Little White Coats
Welcome to Little White Coats!
Little White Coats is the brainchild of Richard M. Pescatore II, a third-year medical student at the Philadelphia College of Osteopathic Medicine. Follow him here as he finishes medical school and then starts a career in emergency medicine.
Rick is also a lieutenant in the Buena Vista (NJ) Emergency Medical Services. 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 Rick 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, December 05, 2013
A trip to Cambodia two years ago changed my life. I learned more about medicine and myself than I’d ever anticipated in the space of just a few weeks, and I begrudgingly left behind the blue shores of discovery to return to a course of medical education that had been forever altered. I started writing, threw myself into my studies, and found FOAM. During the rest of my didactic years and throughout my months of clinical education, I harnessed my experience as a cache of motivation and a muse for my weekly writings.
Now I find myself once more on the tarmac of an international airport, this time in Khartoum. Men with guns are all around, and out the window I see AK-47s and curtained military vehicles that obscure the natural landscape. Swirls of sand would stretch on as far as the eye can see, but ranks of Sudanese military aircraft and Gulfstreams emblazoned with the United Nations logo block the view. I’m not allowed off the plane.
The past few months have been filled with daylong interviews and late evening applicant meetings. I’ve walked the interview trail to half of the programs in Philadelphia, and ridden a roller coaster of anxiety about the future. Each interview has left me simultaneously excited about the opportunities ahead and filled with fear that my name might not top any rank lists come March. The uncertainty of residency — where I’ll find myself on July 1 — has made it difficult to find myself in the present.
I’m asked to define myself at each residency interview. Mentors have pushed me to refine my “elevator speech” and to do all I can to condense my description into just a few sentences, a 30-second spiel on the way to the 10th floor. So much of who I am is defined by the journey I’ve taken these past four years, and I’ve allowed the destination at the end of medical school to become my label. With that final designation still in doubt, I’ve let a nebulous future create an unsteady present.
I’ve had the opportunity to do so much since donning my little white coat with the help of so many mentors, colleagues, and classmates. I’ve healed and comforted the sick and injured, taught legions of eager equals, and crossed continents by plane and prose. I’ve erred, stumbled, and fallen. I’ve become a homeowner and a husband.
I’ll never master that 30-second elevator speech because as much as I am defined by my future, I am molded by my present and fashioned from my past. I don’t know what’s to come over the next few months, but for today I can say, “I’m Rick, and I’m going to Ethiopia to try to make a difference.”
Monday, October 07, 2013
Franklin was a patient I saw regularly on the psych service. He’d come into our crisis center from time to time, a cascade of obsessive worry and unchecked anxiety bringing him back to a brink with which he was all too familiar. Sometimes he just needed a safe place to gather his thoughts; occasionally he’d need more intensive intervention. I came to know Franklin quite well over my four weeks in the psychiatric ED. He’d wave from the EMS stretcher as I peeked over the nurse’s station counter at the new arrival. Franklin was once again resting in Room 4 when I left at the end of the month. I waved goodbye when I walked out the double doors for the last time.
Months have passed since then. I left the world of psychiatry for a few “audition” rotations at local emergency medicine residency programs. I’ve learned more with each day, seen hundreds of patients, and traveled to a half-dozen hospitals, each of their gray and fluorescent-lighted hallways looking just like the one before. I forgot about Franklin.
I’m on a “sub-I” now, assigned by the school for a few weeks on an eternal, uh, internal medicine service down the road from the psych ED. It’s a lot of managing magnesium and calling case workers, and I’d be lying to say I awake each morning eager to round for three hours. When my resident directed me down to the ED to admit “the hypertensive patient in Room 18,” I grumbled something about ACEP clinical policies and trudged off to the department. My eyes widened with surprise when I saw Franklin resting comfortably in the bed to be admitted.
Franklin’s mind was at ease for the first time since I’d met him. He denied the anxiety I’d become so accustomed to seeing him suffer, and he dismissed any worries of the future to come. I nodded and smiled while writing his H+P, glad to see my patient was doing so well but struck by the change in our roles, how my anxiety was worse than his.
