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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.

Friday, September 25, 2015

I’ve been thinking a lot lately about the future. My mind wanders constantly, always returning to thoughts of what’s to come. I think about life as an attending and wonder if fellowship is the right choice for me. I’ve become consumed by questions both personal and professional. Should I search for a job in academics or in the community? Will fellowship make me a better doctor? How will I pay my loans? With my first child on the way, will I be a good father?


For the first time that I can recall, I don’t know what comes next. It struck me recently that I’ve been writing these bimonthly missives for nearly four years. Every step since then has been carefully calculated, every medical school rotation designed to bring me closer to the prize, every research hour and every typed word deliberately considered. The endpoint was always clear, the goal always in sight. It never occurred to me that I might ever have to ask, what’s next? Such has been my distraction this past month on the hospital’s trauma service. It’s an interesting irony, really, that a rotation so defined by immediacy and the present has left me so obsessed with the future. Even while witnessing the daily evidence that no tomorrow is certain, I can’t throw off the uncertainty that clouds every minute.


And that’s the problem, that a preoccupation with the future serves only to tarnish the present. While ruminating on the years to come I’ve almost missed those magical moments that come only rarely, if at all. I nearly missed the opportunity to explore the world of surgical critical care, and almost neglected to value the lessons borne from traumatic tragedy. When my wife placed my hand on the fluttering kicks in her belly for the first time, I almost lost a once-in-a-lifetime moment, distracted by an ever-growing task list and mounting preoccupations.


I worry constantly about the next steps in this long journey, and it’s likely that it’s no longer about what’s next but about what’s now. I still look to future accomplishments as a guide for daily action, but I’m slowly starting to think that the mindset that has driven me all along has to change. I’m gradually growing to think that the fulfillment I’ve always sought through ongoing achievement must be supplanted by daily satisfaction in the privilege of patient care. Having worked so hard to reach residency, perhaps it would be a mistake not to savor each second for exactly what it is.


My first trip to the annual ACEP conference is just around the corner, and I couldn’t be more excited to meet the dozens of emergency medicine fixtures that have helped me along the way. If you’re planning to be in Boston, please be sure to say hello!


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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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About the Author

Rick Pescatore, DO