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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.

Monday, February 1, 2016

It's amazing how quickly things can change. The past nine months of residency have held all the highs and lows that one would expect, all the while underlined by a 40-week countdown. Every plan I have for the future has been qualified by the expected arrival of my family's newest member, and I've worked furiously with the knowledge that time once dedicated to research, writing, and reading would soon be spoken for.

My wife and I welcomed our daughter on Dec. 22. Eloise Jane waited for me to finish one last holiday shift before signaling her arrival, and gave us only a few hiccups on her way into our arms. The entire experience was more magical than I could have ever anticipated, and it surely has changed me as a person and as a physician.

It was an odd feeling, really, sitting in the delivery room waiting for Eloise. More than once, I felt lost — even with separate months on the OB service as a medical student and later as a resident, there were terms, plans, and medications I struggled to understand.  My superficial knowledge of fetal heart tracings was more a curse than a blessing, and I panicked with every momentary dip of the line. My wife, an obstetrician, repeatedly reassured me, but it did little to allay my perpetual worry. I watched with wonder as a team of confident experts brought my daughter into the world. The process was organized, quiet, and rehearsed in every way that an ED delivery isn't, and each hurdle was handled with ease by the skilled hands at our bedside.

With Eloise's first cry, my whole world brightened. I announced her delivery to our assembled family with the proudest of voices, and couldn't stop staring at the little miracle who slept so peacefully pressed against her mother's chest. All of the stressors of the weeks and months before melted away in the face of all of the new possibilities laid out in front of me.

Having a baby during residency has not been easy. Shifts seem to stretch on longer than ever before, with dozens of charts standing between me and home. Where before an extra hour or two in the hospital was of little consequence, now I feel the continuous pull back to the nursery. I rush home for the chance to hold her for a few minutes before collapsing into bed, only to be awakened just a few minutes later for another diaper change. I don't not think my wife has slept since Christmas, but she amazingly juggles the tasks of home, work, and infant with ease.

I've learned more in the past few weeks than in any number of pediatrics rotations or peds ED shifts.  Those 2 a.m. chief complaints I once considered lunacy — "noisy breathing" or "crying" — I now completely understand because I all but order the intussusception ultrasound with every balled-up scream. It took no time at all for me to master the swaddle with which I've struggled so much in the department, and I can change a diaper like nobody's business. They're minor lessons in the grand scheme of things, but I think they've helped me connect with my youngest patients and their parents, and helped me to understand their fears and confusion.​

Everything is different now. My plans for a post-residency future are now influenced by school districts and grandparent availability. Research projects that were well in motion have slowed until I can master chart reviewing while burping, or until Eloise completes her IRB training. Podcasts have become an integral part of my study routine, and I suspect that my daughter may come to recognize the voices of EM:RAP more than my own. I look forward to every day left in residency and beyond, all of them brighter now with Eloise in my world.


Tuesday, December 1, 2015

It was sometime last week that I hit the low point. I’m not sure what finally did it, but I was done. I was exhausted by what seemed to be endless disappointment with each new day and drained by too many bedside battles lost to the inexorable march of disease. Scheduled to speak at a state EMS conference, I nearly missed my own lecture as I stumbled in the dark depths of my anguish. Once upon a time, such a presentation would have served as an energizing return, yet I emerged only further disenfranchised, frustrated yet again by the seemingly impossible resistance to change. Once I was back at work, I felt besieged by social complaints that I couldn’t address. I recall driving home after a particularly difficult shift when a thought kept relentlessly repeating in my mind: Perhaps when you pour your soul into something, you eventually run out of soul.


It’s a sobering realization that after so many years working toward one thing and dedicating yourself toward a seemingly utopian goal, the light at the end of the tunnel might simply burn out. Was that what had happened? Was it possible that this path I had worked so hard to travel had been the wrong one all along? For so many years, I can only remember yearning for the days when going to work would mean returning to the emergency department, ready and willing to fight the scourge of illness and injury, honored to serve as a soldier on the front lines of American health care while simultaneously bolstering its foundational safety net. My persona had been fashioned toward this end. Maybe it’s fitting, then, that it took another’s end to show me how far I’d drifted from my own.


Mr. Jacks had been in the ED at least five times over the past few weeks. Gripped by a fast-moving cancer that had found its way to every corner of his weak and tired frame, he all too frequently needed the brief respite that a night in the hospital could provide. Unable to eat and under daily assault by pain I can’t even begin to imagine, our brick walls held the drugs and fluids that could carry him over the latest hurdle in a never-ending tide of the same. Whether by laudable stubbornness or misplaced hope, Mr. Jacks seemed unaware of the now-inescapable end that drew closer with each return to the ED. It happened, just as my own days seemed darkest, that I walked into Mr. Jacks’ room.


He looked even worse than I remembered. Unable to drink or eat because of the gripping pain, he had lost the last of what little muscle he had. Yellowed skin clutched closely to withered bone. He moved his head weakly as I said hello once again. All around him sat a worried family: three girls just younger than I and his ever-present wife. I moved quickly through the mandatory questions as she tightly held his trembling hand. My exam was cursory. There were no secrets hiding within this man’s gaunt frame, only the ceaseless blight that had staked its claim long ago. By now, they all knew the drill. The night promised dozens of blood tests (the results of which would add nothing to the current struggle) and yet another CT scan, our hand forced by a clinical picture that almost guaranteed the presence of a tumor-borne shunt.


But we stopped. The nurses readied the supplies to access a too-worn port and its calloused covering, and Mr. Jacks asked them to stop. He stared back at me, blue eyes standing in stark contrast to the amber that invaded all around. One thing became evident in that room filled with so much confusion and fear — there would be no more ambulance rides back and forth to the hospital and no more painful transfers to impossibly uncomfortable radiology tables. The time had come to break from the incessant bustle of the department, to shelve the constantly ticking disposition timer, and — more than ever — to be perfectly present in Mr. Jacks’ tiny treatment room. His monitor and vitals forced questions of pain, disease, and death, but Mr. Jacks had finally turned to inquiries of peace and comfort.


I sat at the bedside for an eternity that passed in a moment. As my pager buzzed silently against my waist, I was honored to help my patient’s justifiably reticent family understand his wish for relief. I sat in awe as Mr. Jacks’ oldest daughter stood strong at the foot of the bed, a hint of a tear trapped in her eye, and explained to her mother that giving in was not the same as giving up — that in acceptance, there is hope. For the first time in too long, I simply stayed.


Mr. Jacks went home that night, a better plan for his abbreviated future in place. It was an encounter I’ve had a dozen times before, but for some reason, it had been different. Entering the shift in the doldrums of disenchantment, the long minutes spent at that bedside helped me to see that the path had been right all along, and that the light I thought extinguished had simply been obscured by the forest of distractions through which it coursed. My frustrations were born not from disappointment in emergency medicine but rather from the many diversions from the same.


I’ve made the conscious decision to enjoy my work again. It seems obvious and perhaps a bit trite, but it seems to be working. I’ve remembered to savor every interaction and appreciate each moment for its own worth. I’m returning to the foundation that I love, and I feel like I’m back on a path from which I’d wandered all too far.

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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