I’ve found myself too frequently consumed with concerns about the months to come since submitting my residency application last week. My email inbox remains conspicuously devoid of interview invitations while my friends rave about their scheduled visits to the nation’s meccas of medicine. I watch my fiancée wake at the crack of dawn to make the short drive to her hospital, and wonder if I’ll be living hours away this time next year, having lost the geography battle to area programs’ unforgiving rank lists. I stress about three-year vs. four-year programs, EMS externships and critical care fellowships, and the failure of the AOA to effect a GME merger. At the end of it all, I worry and wonder if I’ll become the great emergency physician I’ve been working toward.
I finished Franklin’s paperwork with little fanfare and had him brought upstairs, the quiet of a private room probably better for his blood pressure than the nitroprusside drip at which I had raised my eyebrows. It was the end of the day, and I called my resident to update him before heading out the door. I think he recognized my preoccupation, and let me leave with little more than a reminder to check up on some cultures and cytology we’d been waiting on.
I checked my inbox as I walked into the cool evening air, sighing at the negative return. We’ll take care of Franklin, and he’ll likely be sent home before I even get to see him tomorrow. For now, I’ll just continue to check my drips and dosages, and do my best to make patients like Franklin get better.
Tuesday, August 27, 2013
I met Jeffrey when he came to the rural emergency department where I’ve been assigned this month. Restless in one of the small unit’s three acute beds, I quickly noticed the large abscess over his left elbow that had brought him to our door. The pain was apparent, the fear only slightly less so. With no CT or ultrasound, much less the MRI he’d ultimately require, the decision was quickly made to transfer Jeffrey to the larger hospital an hour up the road, where half an hour in a whirring machine would eventually show the bacteria that had invaded his joint and bone.
We chatted for a few brief minutes — about the drug use that had led him to this point, the depression he found himself sinking more deeply into by the day — the same topics, really, that we’ve come accustomed to with the victims of addiction we see all too often. Before the night drew on much longer, Jeffrey had been whisked off by the critical access hospital’s dedicated transfer unit.
After four exciting and challenging weeks at one of the nation’s leading emergency medicine centers, my school has shipped me off to a small community in rural Pennsylvania. The experience, in the two short weeks I’ve been here, has been unlike any other rotation of medical school. I awake each morning to a low-lying mist that conceals the mountaintops on either side of this tiny town. The hospital — no more than a mile down the road — requires me to pass through the town’s only stoplight, which is unfailingly red when I pull up to the white line. I find myself in little time, however, in the parking lot of the small complex nestled into the side of the southern mountain.
I spend most of my days seeing patients in a two-room clinic across the gravel road from the ED. When an ambulance rumbles by or my pager sounds, I hurry next door to start the workup while my attending makes his way in or begins charting. Our catchment area has no more than a few thousand potential patients and a yearly ED census somewhere in the high triple digits, and I’ve quickly come to know many of the residents of this small and tight-knit town. Patients I see in morning clinic wave from their porches as I pass on my evening runs. The nurse who helped me fix a bleeding PICC on Tuesday is the one who slides me a sweating drink from behind the bar on Wednesday. Jeffrey, freshly returned from a weeklong inpatient stay two towns over, flags me down at the gas station to show me how well he’s doing.
Where I’d been initially hesitant about this mandatory month far from home, my experience so far in rural emergency medicine has been an eye-opening opportunity. I’ve taught basic skills to the borough’s fledgling rescue squad, and roared off into the night with the volunteers in their incongruously well-appointed ambulance. I bumped down abandoned dirt roads in the forgotten hours of the morning, and I’ve stabilized patients in the back of the rig and been able to then continue their care in the emergency department. With no imaging, consults, or backup, I’ve learned volumes from the emergency physicians who staff this medical outpost.
Two more weeks to go until I pack up the car and head back to Philadelphia for another month in a mecca of emergency medicine. Until then, each day here in rural America provides another chance to be a part of a hospital so thoroughly interwoven into the surrounding community. Each patient offers another opportunity to witness the special medicine practiced by an emergency physician known and trusted by his patient-neighbors.
Monday, July 15, 2013
I walked out of Step 2 on Wednesday and felt like a major weight had been removed. No matter how it turns out, it’s done. My last exam of medical school is in the bag, giving me a few short days to get my life in order before hunkering down for my next rotation. A haircut that I’ve been postponing for far too long. The laundry I should have folded last week. The phone calls, dinners, and emails that tend to accumulate at the wire.
