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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.

Monday, March 24, 2014
Today is Match Day. It's the medical school equivalent of Christmas, if Christmas came only once, and was one of the pivotal moments in a soon-to-be physician's career. Match Day is the culmination not just of the long and sometimes arduous journey that is medical school, but also the obvious end of the rollercoaster process of "The Match."
It formally began nearly a year ago. The online application system opened, and candidates across the country and around the world scrambled to submit paperwork as quickly as possible, speed and accuracy of documentation substituting in our minds as some misguided measure of dedication. Once the personal statements, board scores, and letters of recommendation were sent off, it was time to wait. That would become a common theme in the process.
We waited through the early Autumn, eagerly anticipating offers of interview from our favorite programs. We panicked when our inboxes remained empty, but breathed a sigh of relief after the ACEP Scientific Assembly when the notices finally came. We scrambled yet again to schedule interviews and dates. Latecomers were stuck with five days straight of interviews in every corner of the country. Once scheduled, though, it was time to wait again.
Interviews were an exercise in Tantalus’s torture. I was intent on staying in Philadelphia, and I saw myself content at every program with which I interviewed, and I could only count the days until I might don the longer coat I so coveted. I stood in awe at the history and wisdom held within Drexel's old halls, and delighted at the modernity and expertise throughout Einstein's. Jefferson's ultrasound experience wooed me just as Christiana's EMS opportunities did. I reveled among the FOAM superstars at Temple. I survived the legendary McNamara interview.
And just like that, it was time to wait again. Emails came and went, but we know not to put too much stock in assurances. The Match has surprised more than a few of our friends and predecessors.
Monday was an important day. Known in some venues as "Pre-Match Day,” the noon email from the NRMP was arguably the most important one of the week. I had matched ... somewhere. The hard work and long wait hadn't been for nothing, and my goal of becoming an emergency physician was set to come true. I was thrilled, but had little time for celebration as I returned to work. The real Match Day, the one I'd been waiting for, was still days away. And so I waited some more.
I can remember the first patient I ever saw. I was an 18-year-old EMT student, my white polo shirt and black rescue pants still bearing the folded creases from the store shelf where I’d bought them earlier that day. I was nervous. Through luck or fate I’d been assigned to the region’s largest trauma center and busiest emergency department — Cooper University Hospital in Camden, NJ — and I fumbled with the blood pressure cuff as I awkwardly wrapped it around the skinny arm of my first charge.
My fingers fumbled similarly when the match notice from the NRMP chirped from my inbox this afternoon. My stomach tightened as I clicked through the requisite screens, and my spine sent chills throughout my arms and legs. I finally made it to the result, and my smile stretched from ear to ear. I had matched my first choice, and nearly a decade after that fateful night in EMT school, I would be returning to Cooper as a young emergency physician.
My phone began to erupt with notes of congratulation and news of classmates' fortunes. A friend rejoiced over his perfect match while another sang a more remorseful song. All the while, my elation stayed firm.
But just like the months that stood between each step of The Match, the waiting begins again. I'll start residency soon enough, but until then it’s just a waiting game until I can cross the dais, collect my diploma, and begin this next step of the journey.

Friday, February 07, 2014
It was late or early, depending on your perspective. The buna makers were beginning to rouse from their short night’s sleep, and I rested heavily in a wicker chair, surveying the table in front of me. It was littered with the evidence of a night gone on too long, and I took a few moments to reflect on the somewhat surreal events of the earlier hours.
We had started huddled around the smallest of tables — a crowd of physicians from one of Ethiopia’s hospitals, a pair of young American doctors, and me. We chewed Khat root and sipped honey wine as the divide of thousands of miles disappeared among the shared language of medicine. We ate, drank, and laughed as we learned and grew among mutual instruction.
My medical school adventure is nearing its conclusion, and I’ve come to find that it’s the intimate hours of teaching and tuition that I look forward to most. Once or twice a month I get the chance to head back to school and climb the stairs leading to the simulation lab. More often than not, I've traded the day off from rotations for a night shift the evening before, so it's usually with a large cup of coffee in one hand that I push open the heavy wooden doors separating the fake patients from the outside world. Once settled in to the correct room and with the correct amount of cream in my coffee, I have the incredible opportunity to teach eager medical and PA students.
As much as teaching invigorates and excites me, the hours in front of the lectern are flanked by many more spent rehashing and reviewing material that seems to change by the minute. “Expertise” doesn’t seem to exist in the era of #FOAMed. A litany of experience and perspective pours from the community as soon as a new idea is shared or published. The benefit is universal — student and teacher alike are able to expand their horizons and find new avenues by which to pursue their own interests — but the instantaneous knowledge-sharing made possible by FOAM demands continual and dedicated review of the material by instructors.
It’s a concept, I fear, that may be missing in traditional medical education. We’ve become accustomed to hearing medical dogma repeated from generation to generation. Far too many professors stand in front of legions of eager learners and pass down wisdom that they, too, once heard while sitting in the same seats as their audience.
My late night in Ethiopia reinforced that the pursuit of better patient care is universal, that the thirst for clinical prowess is never quenched, not in American lecture halls and never in African deserts. We have all become perpetual learners in this era of open access education. Whether we’re students just donning little white coats for the first time, residents poised for graduation, or even attendings who have seen more than most, we hold the most special of privileges in the health and safety of our patients, and we must strive through diligent study and continuous training to be worthy of the task.

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.
Ben and I are on our way to Asendabo, a small village about six hours west of Addis Ababa, the capital of Ethiopia. He has been there before; I’m along to lend a hand in his organization’s efforts to bring sustainable emergency medical services and obstetric care to an area in dire need of even the most basic resources. It’s an opportunity for me to participate in an important effort with admirable goals, and it’s a chance to recapture the fire I knew from before.
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.