty needles, increasing the risk of HIV and hepatitis transmission. I sat off to the side, my bright green scrubs making my purpose clearly evident. If anyone needed help, "They’ll ask us,” the NP informed me. And a few did. Of the hundreds of tempest-tossed who passed through, a handful asked a quick question, "Where can I ... uh ... you know ... talk to someone?" A knowing smile from the sage nurse and a ready pamphlet satisfied those concerns. One or two had a rash or bump they wanted checked, and we had to summon an ambulance for one gentleman with all the hallmarks of cellulitis and sepsis.


I went back a few times. Soon enough, though, my eyes started falling on more and more discarded needles in the gutters and on the side of the road. Whether there were more to be seen or I was just noticing them for the first time, I knew that I was part of the supply chain. Study after study will demonstrate that needle exchange programs drastically decrease the rates of HIV and other needle-borne disease, but I struggled with the collateral damage. The needle exchange and I went our separate ways.


I reunited with heroin and its victims when I began residency. Every day, I encounter casualties of addiction. Overdoses, abscesses, and endocarditis are familiar diagnoses. It’s the odd shift when there is not at least one drowsy patient in the hallway bed. Opioid abuse is so common, in fact, that I’ve sought additional resources to understand these patients a little better. I toured the city with the local state police commander, my eyes open wide as he showed me the dark alleys and barred porches where the transactions are held, taking notes as he recommended expecting certain adulterants if my patient came from one part of the city versus another. I’ve scoured online message boards, learning about “greasing,” “morning shots,” cotton fever, and lime juice cookdowns.


It seems that heroin has become as much a part of my learning journey as chest pain, shortness of breath, and nonspecific belly pain. What was once a brief exploration of a not-too-distant underbelly is now an important consideration nearly every time I walk into the ED. I’m thankful for the peek into the world the needle exchange offered me, and can only hope that we can part ways again.


What have your encounters with heroin patients been like? What do you think of needle exchange programs?

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