It’s no secret that medicine has a tendency to envelop your life, and I can only imagine the extra hours that residency will claim. Things get pushed to the side, priorities are readjusted, and the elements that used to complete your day slowly disappear. It’s a simple reality that sacrifices will have to be made to dedicate the time and effort that the profession demands. The future reality has only become more apparent as my fiancée kicks off her second week of OB/GYN residency. All that being said, though, it seems that emergency physicians in particular have a knack for holding on to an outlet — some distraction, dedication, or hobby that pulls you back and helps to keep the big picture in mind.
Once upon a time I was a somewhat decent runner. I'd wake up every day to blaze through a few miles with the team, relishing the view of the morning sun rising over the Chesapeake as we sprinted through the last straightaway. We'd do it again in the afternoon before collapsing on the grass in front of Luce Hall, lungs burning with each gasp. Each mile helped to define my experience, and nothing was better than getting lost in the steady shuffle of sneakers around me. But that all ended after I tossed my cap in the air. A few years passed, and I started running less and less. Miles on the trail were replaced by hours on watch. When medical school began, it was an escape to the gym for an hour and a half between studying. Then an hour. Then three quarters.
It was in Cambodia that I started to run again. There was so much I wanted to see — the temples, the palace, the dusty dirt roads that led to somewhere unknown — and running was the perfect way to do it. I was surprised at first by how much speed and endurance I'd lost, and I struggled in the oppressive humidity. Slowly, though, my legs came back to me. I stole a few coveted miles on my way home inside of the Seoul-Inchon Airport. I overcame jetlag over the next few days by trading rest for road. And the morning miles steeled me for each day when school began again. The pains in my knee and the dripping sweat offered brief but welcome solitude and helped me to organize my thoughts and plans.
But I couldn't seem to regain the passion and pace that I maintained so easily a few years ago. I embraced the peace of the run, but my mind would still drift to the to-do list that beckoned from my desk. I cut the miles shorter with unread journal articles and unpublished research as my excuses. If I missed Thursday's easy run or Sunday's sprints, I would rationalize with responsibility. When the gun went off at the Thanksgiving 5K, rubbery legs and burning lungs underlined my procrastination. A terrible finishing time highlighted it.
Reluctantly, I’ve come to the conclusion that I’ll never again break the turns like I once did. It’s a terrible irony that medical school ended up being such a detriment to my health, but I know I’m certainly not the first. With rising responsibilities and an increasingly shaded calendar, it becomes important to inject these hobbies where we can.
My next rotation is just 10 miles down the road, but that amounts to at least 45 minutes in the daily snarl of Philly traffic. It’s the perfect opportunity to pull my bike out of the garage, brush away the cobwebs, and start each day with a nod to the cardiovascular past. Making sure to remember the things that define us, the daily diversions that make us who we are, help us face each day with the same passion and ardor that brought us here.
Wednesday, June 05, 2013
My third year of medical school ended last week, marking a transition to senior year that seems much less momentous than this same month a year ago. Last time the move from books to bedside felt like a pinnacle of achievement, but this time I’ll pick up almost exactly where I left off. There are no board scores crawling through the mail, no ceremonies, no pomp, no circumstance. The graduation to MS4 is not an achievement as much as an expected progression. It seems obvious and, well, boring, but the ease of the transition is, perhaps, what makes it important.
I began clinical clerkships with an outsider’s knowledge — a peripheral understanding of the world of medicine. Through the dedicated instruction and committed mentorship of so many, my classmates and I have broadened our horizons and found a long-awaited place among the health care team.
Maybe what’s more momentous about the move to my final year is the realization of how growth in medicine is accompanied by growth independent of it. Where once I may have seized every chance to be in the ED or on the ward, no longer is that the default. Not because of exhaustion or satiety — far from it — but rather because of the recognition that there is more to becoming a good physician than the lessons within the hospital walls. The early morning basketball game that helps up forget the frustration of editing an abstract for the fifth time. The long-overdue dinner and a movie that reminds us that we’re still loved, no matter what the surgery attending has to say in his fit of rage. It’s the stolen moments with family and friends that show us how success comes not in spite of others but only because of their support and company.
So, I’m a fourth year now, a little older, a little wider, and maybe even a little wiser. Monday morning the alarm will sound just like every day of third year, and I’ll drive to the hospital along the same old roads. There is one important difference, though. After too long apart, I’m finally back in the emergency department, starting a long stretch of auditions for a coveted residency spot.