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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 first-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 starts his 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.

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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Wednesday, October 15, 2014

I’ve spent the past few weeks away from the emergency department. Having tackled my first three months of residency, the schedule now has me rotating through one of our hospital’s critical care units. I show up every day and take my spot among the ranks of internal medicine residents who keep the hospital floors humming.


It’s a different experience from what I’m used to. The hours are longer, but usually not as hurried as my shifts in the ED. Where I might strive to see and disposition 20 patients from the department, it’s a busy day on the floor when I see more than a half-dozen. The day progresses differently, with plenty of time for in-depth discussion and comprehensive dissection of each case. Attending physicians and senior residents spend countless minutes exploring subtopics and clinical questions, and it’s a new experience to see where patients go and what happens to them once they leave the ED. Perhaps more importantly, this serves as an essential opportunity to form closer relationships with the admitting teams and consulting services that I often see so transiently while on shift.


It’s a mixed bag. I’m dismayed each morning by the rounds that seem to never end, but I revel in the incredible conversation and seemingly endless knowledge of my team members. I enjoy the broad differential entertained by the inpatient teams, but sometimes I become exasperated with what occasionally feels like zebra hunting. Still, I suppose, the medical safari has opened my mind to a host of maladies and broadened my differential for the future.


The patients and pathologies I have the chance to see each day are motivating and captivating. I’ve learned the value of exploration, and have come to appreciate the lengths to which the inpatient diagnosticians go to ensure the best for my patients. As October comes to an end, however, I’m eager to make my way back to the emergency department, and can’t wait for the familiarity and flow I’ve come to love.


Fellow interns, how is your first year going? Senior residents, any advice for us newbies?

Wednesday, August 06, 2014

With July come and gone, my fellow interns and I are starting to feel (slightly) more confident in our newfound roles as emergency medicine residents. I still haven’t figured out how to get surgery to come downstairs quicker, but I can at least direct my patients toward the bathroom without consulting a tech first (just around the corner, across from the stretchers). Each day holds its own lessons, excitements, victories, and disappointments. So far, it’s everything I’d hoped for.


Our residency orientation closed with a presentation by one of our seasoned attendings called, “The Ten Commandments of Emergency Medicine.” These maxims, which at this rate would take up more than a few stone tablets, yield advice ranging from “ovaries complicate things” to “be on the lookout for the Holy Grail.” ( It’s the perfect lecture before we hit the department, a mixture of sage guidance and lighthearted warnings for the new interns. One commandment in particular, though, has stuck with me: an admonishment to “spend our coins wisely.”


It’s an apt metaphor. We all begin with a certain number of “coins in our pocket,” or mental energy and motivation, at the beginning of each day or shift. They’re a fluid resource. A difficult patient or situation may try to steal our coins, just as a great case or well-timed cup of coffee can replenish the stack. A bad day’s sleep on a string of nights might start your coffers lower than usual. It might cost a few coins to fight GI on the NG tube or to try to sell a social admit to a grumpy medicine resident.


I think about the coins metaphor often as I move throughout my day, and I’ve brought the imagery home so my wife understands when I tell her I’m running low on coins and don’t have the energy to do this task or to argue that point. I’ve had more than a few shifts where nothing seems to go right, where all of the answers I offer are wrong, where my lumbar punctures resemble more of a merlot than a champagne tap, and where my patients get stuck in a holding pattern I just can’t seem to break.


But I’m finding I have coins to spare even on the worst days. Maybe it’s because I’m still just so excited to finally be where I am. More than likely, it has something to do with the safety net I know is all around me: a smiling third-year by my side with every critical patient, a seasoned nurse to help at every turn, and a collected attending I can always catch out of the corner of my eye, keeping one of theirs on me at each step. So far, at least, I’ve been able to spend my coins freely, and I’m fortunate enough that the incredible people with whom I get to work ensure that my change purse remains full.